reglab/statecodes huggingface dataset:
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-12 - Provisions governing contractual arrangements between health carriers and intermediaries.

58-17F-12. Provisions governing contractual arrangements between health carriers and intermediaries.
In any contractual arrangement between a health carrier and an intermediary, the following shall apply:
(1)The health carrier's ultimate statutory responsibility to monitor the offering of covered benefits to covered persons shall be maintained whether or not any functions or duties are contractually delegated or assigned to the intermediary;
(2)The health carrier may approve or disapprove participation status of a subcontracted provider in its own or a contracted network for the purpose of delivering covered benefits to the carrier's covered persons;
(3)The health carrier shall maintain copies of all intermediary health care subcontracts at its principal place of business in the state, or ensure that it has access to all intermediary subcontracts, including the right to make copies to facilitate regulatory review, upon twenty days prior written notice from the health carrier;
(4)If applicable, an intermediary shall transmit utilization documentation and claims paid documentation to the health carrier. The carrier shall monitor the timeliness and appropriateness of payments made to providers and health care services received by covered persons;
(5)An intermediary shall maintain the books, records, financial information, and documentation of services provided to covered persons and preserve them for examination pursuant to chapter 58-3;
(6)An intermediary shall allow the director access to the intermediary's books, records, financial information, and any documentation of services provided to covered persons, as necessary to determine compliance with this chapter; and
(7)The health carrier may, in the event of the intermediary's insolvency, require the assignment to the health carrier of the provisions of a provider's contract addressing the provider's obligation to furnish covered services.
Source: SL 2011, ch 219, §12.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub.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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-13 - Sample contract forms to be filed with director--Material changes to be submitted--Certain changes not material--Director's inaction within certain time deemed approval--Contract copies to be provided upon request.

58-17F-13. Sample contract forms to be filed with director--Material changes to be submitted--Certain changes not material--Director's inaction within certain time deemed approval--Contract copies to be provided upon request.
Any health carrier shall file with the director sample contract forms proposed for use with its participating providers and intermediaries. Any health carrier shall submit material changes to a sample contract that would affect a provision required by this chapter, or any rules promulgated pursuant to this chapter, to the director for approval thirty days prior to use. Changes in provider payment rates, coinsurance, copayments, or deductibles, or other plan benefit modifications are not considered material changes for the purpose of this section. If the director takes no action within sixty days after submission of a material change to a contract by a health carrier, the change is deemed approved. The health carrier shall maintain provider and intermediary contracts and provide copies to the division or department upon request.
Source: SL 2011, ch 219, §13.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-14 - Contract does not relieve health carrier of liability.

58-17F-14. Contract does not relieve health carrier of liability.
The execution of a contract by a health carrier does not relieve the health carrier of its liability to any person with whom it has contracted for the provision of services, nor of its responsibility for compliance with the law or applicable regulations. Any contract shall be in writing and subject to review by the director, if requested.
Source: SL 2011, ch 219, §14.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-15 - Remedies available to director against health carrier found not in compliance.

58-17F-15. Remedies available to director against health carrier found not in compliance.
In addition to any other remedies permitted by law, if the director determines that a health carrier has not contracted with enough participating providers to assure that covered persons have accessible health care services in a geographic area, that a health carrier's access plan does not assure reasonable access to covered benefits, that a health carrier has entered into a contract that does not comply with this chapter, or that a health carrier has not complied with a provision of this chapter, the director may institute a corrective action that shall be followed by the health carrier or may use any of the director's other enforcement powers to obtain the health carrier's compliance with this chapter.
A covered person shall have access to emergency services twenty-four hours a day, seven days a week to treat emergency medical conditions that require immediate medical attention.
Source: SL 2011, ch 219, §15.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-16 - Managed care contractor to register with director.

58-17F-16. Managed care contractor to register with director.
Each managed care contractor, as defined in §58-17F-1, shall register with the director prior to engaging in any managed care business in this state. The registration shall be in a format prescribed by the director. In prescribing the form or in carrying out other functions required by §§58-17F-16 to 58-17F-20, inclusive, the director shall consult with the secretary if applicable. The director or the secretary may require that the following information be submitted:
(1)Information relating to its actual or anticipated activities in this state;
(2)The status of any accreditation designation it holds or has sought;
(3)Information pertaining to its place of business, officers, and directors;
(4)Qualifications of review staff; and
(5)Any other information reasonable and necessary to monitor its activities in this state.
Source: SL 2011, ch 219, §16.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-17 - Filing changes in registration information.

58-17F-17. Filing changes in registration information.
Any managed care contractor which has previously registered in this state shall, on or before July first of each year, file with the Division of Insurance any changes to the initial or subsequent annual registration for the managed care contractor.
Source: SL 2011, ch 219, §17.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-18 - Request for information from managed care contractor.

58-17F-18. Request for information from managed care contractor.
The director or the secretary may request information from any managed care contractor at any time pertaining to its activities in this state. The managed care contractor shall respond to all requests for information within twenty days.
Source: SL 2011, ch 219, §18.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-19 - Activities of nonregistered managed care contractor prohibited.

58-17F-19. Activities of nonregistered managed care contractor prohibited.
No managed care contractor may engage in managed care activities in this state unless the managed care contractor is properly registered. The director may issue a cease and desist order against any managed care contractor which fails to comply with the requirements of §§58-17F-16 to 58-17F-20, inclusive, prohibiting the managed care contractor from engaging in managed care activities in this state.
Source: SL 2011, ch 219, §19.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-20 - Registration fee for managed care contractor.

58-17F-20. Registration fee for managed care contractor.
The director may require the payment of a fee in conjunction with the initial or annual registration of a managed care contractor not to exceed two hundred fifty dollars per registration. The fee shall be established by rules promulgated pursuant to chapter 1-26.
Source: SL 2011, ch 219, §20.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17F - Network Adequacy Standards › Section 58-17F-21 - Promulgation of rules.

58-17F-21. Promulgation of rules.
The director may, after consultation with the secretary, promulgate, pursuant to chapter 1-26, reasonable rules to protect the public in its purchase of network health insurance products and to achieve the goals of this chapter, by ensuring adequate networks and by assuring quality of health care to the public that purchases network products. The rules may include:
(1)Definition of terms;
(2)Provider/covered person ratios;
(3)Geographic access requirements;
(4)Accessibility of care;
(5)Contents of reports and filings;
(6)Notification requirements;
(7)Selection criteria; and
(8)Record keeping.
Source: SL 2011, ch 219, §21.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17G - Quality Assessment And Improvements › Section 58-17G-3 - Health carrier to develop and maintain systems to measure quality of services--System requirements--Description of quality assessment program to be filed with director.

58-17G-3. Health carrier to develop and maintain systems to measure quality of services--System requirements--Description of quality assessment program to be filed with director.
Any health carrier that provides managed care plans shall develop and maintain the infrastructure and disclosure systems necessary to measure the quality of health care services provided to covered persons on a regular basis and appropriate to the types of plans offered by the health carrier. A health carrier shall:
(1)Utilize a system designed to assess the quality of health care provided to covered persons and appropriate to the types of plans offered by the health carrier. The system shall include systematic collection, analysis, and reporting of relevant data in accordance with statutory and regulatory requirements. The level of quality assessment activities undertaken by a health plan may vary based on the plan's structure with the least amount of quality assessment activities required being those plans which are open and the provider network is simply a discounted fee for service preferred provider organization; and
(2)File a written description of the quality assessment program with the director in the prescribed general format, which shall include a signed certification by a corporate officer of the health carrier that the filing meets the requirements of this chapter.
Source: SL 2011, ch 219, §23.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17G - Quality Assessment And Improvements › Section 58-17G-4 - Health carrier issuing closed plan to develop quality improvement activities--Minimum requirements of quality improvement activities.

58-17G-4. Health carrier issuing closed plan to develop quality improvement activities--Minimum requirements of quality improvement activities.
Any health carrier that issues a closed plan, or a combination plan having a closed component, shall, in addition to complying with the requirements of §58-17G-3, develop and maintain the internal structures and activities necessary to improve the quality of care being provided. Quality improvement activities for a health carrier subject to the requirements of this section shall involve:
(1)Developing a written quality improvement plan designed to analyze both the processes and outcomes of the health care delivered to covered persons;
(2)Establishing an internal system to implement the quality improvement plan and to specifically identify opportunities to improve care and using the findings of the system to improve the health care delivered to covered persons; and
(3)Assuring that participating providers have the opportunity to participate in developing, implementing, and evaluating the quality improvement system.
The health carrier shall provide a copy of the quality improvement plan to the director or secretary, if requested.
Source: SL 2011, ch 219, §24.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17G - Quality Assessment And Improvements › Section 58-17G-5 - Carrier may be deemed in compliance if private accrediting body meets requirements.

58-17G-5. Carrier may be deemed in compliance if private accrediting body meets requirements.
If the director and secretary find that the requirements of any private accrediting body meet the requirements of network adequacy, quality assurance, or quality improvement as set forth in this chapter, the carrier may, at the discretion of the director and secretary, be deemed to have met the applicable requirements.
Source: SL 2011, ch 219, §25.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17G - Quality Assessment And Improvements › Section 58-17G-6 - Division to monitor complaints regarding managed care policies.

58-17G-6. Division to monitor complaints regarding managed care policies.
The Division of Insurance shall separately monitor complaints regarding managed care policies.
Source: SL 2011, ch 219, §26.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17G - Quality Assessment And Improvements › Section 58-17G-7 - Promulgation of rules.

58-17G-7. Promulgation of rules.
The director may, after consultation with the secretary, promulgate, pursuant to chapter 1-26, reasonable rules to protect the public in its purchase of network health insurance products and to achieve the goals of this chapter, by assuring quality of health care to the public that purchases network products. The rules may include:
(1)Definition of terms;
(2)Contents of reports and filings;
(3)Record keeping;
(4)Setting of quality criteria based upon type of network; and
(5)Quality assurance plans or quality improvement plans or both.
Source: SL 2011, ch 219, §27.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-3 - Urgent care request defined.

58-17H-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.
Source: SL 2011, ch 219, §92.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-4 - Applicability of chapter.

58-17H-4. Applicability of chapter.
The provisions of this chapter apply to any health carrier that provides or performs utilization review services. The requirements of this chapter also apply to any designee of the health carrier or utilization review organization that performs utilization review functions on the carrier's behalf.
Source: SL 2011, ch 219, §29.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-5 - Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.

58-17H-5. Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.
If conducting utilization review or making a benefit determination for emergency services, a health carrier that provides benefits for services in an emergency department of a hospital shall comply with the provisions of §§58-17H-5 to 58-17H-13, inclusive. A health carrier shall cover emergency services necessary to screen and stabilize a covered person and may not require prior authorization of such services if a prudent layperson would have reasonably believed that an emergency medical condition existed even if the emergency services are provided on an out of-network basis. A health carrier shall cover emergency services whether the health care provider furnishing the services is a participating provider with respect to such services. If the emergency services are provided out-of-network, the services shall be covered without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers. Emergency services are provided out-of-network by complying with the cost sharing requirements set forth in §§58-17H-7 to 58-17H-10, inclusive, and without regard to any other term or condition of coverage other than the exclusion of or coordination of benefits, an affiliation or waiting periods as permitted under section 2704 of the Public Health Service Act, as amended to January 1, 2011, or cost sharing requirements as set forth in §§58-17H-6 to 58-17H-10, inclusive.
Source: SL 2011, ch 219, §30.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-6 - In-network emergency services.

58-17H-6. In-network emergency services.
Coverage of in-network emergency services are subject to applicable copayments, coinsurance, and deductibles.
Source: SL 2011, ch 219, §31.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-7 - Cost-sharing requirements for out-of-network emergency services.

58-17H-7. Cost-sharing requirements for out-of-network emergency services.
Cost-sharing requirements for out-of-network emergency services expressed as a copayment amount or coinsurance rate imposed with respect to a covered person cannot exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-network.
Source: SL 2011, ch 219, §32.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-8 - Cost-sharing requirements for covered persons--Payments to out-of-network providers.

58-17H-8. Cost-sharing requirements for covered persons--Payments to out-of-network providers.
Notwithstanding §58-17H-7, a covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount the health carrier is required to pay pursuant to this section.
A health carrier complies with the requirements of this section if it provides payment of emergency services provided by an out-of-network provider in an amount not less than the greatest of the following:
(1)The amount negotiated with in-network providers for emergency services, excluding any in-network copayment or coinsurance imposed with respect to the covered person;
(2)The amount of the emergency service calculated using the same method the plan uses to determine payments for out-of-network services, but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or
(3)The amount that would be paid under Medicare for the emergency services, excluding any in-network copayment or coinsurance requirements.
Source: SL 2011, ch 219, §33.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-9 - Exceptions for payments by capitated and other plans without negotiated fees.

58-17H-9. Exceptions for payments by capitated and other plans without negotiated fees.
For capitated or other health benefit plans that do not have a negotiated per-service amount for in-network providers, subdivision 58-17H-8(1) does not apply.
Source: SL 2011, ch 219, §34.
Commission Note: 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."
2023 South Dakota Codified Laws › Title 58 - Insurance › Chapter 17H - Utilization Review And Benefit Determinations › Section 58-17H-10 - Negotiated amounts for in-network providers for a particular emergency service.

58-17H-10. Negotiated amounts for in-network providers for a particular emergency service.
If a health benefit plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subdivision 58-17H-8(1) is the median of these negotiated amounts.
Source: SL 2011, ch 219, §35.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §36.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §37.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §38.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §39.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §40.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §41.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §42.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §43.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §44.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §45.
Commission Note: 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."
2023 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.
Source: SL 2011, ch 219, §46.
Commission Note: 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."