ARSD 67:54:09:19. 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 information: (1) The participant's full name; (2) The participant's medical assistance identification number from the participant's medical identification card; (3) 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 from this charge; (7) The units of service furnished, if more than one, for claims submitted for respite care, service coordination, personal care, companion care, or supported employment; (8) The applicable procedure codes contained in § 67:54:09:18; (9) The applicable diagnosis codes; (10) The provider's name and National Provider Identification number; and (11) The type of service provided. A separate claim must be submitted for each participant.