ARSD 67:45:02:12. Claim requirements

A claim for services provided under this chapter must be submitted on a form or in an electronic format that contains the following: (1) The service recipient's full name; (2) The recipient's medical assistance identification number from the recipient's medical assistance identification card; (3) Third-party liability information as required under chapter 67:16:26; (4) Beginning and end dates of service. A provider may only bill for one month at a time; (5) The number of covered days; (6) The total charges; (7) The type of bill; (8) The provider's name, address, telephone number, and National Provider Identification number; (9) The applicable diagnosis codes; (10) The patient status code indicating the patient's status on the final day of service of the billing period; and (11) The revenue code identifying the specific accommodation, ancillary service, or billing calculation. A separate claim form must be submitted for each recipient.