ARSD 67:54:06:16. Claim requirements

A claim for services provided under this chapter must be submitted on a form which contains the following information: (1) The recipient's full name; (2) The recipient's medical assistance identification number from the recipient's medical identification card; (3) The third-party liability information required under chapter 67:16:26; (4) The date of service; (5) The place of service; (6) The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge; (7) The units of service furnished, if more than one, for each procedure; (8) The applicable procedure codes; (9) The type of service; and (10) The provider's name and medical assistance identification number. A separate claim form must be used for each client.