reglab/statecodes huggingface dataset:
2023 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.
Source: SL 2011, ch 219, §47.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub.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-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.
Source: SL 2011, ch 219, §48.
Commission Note: SL 2012, ch 239, §1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub.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-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.
Source: SL 2011, ch 219, §49.
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-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.
Source: SL 2011, ch 219, §50.
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-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.
Source: SL 2011, ch 219, §51.
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-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.
Source: SL 2011, ch 219, §52.
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-29 - Concurrent review determinations--Timing--Notification requirements.

58-17H-29. Concurrent review determinations--Timing--Notification requirements.
For concurrent review determinations, if a health carrier has certified an ongoing course of treatment to be provided over a period of time or number of treatments:
(1)Any reduction or termination by the health carrier during the course of treatment before the end of the period or number treatments, other than by health benefit plan amendment or termination of the health benefit plan, shall constitute an adverse determination; and
(2)The health carrier shall notify the covered person of the adverse determination in accordance with §58-17H-32 at a time sufficiently in advance of the reduction or termination to allow the covered person or, if applicable, the covered person's authorized representative, to file a grievance to request a review of the adverse determination pursuant to chapter 58-17I, and obtain a determination with respect to that review of the adverse determination before the benefit is reduced or terminated.
The health care service or treatment that is the subject of the adverse determination shall be continued without liability to the covered person until the covered person has been notified of the determination by the health carrier with respect to the internal review request made pursuant to chapter 58-17I.
Source: SL 2011, ch 219, §54.
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-30 - Retrospective review determinations--Timing--Notification requirements.

58-17H-30. Retrospective review determinations--Timing--Notification requirements.
For retrospective review determinations, the health carrier shall make the determination within a reasonable period of time, but in no event later than thirty days after the date of receiving the benefit request.
In the case of a certification, the health carrier may notify in writing the covered person and the provider rendering the service.
If the determination is an adverse determination, the health carrier shall provide notice of the adverse determination to the covered person or, if applicable, the covered person's authorized representative, in accordance with §58-17H-32. The time period for making a determination and notifying the covered person or, if applicable, the covered person's authorized representative, of the determination pursuant to this section may be extended once by the health carrier for up to fifteen days, if the health carrier:
(1)Determines that an extension is necessary due to matters beyond the health carrier's control; and
(2)Notifies the covered person or, if applicable, the covered person's authorized representative, prior to the expiration of the initial thirty-day time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.
If the extension under this section is necessary due to the failure of the covered person or, if applicable, the covered person's authorized representative to submit information necessary to reach a determination on the request, the notice of extension shall specifically describe the required information necessary to complete the request and give the covered person or, if applicable, the covered person's authorized representative at least forty-five days from the date of receipt of the notice to provide the specified information.
Source: SL 2011, ch 219, §55.
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-31 - Calculation of time period for determination for prospective and retrospective reviews.

58-17H-31. Calculation of time period for determination for prospective and retrospective reviews.
For purposes of calculating the time periods within which a determination is required to be made for prospective and retrospective reviews, the time period within which the determination is required to be made begins on the date the request is received by the health carrier in accordance with the health carrier's procedures established pursuant to §58-17H-16. If the time period for making the determination for a prospective or retrospective review is extended due to the covered person or, if applicable, the covered person's authorized representative's failure to submit the information necessary to make the determination, the time period for making the determination shall be tolled from the date on which the health carrier sends the notification of the extension to the covered person or, if applicable, the covered person's authorized representative, until the earlier of: the date on which the covered person or, if applicable, the covered person's authorized representative, responds to the request for additional information or the date on which the specified information was to have been submitted. 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-28 and 58-17H-30, the health carrier may deny the certification of the requested benefit.
Source: SL 2011, ch 219, §56.
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-33 - Information required to be provided to covered persons and prospective covered persons.

58-17H-33. Information required to be provided to covered persons and prospective covered persons.
In the certificate of coverage or member handbook provided to covered persons, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of covered persons with respect to those procedures. A health carrier shall include a summary of its utilization review and benefit determination procedures in materials intended for prospective covered persons. A health carrier shall print on its membership cards a toll-free telephone number to call for utilization review and benefit decisions.
Source: SL 2011, ch 219, §58.
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-34 - Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.

58-17H-34. Health carrier may be deemed to meet utilization review 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 utilization review as set forth in this chapter, 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, §59.
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-35 - Registration of utilization review organizations--Required information.

58-17H-35. Registration of utilization review organizations--Required information.
Any utilization review organization which engages in utilization review activities in this state shall register with the Division of Insurance prior to conducting 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 §§58-17H-35 to 58-17H-39, 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, §60.
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-36 - Filing changes in registration information.

58-17H-36. Filing changes in registration information.
Any utilization review organization 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 utilization review organization.
Source: SL 2011, ch 219, §61.
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-37 - Requests for information from utilization review organizations.

58-17H-37. Requests for information from utilization review organizations.
The director or the secretary may request information from any utilization review organization at any time pertaining to its activities in this state. The utilization review organization shall respond to all requests for information within twenty days.
Source: SL 2011, ch 219, §62.
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-38 - Activities of nonregistered utilization review organizations prohibited.

58-17H-38. Activities of nonregistered utilization review organizations prohibited.
A utilization review organization may not engage in utilization review in this state unless the utilization review organization is properly registered. The director may issue a cease and desist order against any utilization review organization which fails to comply with the requirements of §§58-17H-35 to 58-17H-39, inclusive, prohibiting the utilization review organization from engaging in utilization review activities in this state.
Source: SL 2011, ch 219, §63.
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-39 - Registration fee for utilization review organizations.

58-17H-39. Registration fee for utilization review organizations.
The director may require the payment of a fee in conjunction with the initial or annual registration of a utilization review organization 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, §64.
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-40 - Urgent care requests--Written procedures required for receipt and determination of requests.

58-17H-40. Urgent care requests--Written procedures required for receipt and determination of requests.
Each health carrier shall establish written procedures, in accordance with §§58-17H-40 to 58-17H-48, inclusive, for receiving benefit requests from covered persons or their authorized representatives and for making and notifying covered persons or their authorized representatives of expedited utilization review and benefit determinations with respect to urgent care requests and concurrent review urgent care requests.
Source: SL 2011, ch 219, §65.
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-41 - Insufficient information for determination--Notice and statement of necessary information.

58-17H-41. Insufficient information for determination--Notice and statement of necessary information.
If the covered person or, if applicable, the covered person's authorized representative has failed to provide sufficient information for the health carrier to make a determination, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, either orally or, if requested by the covered person or the covered person's authorized representative, in writing of this failure and state what specific information is needed as soon as possible, but in no event later than twenty-four hours after receipt of the request.
Source: SL 2011, ch 219, §66.
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-42 - Insufficient information for determination of prospective urgent care requests.

58-17H-42. Insufficient information for determination of prospective urgent care requests.
If the benefit request involves a prospective review urgent care request, the provisions of §58-17H-41 apply only in the case of a failure that:
(1)Is a communication by a covered person or, if applicable, the covered person's authorized representative, that is received by a person or organizational unit of the health carrier responsible for handling benefit matters; and
(2)Is a communication that refers to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment, or provider for which approval is being requested.
Source: SL 2011, ch 219, §67.
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-43 - Urgent care requests--Timely notification of determination.

58-17H-43. Urgent care requests--Timely notification of determination.
For an urgent care request, unless the covered person or the covered person's authorized representative has failed to provide sufficient information for the health carrier to determine whether, or to what extent, the benefits requested are covered benefits or payable under the health carrier's health benefit plan, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative of the health carrier's determination with respect to the request, whether or not the determination is an adverse determination, as soon as possible, taking into account the medical condition of the covered person, but in no event later than twenty-four hours after the date of the receipt of the request by the health carrier. 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.
Source: SL 2011, ch 219, §68.
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-44 - Time within which to submit necessary information.

58-17H-44. Time within which to submit necessary information.
The health carrier shall provide the covered person or, if applicable, the covered person's authorized representative, a reasonable period of time to submit the necessary information, taking into account the circumstances, but in no event less than forty-eight hours after the date of notifying the covered person or the covered person's authorized representative of the failure to submit sufficient information, as provided in §§58-17H-41 and 58-17H-42.
Source: SL 2011, ch 219, §69.
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-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.
Source: SL 2011, ch 219, §70.
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-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.
Source: SL 2011, ch 219, §71.
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-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.
Source: SL 2011, ch 219, §72.
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-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.
Source: SL 2011, ch 219, §74.
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-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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
Source: SL 2011, ch 219, §94.
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 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.
Source: SL 2011, ch 219, §76.
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 17I - Grievance Procedure › Section 58-17I-6 - Grievance procedures--Filing--Certificate of compliance--Contact information.

58-17I-6. Grievance procedures--Filing--Certificate of compliance--Contact information.
Except as specified in this chapter, each health carrier shall use written procedures for receiving and resolving grievances from covered persons, as provided in §§58-17I-7 to 58-17I-11, inclusive. If a health carrier fails to strictly adhere to the requirements of §§58-17I-7 to 58-17I-10, inclusive, or §§58-17I-12 to 58-17I-15, inclusive, with respect to receiving and resolving grievances involving an adverse determination, the covered person shall be deemed to have exhausted the provisions of this chapter, and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§58-17I-7 to 58-17I-10, inclusive, or §§58-17I-12 to 58-17I-15, inclusive, or that any error the carrier committed was de minimus.
A covered person may file a request for external review in accordance with rules promulgated by the director. In addition 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.
A health carrier shall file with the director a copy of the procedures required under this section, including all forms used to process requests made pursuant to §§58-17I-7 to 58-17I-11, inclusive. Any subsequent material modifications to the documents also shall be filed. The director may disapprove a filing received in accordance with this section that fails to comply with this chapter, or applicable rules. A description of the grievance procedures required under this section shall be set forth in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to covered persons. The grievance procedure documents shall include a statement of a covered person's right to contact the Division of Insurance for assistance at any time. The statement shall include the telephone number and address of the Division of Insurance.
Source: SL 2011, ch 219, §78; SL 2023, ch 165, §2.
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."