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 name;

          (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 each recipient.

          Source: 17 SDR 4, effective July 16, 1990; 35 SDR 253, effective May 12, 2009.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-Reference: Claims, ch 67:16:35.

          Note: 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 desk.