reglab/housing_qa huggingface dataset:
SD Codified L § 58-17H-11 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-11 - General cost-sharing requirements allowed.

58-17H-11. General cost-sharing requirements allowed.Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible or out-of-pocket maximum, may be imposed with respect to emergency services provided out-of-network if the cost-sharing requirement generally applies to out-of-network benefits. A deductible may be imposed with respect to out-of-network emergency services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum generally applies to out-of-network benefits, that out-of-network maximum applies to out-of-network emergency services. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub.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, §36.
SD Codified L § 58-17H-12 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-12 - Access to representative for post-evaluation or post-stabilization services.

58-17H-12. Access to representative for post-evaluation or post-stabilization services.For immediately required post-evaluation or post-stabilization services, a health carrier shall provide access to a designated representative twenty-four hours a day, seven days a week, to facilitate review, or otherwise provide coverage with no financial penalty to the covered person. (SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub.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, §37.
SD Codified L § 58-17H-13 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-13 - Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.

58-17H-13. Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.If the director and the secretary find that the requirements of any private accrediting body meet the requirements of coverage of emergency medical services as set forth in §§58-17H-4 to 58-17H-12, inclusive, the health carrier may, at the discretion of the director and secretary, be deemed to have met the applicable requirements. (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, §38.
SD Codified L § 58-17H-14 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-14 - Health carrier responsibility for utilization review activities.

58-17H-14. Health carrier responsibility for utilization review activities.A health carrier is responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter and applicable rules are met. The health carrier shall also ensure that appropriate personnel have operational responsibility for the conduct of the health carrier's utilization review program. (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, §39.
SD Codified L § 58-17H-15 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-15 - Director to hold health carrier responsible for utilization review performance of contractor.

58-17H-15. Director to hold health carrier responsible for utilization review performance of contractor.If a health carrier contracts to have a utilization review organization or other entity perform the utilization review functions required by this chapter, or applicable rules, the director shall hold the health carrier responsible for monitoring the activities of the utilization review organization or entity with which the health carrier contracts and for ensuring that the requirements of this chapter, and applicable rules, are met. (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, §40.
SD Codified L § 58-17H-16 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-16 - Written utilization review program required--Contents of program document.

58-17H-16. Written utilization review program required--Contents of program document.A health carrier that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated for the filing of benefit requests, the notification of utilization review and benefit determinations, and the review of adverse determinations in accordance with chapter 58-17I.The program document shall describe the following:(1)Procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;(2)Data sources and clinical review criteria used in decision-making;(3)Mechanisms to ensure consistent application of review criteria and compatible decisions;(4)Data collection processes and analytical methods used in assessing utilization of health care services;(5)Provisions for assuring confidentiality of clinical and proprietary information;(6)The organizational structure that periodically assesses utilization review activities and reports to the health carrier's governing body; and(7)The staff position functionally responsible for day-to-day program management.A health carrier shall prepare an annual summary report in the format specified of its utilization review program activities and file the report, if requested, with the director and the secretary. A health carrier shall maintain records for a minimum of six years of all benefit requests and claims and notices associated with utilization review and benefit determinations made in accordance with §§58-17H-27 to 58-17H-32, inclusive, and §§58-17H-40 to 58-17H-48, inclusive. The health carrier shall make the records available for examination by covered persons and the director upon 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, §41.
SD Codified L § 58-17H-17 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-17 - Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.

58-17H-17. Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier may develop its own clinical review criteria, or it may purchase or license clinical review criteria from qualified vendors. A health carrier shall make available its clinical review criteria upon request to authorized government agencies including the Division of Insurance and the Department of Health. (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, §42.
SD Codified L § 58-17H-18 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-18 - Program to be administered by qualified licensed health care professionals.

58-17H-18. Program to be administered by qualified licensed health care professionals.Qualified licensed health care professionals shall administer the utilization review program and oversee review decisions. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care provider. (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, §43.
SD Codified L § 58-17H-19 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-19 - Determinations to be issued in timely manner--Process to ensure consistency.

58-17H-19. Determinations to be issued in timely manner--Process to ensure consistency.A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§58-17H-27 to 58-17H-32, inclusive, and §§58-17H-40 to 58-17H-48, inclusive. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.If a health carrier fails to strictly adhere to the requirements of §§58-17H-27 to 58-17H-32, inclusive, and §§58-17H-40 to 58-17H-48, inclusive, with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the provisions of chapters 58-17G and 58-17H, and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§58-17H-27 to 58-17H-32, inclusive, and §§58-17H-40 to 58-17H-48, inclusive, as applicable, or that any error it committed was de minimus.Any covered person may file a request for external review in accordance with rules promulgated by the director. In addition to the external review rights a covered person is entitled to pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim. (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, §44.
SD Codified L § 58-17H-20 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-20 - Effectiveness and efficiency of program to be routinely reviewed.

58-17H-20. Effectiveness and efficiency of program to be routinely reviewed.Any health carrier shall routinely assess the effectiveness and efficiency of its utilization review program. (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, §45.
SD Codified L § 58-17H-21 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-21 - Data systems to support program activities and generate management reports.

58-17H-21. Data systems to support program activities and generate management reports.Any health carrier's data system shall be sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively. (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, §46.
SD Codified L § 58-17H-22 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-22 - Health carrier oversight of delegated activities--Requirements.

58-17H-22. Health carrier oversight of delegated activities--Requirements.If a health carrier delegates any utilization review activities to a utilization review organization, the health carrier shall maintain adequate oversight, which shall include:(1)A written description of the utilization review organization's activities and responsibilities, including reporting requirements;(2)Evidence of formal approval of the utilization review organization program by the health carrier; and(3)A process by which the health carrier evaluates the performance of the utilization review organization. (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, §47.
SD Codified L § 58-17H-23 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-23 - Utilization review to be coordinated with other medical management activity of health carrier.

58-17H-23. Utilization review to be coordinated with other medical management activity of health carrier.Each health carrier shall coordinate the utilization review program with other medical management activity conducted by the carrier, such as quality assurance, credentialing, provider contracting data reporting, grievance procedures, processes for assessing member satisfaction, and risk management. (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, §48.
SD Codified L § 58-17H-24 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-24 - Health carrier to provide free access to review staff.

58-17H-24. Health carrier to provide free access to review staff.Each health carrier shall provide covered persons and participating providers with access to its review staff by a toll-free number or collect call telephone line. (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, §49.
SD Codified L § 58-17H-25 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-25 - Only information necessary for review or determination to be collected.

58-17H-25. Only information necessary for review or determination to be collected.If conducting a utilization review, the health carrier shall collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit 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, §50.
SD Codified L § 58-17H-26 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-26 - Independence and impartiality required for utilization review.

58-17H-26. Independence and impartiality required for utilization review.In conducting utilization review, the health carrier shall ensure that the review is conducted in a manner to ensure the independence and impartiality of the individuals involved in making the utilization review or benefit determination.In ensuring the independence and impartially of individuals involved in making the utilization review or benefit determination, no health carrier may make decisions regarding hiring, compensation, termination, promotion, or other similar matters based upon the likelihood that the individual will support the denial of benefits. (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, §51.
SD Codified L § 58-17H-27 (2021)
2021 South Dakota Codified Laws|Title 58 - Insurance|Chapter 17H - Utilization Review And Benefit Determinations|Section 58-17H-27 - Written procedures required for making determinations--Notification.

58-17H-27. Written procedures required for making determinations--Notification.A health carrier shall maintain written procedures pursuant to this chapter, for making standard utilization review and benefit determinations on requests submitted to the health carrier by covered persons or their authorized representatives for benefits and for notifying covered persons and their authorized representatives of its determinations with respect to these requests within the specified time frames required under this chapter. If a period of time is extended as permitted by this chapter due to a claimant's failure to submit information necessary to decide a prospective, retrospective, or disability claim, the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information. (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, §52.