reglab/housing_qa huggingface dataset:
SD Codified L § 58-17H-45 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-45 - Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.

58-17H-45. Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.The health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, of its determination with respect to the urgent care request as soon as possible, but in no event more than forty-eight hours after the earlier of:(1)The health carrier's receipt of the requested specified information; or(2)The end of the period provided for the covered person or, if applicable, the covered person's authorized representative, to submit the requested specified information.If the covered person or the covered person's authorized representative fails to submit the information before the end of the period of the extension, as specified in §58-17H-44, the health carrier may deny the certification of the requested benefit. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with §58-17H-32. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §70.
SD Codified L § 58-17H-46 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-46 - Concurrent review urgent care requests--Extended care requests--Time for determination and notice.

58-17H-46. Concurrent review urgent care requests--Extended care requests--Time for determination and notice.For concurrent review urgent care requests involving a request by the covered person or the covered person's authorized representative to extend the course of treatment beyond the initial period of time or the number of treatments, if the request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments, the health carrier shall make a determination with respect to the request and notify the covered person or, if applicable, the covered person's authorized representative, of the determination, whether it is an adverse determination or not, as soon as possible, taking into account the covered person's medical condition but in no event more than twenty-four hours after the date of the health carrier's receipt of the request. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with §58-17H-48. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §71.
SD Codified L § 58-17H-47 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-47 - Calculation of time periods for determination.

58-17H-47. Calculation of time periods for determination.For purposes of calculating the time periods within which a determination is required to be made under §§58-17H-43 to 58-17H-45, inclusive, the time period within which the determination is required to be made shall begin on the date the request is filed with the health carrier in accordance with the health carrier's procedures established pursuant to §58-17H-16 for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §72.
SD Codified L § 58-17H-49 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-49 - Promulgation of rules.

58-17H-49. Promulgation of rules.The director may, after consultation with the secretary, promulgate rules, pursuant to chapter 1-26, to carry out the provisions of this chapter. The rules shall provide for a timely administration of utilization review by the public and assure that utilization review decisions are made in a fair and clinically acceptable manner. The rules may include the following:(1)Definition of terms;(2)Timing, form, and content of reports;(3)Application of clinical criteria as it relates to utilization review;(4)Written determinations; and(5)Utilization review procedures.The director may promulgate rules, pursuant to chapter 1-26, pertaining to claims for group disability income plans. The rules shall be consistent with applicable federal requirements included in 29 CFR Part 2560 as amended to January 1, 2011. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §74.
SD Codified L § 58-17H-50 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-50 - Coverage for cancer treatment medication.

58-17H-50. Coverage for cancer treatment medication.Any health benefit plan as defined in §58-17H-2 that provides benefits for injected or intravenously administered cancer treatment medication used to kill or slow the growth of cancerous cells shall provide no less favorable benefits for prescribed, orally administered anticancer medication covered by the plan, regardless of the formulation or benefit category determination by the health plan. Source: SL 2015, ch 252, §1, eff. Jan. 1, 2016.
SD Codified L § 58-17H-51 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-51 - Reclassification of benefits with respect to cancer treatment medications.

58-17H-51. Reclassification of benefits with respect to cancer treatment medications.A health carrier may not reclassify benefits with respect to cancer treatment medications or increase a copayment, deductible, or coinsurance amount for covered cancer treatment medications that are injected or intravenously administered unless:(1)The increase is applied generally to other medical or pharmaceutical benefits covered under the plan and is not done to circumvent §58-17H-50;(2)The reclassification of benefits with respect to cancer treatment medications is done in a manner that is consistent with §§58-17H-50 to 58-17H-52, inclusive; or(3)A health carrier is applying cost-sharing increases consistent with the annual increases in the cost of health care. Source: SL 2015, ch 252, §2, eff. Jan. 1, 2016.
SD Codified L § 58-17H-52 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-52 - Medical management practices complying with chapter.

58-17H-52. Medical management practices complying with chapter.Nothing in §§58-17H-50 and 58-17H-51 prohibits a health carrier from performing medical management practices that comply with the provisions of this chapter. Source: SL 2015, ch 252, §3, eff. Jan. 1, 2016.
SD Codified L § 58-17H-53 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-53 - Step therapy protocols.

  58-17H-53  .  Step therapy protocols.   A health carrier, health benefit plan, or utilization review organization shall consider available recognized evidence-based and peer-reviewed clinical practice guidelines when establishing a step therapy protocol. Upon written request of a covered person, a health carrier, health benefit plan, or utilization review organization shall provide any clinical review criteria applicable to a specific prescription drug covered by the health carrier, health benefit plan, or utilization review organization.     Source:  SL 2020, ch 209, § 2.
SD Codified L § 58-17H-54 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-54 - Step therapy protocols--Process--Transparency.

  58-17H-54  .  Step therapy protocols--Process--Transparency.   When coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization through the use of a step therapy protocol, the covered person and the prescribing health care professional shall have access to a clear, readily accessible, and convenient process to request a step therapy override exception. A health carrier, health benefit plan, or utilization review organization may use its existing medical exceptions process to satisfy this requirement. The process used shall be easily accessible on the internet site of the health carrier, health benefit plan, or utilization review organization.     Source:  SL 2020, ch 209, § 3.
SD Codified L § 58-17H-56 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-56 - Limitations.

  58-17H-56  .  Limitations.   Nothing in §§  58-17H-53   to 55-17H-56 shall be construed to prevent:   (1) A health carrier, health benefit plan, or utilization review organization from requiring a covered person to try a prescription drug with the same generic name and demonstrated bioavailability or biological product that is an interchangeable biological product pursuant to §§  36-11-46.1   and   36-11-46.9   before providing coverage for the equivalent branded prescription drug;   (2) A health care professional from prescribing a prescription drug that is determined to be medically appropriate.     Source:  SL 2020, ch 209, § 5.
SD Codified L § 58-17I-3 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17I - Grievance Procedure|Section 58-17I-3 - Urgent care request defined.

58-17I-3. Urgent care request defined.For the purposes of this chapter, the term, urgent care request means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination:(1)Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or(2)In the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.Except as provided in subdivision (1) of this section, in determining whether a request is to be treated as an urgent care request, an individual acting on behalf of the health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. Any request that a physician with knowledge of the covered person's medical condition determines is an urgent care request within the meaning of subdivisions (1) and (2) of this section shall be treated as an urgent care request. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §94.
SD Codified L § 58-17I-4 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17I - Grievance Procedure|Section 58-17I-4 - Register of grievances required--Information to be compiled--Maintenance.

58-17I-4. Register of grievances required--Information to be compiled--Maintenance.Each health carrier shall maintain in a register written records to document all grievances received including the notices and claims associated with the grievances during a calendar year. A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with §§58-17I-7 to 58-17I-11, inclusive, and is required to be included in the register. For each grievance the register shall contain the following information:(1)A general description of the reason for the grievance;(2)The date received;(3)The date of each review or, if applicable, review meeting;(4)Resolution at each level of the grievance, if applicable;(5)Date of resolution at each level, if applicable; and(6)Name of the covered person for whom the grievance was filed.The register shall be maintained in a manner that is reasonably clear and accessible to the director. A health carrier shall retain the register compiled for a calendar year for five years. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §76.
SD Codified L § 58-17I-5 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17I - Grievance Procedure|Section 58-17I-5 - Report to director required--Contents.

58-17I-5. Report to director required--Contents.Each health carrier shall submit to the director, at least annually, a report in the format specified by the director. The report shall include for each type of health benefit plan offered by the health carrier:(1)The certificate of compliance required by §58-17I-6;(2)The number of covered lives;(3)The total number of grievances;(4)The number of grievances resolved at each level, if applicable, and their resolution;(5)The number of grievances appealed to the director of which the health carrier has been informed;(6)The number of grievances referred to alternative dispute resolution procedures or resulting in litigation; and(7)A synopsis of actions being taken to correct problems identified. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §77.
SD Codified L § 58-17I-7 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17I - Grievance Procedure|Section 58-17I-7 - Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review.

58-17I-7. Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review.Within one hundred eighty days after the date of receipt of a notice of an adverse determination sent pursuant to chapter 58-17H, any covered person or the covered person's authorized representative may file a grievance with the health carrier requesting a first level review of the adverse determination. The health carrier shall provide the covered person with the name, address, and telephone number of a person or organizational unit designated to coordinate the first level review on behalf of the health carrier. In providing for a first level review under this section, the health carrier shall ensure that the review conducted in a manner under this section to ensure the independence and impartiality of the individuals involved in making the first level review decision. In ensuring the independence and impartiality of individuals involved in making the first level review decision, no health carrier may make decisions related to such individuals regarding hiring, compensation, termination, promotion or other similar matters based upon the likelihood that the individual will support the denial of benefits.The health carrier shall designate one or more health care providers who have appropriate training and experience in the field of medicine involved in the medical judgment to evaluate the adverse determination. No health care provider may have been involved in the initial adverse determination. In conducting the review, a reviewer shall take into consideration all comments, documents, records, and other information regarding the request for services submitted by the covered person or the covered person's authorized representative, without regard to whether the information was submitted or considered in making the initial adverse determination. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §79.
SD Codified L § 58-17I-8 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17I - Grievance Procedure|Section 58-17I-8 - Rights of covered person or authorized representative on review--Access to documentation.

58-17I-8. Rights of covered person or authorized representative on review--Access to documentation.No covered person has the right to attend, or to have a representative in attendance, at the first level review. However, the covered person or, if applicable, the covered person's authorized representative may:(1)Submit written comments, documents, records, and other material relating to the request for benefits for the review or reviewers to consider when conducting the review; and(2)Receive from the health carrier, upon request and free of charge, reasonable access to, and copies of all documents, records and other information relevant to the covered person's request for benefits. A document, record, or other information shall be considered relevant to a covered person's request for benefits if the document, record, or other information:(a)Was relied upon in making the benefit determination;(b)Was submitted, considered, or generated in the course of making the adverse determination, without regard to whether the document, record, or other information was relied upon in making the benefit determination;(c)Demonstrates that, in making the benefit determination, the health carrier, or its designated representatives consistently applied required administrative procedures and safeguards with respect to the covered person as other similarly situated covered persons; or(d)Constitutes a statement of policy or guidance with respect to the health benefit plan concerning the denied health care service or treatment for the covered person's diagnosis, without regard to whether the advice or statement was relied upon in making the benefit determination.The health carrier shall make the provisions of this section known to the covered person or, if applicable, the covered person's authorized representative within three working days after the date of receipt of the grievance. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §80.
SD Codified L § 58-17I-9 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17I - Grievance Procedure|Section 58-17I-9 - Time for decision and notice--Calculation of time periods.

58-17I-9. Time for decision and notice--Calculation of time periods.A health carrier shall notify and issue a decision in writing or electronically to the covered person or, if applicable, the covered person's authorized representative, within the following time frames:(1)With respect to a grievance requesting a first level review of an adverse determination involving a prospective review request, the health carrier shall notify and issue a decision within a reasonable period of time that is appropriate given the covered person's medical condition, but no later than thirty days after the date of the health carrier's receipt of the grievance requesting the first level review made pursuant to §58-17I-7; or(2)With respect to a grievance requesting a first level review of an adverse determination involving a retrospective review request, the health carrier shall notify and issue a decision within a reasonable period of time, but no later than sixty days after the date of the health carrier's receipt of the grievance requesting the first level review made pursuant to §58-17I-7.For purposes of calculating the time periods within which a determination is required to be made and notice provided under this section, the time period shall begin on the date the grievance requesting the review is filed with the health carrier in accordance with the health carrier's procedures established pursuant to §58-17I-6 for filing a request, without regard to whether all of the information necessary to make the determination accompanies the filing. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.") Source: SL 2011, ch 219, §81.