67:16:11:19.02. Claim requirements -- Private duty nursing --
Extended home health aide services. A claim for private duty nursing and
extended home health aide services provided in 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 identification number from the recipient's medical assistance
(3) Third-party liability
information required under chapter 67:16:26;
(4) Date of service;
(5) Place of service;
(6) The provider's usual
and customary charge. The provider may
not subtract other third-party payments from this charge;
(7) The applicable
procedure codes for the covered services provided;
(8) The applicable
diagnostic codes as contained in the International
Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM)
Annotated adopted in § 67:16:01:26;
(9) The units of service
furnished, if more than one;
(10) The provider's name
and national provider identification number; and
(11) The prior
authorization number issued by the department.
A separate claim form must be used for
18 SDR 209, effective June 23, 1992; 19 SDR 26, effective August 23, 1992; 19
SDR 128, effective March 11, 1993; 20 SDR 149, effective March 21, 1994; 21 SDR
183, effective April 30, 1995; 35 SDR 88, effective October 23, 2008.
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.
783-3238 - pricing desk.