Rule 67:16:25:11 Claim requirements -- Wheelchair.
67:16:25:11. Claim requirements -- Wheelchair. A claim
for wheelchair services provided under this chapter must be submitted on a form
or in an electronic format that contains the following information:
(1) The recipient's full
(2) The recipient's medical
assistance number from the recipient's medical assistance identification card;
(3) Third-party liability
information required under chapter 67:16:26;
(4) Date of service;
(5) Place of service;
(6) The point of origin and
the destination of the recipient being transported;
(7) The provider's usual
and customary charge. The provider must
not subtract other third-party or cost-sharing payments from this charge;
(8) The applicable
procedure codes for the services provided;
(9) The units of service
furnished, if more than one; and
(10) The provider's name
and medical assistance identification number.
A separate claim must be submitted for
17 SDR 4, effective July 16, 1990; 35 SDR 253, effective May 12, 2009.
Authority: SDCL 28-6-1.
Implemented: SDCL 28-6-1.
Claims, ch 67:16:35.
The CMS 1500 form substantially meets the requirements of this rule and its
content and appearance are acceptable to the department. These forms are
available for direct purchase through the Superintendent of Documents, U.S.
Government Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing
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