reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:52 - Discretionary clauses › Section 20:06:52:02 - Discretionary clauses prohibited

Current through Register Vol. 51, page 10, July 15, 2024
A discretionary clause is not permitted in any individual or group health policy. No policy offered or issued in this state by a health carrier or plan to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services may contain a discretionary clause or similar provision purporting to reserve discretion to the health carrier or plan to interpret the terms of the policy or to provide standards of interpretation or review that are inconsistent with the laws of this state. The provisions of this rule apply to any health insurance policy issued or renewed after June 30, 2008.
Nothing in this section limits the director's authority under SDCL  58-11-19 to  58-11-21, inclusive, to disapprove or withdraw approval of any policy that contains a discretionary clause or to otherwise disapprove any practice involving a discretionary clause.
General Authority:
SDCL  58-2-39,  58-17-87,  58-18-79,  58-18-79(14),  58-29D-34.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-29D-23,  58-29D-31(2)(6),  58-33-67.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:52 - Discretionary clauses › Section 20:06:52:03 - Application to claims administration services

Current through Register Vol. 51, page 10, July 15, 2024
The provisions of this chapter apply to any health insurer or third party administrator engaged in the business of insurance including any contractual arrangement entered into for the administration of claims under an employer health benefit plan. No health insurer or third party administrator exercising any claims administrative authority may decide or adjudicate any claim by or through the exercise of any discretionary clause.
General Authority:
SDCL  58-2-39,  58-17-87,  58-18-79,  58-18-79(14),  58-29D-34.
Law Implemented:
SDCL  58-17-87,  58-18-79,  58-29D-23,  58-29D-31(2)(6),  58-33-67.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:01 - Definitions

Current through Register Vol. 51, page 10, July 15, 2024
Terms used in this chapter mean:
(1) "Adverse determination," a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. A rescission of coverage is an adverse determination;
(2) "Ambulatory review," utilization review of health care services performed or provided in an outpatient setting;
(3) "Authorized representative," any person to whom a covered person has given express written consent to represent the covered person in an external review; any person authorized by law to provided substituted consent for a covered person; or any family member of the covered person or the covered person's treating health care professional, but only if the covered person is unable to provide consent;
(4) "Best evidence," evidence based on:
(a) Randomized clinical trials;
(b) If randomized clinical trials are not available, cohort studies or case-control studies;
(c) If subsections (a) and (b) are not available, case-series; or
(d) If subsections (a), (b), and (c) are not available, expert opinion;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:02 - Applicability

Current through Register Vol. 51, page 10, July 15, 2024
Except as otherwise provided in this section, this chapter applies to any plan of individual health coverage, including any health benefit plans subject to the provisions of SDCL  58-17-66 to  58-17-87, inclusive, that is not an excepted benefit pursuant to SDCL  58-17-69(13)  and any employer based health plan, including health benefit plans subject to the provisions of SDCL  58-18-42. This chapter does not apply to self funded plans preempted from state regulation pursuant to the Employee Retirement Income Security Act of 1974. Nothing in §§
									20:06:53:01  to 20:06:53:67  applies to grandfathered plans pursuant to 75 Fed. Reg. 116 (2010) to be codified as 26 C.F.R. § 54 and 602, 29 C.F.R. § 2590, and 45 C.F.R. § 147.
General Authority:
SDCL  58-18-87.
Law Implemented:
SDCL  58-18-42,  58-18-51.1.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:03 - Notice of right to external review

Current through Register Vol. 51, page 10, July 15, 2024
A health carrier shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to §§
									20:06:53:12  to 20:06:53:53, inclusive, and include the appropriate statements and information set forth in this section at the same time the health carrier sends written notice of:
(1) An adverse determination upon completion of the health carrier's utilization review process set forth in SDCL  58-17H-1 to  58-17H-49, inclusive; and
(2) A final adverse determination.
As part of the written notice required by this section, a health carrier includes the following, or substantially equivalent, language: "We have denied your request for the provision of, or payment for, a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested by submitting a request for external review to the South Dakota Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, South Dakota 57501." The notice as contained in Appendix A, or a substantially similar form as may be approved by the director, must be used.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:04 - Content of notices

Current through Register Vol. 51, page 10, July 15, 2024
The health carrier shall include in the notice required under §
									20:06:53:03:
(1) For a notice related to an adverse determination, a statement informing the covered person that:
(a) If the covered person has a medical condition where the timeframe for completion of an expedited review of a grievance involving an adverse determination set forth in SDCL  58-17I-12 to  58-17I-15, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may file a request for an expedited external review to be conducted pursuant to §§
										20:06:53:23  to 20:06:53:32, inclusive, or §§
										20:06:53:33  to 20:06:53:54, inclusive;
(b) If:
(i) The adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated; and
(ii) At the same time the covered person or the covered person's authorized representative files a request for an expedited review of a grievance involving an adverse determination as set forth in SDCL  58-17I-12 to  58-17I-15, inclusive, then the independent review organization assigned to conduct the expedited external review will determine whether the covered person is required to complete the expedited review of the grievance prior to conducting the expedited external review; and
(c) The covered person or the covered person's authorized representative may file a grievance under the health carrier's internal grievance process as set forth in SDCL  58-17I-1 to  58-17I-16, inclusive, but if the health carrier has not issued a written decision to the covered person or the covered person's authorized representative within 30 days following the date the covered person or the covered person's authorized representative files the grievance with the health carrier and the covered person or the covered person's authorized representative has not requested or agreed to a delay, the covered person or the covered person's authorized representative may file a request for external review pursuant to §
										20:06:53:06  and shall be considered to have exhausted the health carrier's internal grievance process for purposes of §§
										20:06:53:07  to 20:06:53:11, inclusive; and
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:05 - Review procedures and authorization to accompany notice

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the information required by §
									20:06:53:04, the health carrier shall include a copy of the description of both the standard and expedited external review procedures the health carrier is required to provide pursuant to §
									20:06:53:67, highlighting the provisions in the external review procedures that give the covered person or the covered person's authorized representative the opportunity to submit additional information and including any forms used to process an external review.
As part of any forms provided under this section, the health carrier shall include an authorization form, or other document approved by the director that complies with the requirements of 45 C.F.R §
										164.508, by which the covered person, for purposes of conducting an external review under this chapter, authorizes the health carrier and the covered person's treating health care provider to disclose protected health information, including medical records, concerning the covered person that are pertinent to the external review, as provided in §
									20:06:45:27.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:06 - Request for external review

Current through Register Vol. 51, page 10, July 15, 2024
Except for a request for an expedited external review as set forth in §§
									20:06:53:23  to 20:06:53:32, all requests for external review shall be made in writing to the director.
The form to be used for external review requests is in Appendix B. A covered person or the covered person's authorized representative may make a request for an external review of an adverse determination or final adverse determination.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:07 - Exhaustion of internal grievance process required

Current through Register Vol. 51, page 10, July 15, 2024
Except as provided in §§
									20:06:53:09  to 20:06:53:11, inclusive, a request for an external review pursuant to §§
									20:06:53:12  to 20:06:53:53, inclusive, may not be made until the covered person has exhausted the health carrier's internal grievance process as set forth in SDCL  58-17I-1 to  58-17I-16, inclusive.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16 - 58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:08 - When exhaustion of internal grievance occurs

Current through Register Vol. 51, page 10, July 15, 2024
A covered person shall be considered to have exhausted the health carrier's internal grievance process for purposes of this section, if the covered person or the covered person's authorized representative:
(1) Has filed a grievance involving an adverse determination pursuant to SDCL  58-17I-7 to  58-17I-11, inclusive; and
(2) Except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay, has not received a written decision on the grievance from the health carrier within 30 days following the date the covered person or the covered person's authorized representative filed the grievance with the health carrier. However, a covered person or the covered person's authorized representative may not make a request for an external review of an adverse determination involving a retrospective review determination made pursuant to SDCL  58-17I-7 to  58-17I-11, inclusive, until the covered person has exhausted the health carrier's internal grievance process.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:09 - Request for expedited review

Current through Register Vol. 51, page 10, July 15, 2024
At the same time a covered person or the covered person's authorized representative files a request for an expedited review of a grievance involving an adverse determination as set forth in SDCL  58-17I-12 to  58-17I-15, inclusive, the covered person or the covered person's authorized representative may file a request for an expedited external review of the adverse determination based upon:
(1) Under §§
									20:06:53:23  to 20:06:53:32, inclusive, if the covered person has a medical condition where the timeframe for completion of an expedited review of the grievance involving an adverse determination set forth in SDCL  58-17I-12 to  58-17I-15, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; or
(2) Under §§
									20:06:53:33  to 20:06:53:53, inclusive, if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:10 - Determination of expedited review

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of a request for an expedited external review pursuant to §
									20:06:53:09, the independent review organization conducting the external review in accordance with the provisions of §§
									20:06:53:23  to 20:06:53:32, inclusive, or §§
									20:06:53:33  to 20:06:53:54, inclusive, shall determine whether the covered person is required to complete the expedited review process set forth in SDCL  58-17I-12 to  58-17I-15, inclusive, before it conducts the expedited external review.
Upon a determination made pursuant to this section, the independent review organization immediately shall notify the covered person and, if applicable, the covered person's authorized representative of this determination and that it will not proceed with the expedited external review set forth in §§
									20:06:53:23  to 20:06:53:32, inclusive, until completion of the expedited grievance review process and the covered person's grievance at the completion of the expedited grievance review process remains unresolved.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:11 - Waiver of exhaustion requirement

Current through Register Vol. 51, page 10, July 15, 2024
A request for an external review of an adverse determination may be made before the covered person has exhausted the health carrier's internal grievance procedures as set forth in SDCL  58-17I-7 to  58-17I-11, inclusive, whenever the health carrier agrees to waive the exhaustion requirement. If the requirement to exhaust the health carrier's internal grievance procedures is waived under this section, the covered person or the covered person's authorized representative may file a request in writing for a standard external review as set forth in §§
									20:06:53:12  to 20:06:53:22, inclusive, or §§
									20:06:53:33  to 20:06:53:54, inclusive.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:12 - Standard external review

Current through Register Vol. 51, page 10, July 15, 2024
At any time during the four months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to §§
									20:06:53:03  to 20:06:53:05, inclusive, a covered person or the covered person's authorized representative may file a request for an external review with the director. Within one business day after the date of receipt of a request for external review pursuant to this section, the director shall send a copy of the request to the health carrier.
Within five business days following the date of receipt of the copy of the external review request from the director under this section, the health carrier shall complete a preliminary review of the request to determine whether:
(1) The individual is or was a covered person in the health benefit plan at the time the health care service was requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service was provided;
(2) The health care service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person's health benefit plan, but for a determination by the health carrier that the health care service is not covered because it does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness;
(3) The covered person has exhausted the health carrier's internal grievance process as set forth in SDCL  58-17I-1 to  58-17I-16, inclusive, unless the covered person is not required to exhaust the health carrier's internal grievance process pursuant to §§
									20:06:53:07  to 20:06:53:11, inclusive; and
(4) The covered person has provided all the information and forms required to process an external review, including the release form provided under §§
									20:06:53:04  and 20:06:53:05.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:13 - Notification following preliminary review

Current through Register Vol. 51, page 10, July 15, 2024
Within one business day after completion of the preliminary review, the health carrier shall notify the director and covered person and, if applicable, the covered person's authorized representative in writing whether:
(1) The request is complete; and
(2) The request is eligible for external review.
If the request is not complete, the health carrier shall inform the covered person and, if applicable, the covered person's authorized representative and the director in writing and include in the notice what information or materials are needed to make the request complete. If the request is not eligible for external review, the health carrier shall inform the covered person, if applicable, the covered person's authorized representative and the director in writing and include in the notice the reasons for its ineligibility.
The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the director.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:14 - Determination by the director and assignment of independent review organization

Current through Register Vol. 51, page 10, July 15, 2024
The director may determine that a request is eligible for external review under §
									20:06:53:12  notwithstanding a health carrier's initial determination that the request is ineligible and require that it be referred for external review. In making a determination under this section, the director's decision shall be made in accordance with the terms of the covered person's health benefit plan and is subject to all applicable provisions of this chapter.
Whenever the director receives a notice that a request is eligible for external review following the preliminary review conducted pursuant to §
									20:06:53:13, within one business day after the date of receipt of the notice, the director shall:
(1) Assign an independent review organization from the list of approved independent review organizations compiled and maintained by the director pursuant to §§
									20:06:53:55  and 20:06:53:56, to conduct the external review and notify the health carrier of the name of the assigned independent review organization; and
(2) Notify in writing the covered person and, if applicable, the covered person's authorized representative of the request's eligibility and acceptance for external review. The director shall include in the notice provided to the covered person and, if applicable, the covered person's authorized representative a statement that the covered person or the covered person's authorized representative may submit in writing to the assigned independent review organization at any time during the five business days following the date of receipt of the notice provided pursuant to § 20:06:53:14  additional information that the independent review organization shall consider when conducting the external review. The independent review organization is not required to, but may, accept and consider additional information submitted after five business days.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:15 - Independence of review decision

Current through Register Vol. 51, page 10, July 15, 2024
In reaching a decision, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier's utilization review process as set forth in SDCL  58-17H-1 to  58-17H-49, inclusive, or the health carrier's internal grievance process as set forth in SDCL  58-17I-1 to  58-17I-16, inclusive.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:16 - Health carrier required to provide information

Current through Register Vol. 51, page 10, July 15, 2024
Within five business days after the date of receipt of the notice provided pursuant to §
									20:06:53:14, the health carrier or its designee utilization review organization shall provide to the assigned independent review organization any documents and any information considered in making the adverse determination or final adverse determination.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:17 - Effect of failure to act on external review process

Current through Register Vol. 51, page 10, July 15, 2024
The failure by the health carrier or its utilization review organization to provide the documents and information within the time specified in §
									20:06:53:16  may not delay the conduct of the external review except as follows:
(1) If the health carrier or its utilization review organization fails to provide the documents and information within the time specified in §
									20:06:53:16, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination; or
(2) Within one business day after making the decision under subdivision (1), the independent review organization shall notify the covered person, if applicable, the covered person's authorized representative, the health carrier, and the director.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:18 - Independent review organization review of information

Current through Register Vol. 51, page 10, July 15, 2024
The assigned independent review organization shall review all of the information and documents received pursuant to §
									20:06:53:16  and any other information submitted in writing to the independent review organization by the covered person or the covered person's authorized representative pursuant to §
									20:06:53:14. Upon receipt of any information submitted by the covered person or the covered person's authorized representative pursuant to §
									20:06:53:14, the assigned independent review organization shall within one business day forward the information to the health carrier.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:19 - Carrier reconsideration

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of the information, if any, required to be forwarded pursuant to §
									20:06:53:18, the health carrier may reconsider its adverse determination or final adverse determination that is the subject of the external review. Reconsideration by the health carrier of its adverse determination or final adverse determination pursuant to this section may not delay or terminate the external review.
The external review may only be terminated if the health carrier decides, upon completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the health care service that is the subject of the adverse determination or final adverse determination. Within one business day after making a decision to reverse its adverse determination or final adverse determination, as provided in this section, the health carrier shall notify the covered person, if applicable, the covered person's authorized representative, the assigned independent review organization, and the director in writing of its decision.
The assigned independent review organization shall terminate the external review upon receipt of the notice of a reversal from the health carrier sent pursuant to this section.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:20 - Information to be considered by independent review organization

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the documents and information provided pursuant to §§
									20:06:53:16  and 20:06:53:17, the assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:
(1) The covered person's medical records;
(2) The attending health care professional's recommendation;
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person's authorized representative, or the covered person's treating provider;
(4) The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that the independent review organization's decision is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier;
(5) The most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or professional medical societies, boards, and associations;
(6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization; and
(7) The opinion of the independent review organization's clinical reviewer or reviewers after considering subdivisions (1) to (6), inclusive, to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:21 - Independent review organization decisions

Current through Register Vol. 51, page 10, July 15, 2024
Within 45 days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the covered person, the covered person's authorized representative, the health carrier, and the director.
The independent review organization shall include in the notice sent pursuant to this section the following:
(1) A general description of the reason for the request for external review;
(2) The date the independent review organization received the assignment from the director to conduct the external review;
(3) The date the external review was conducted;
(4) The date of its decision;
(5) The principal reason or reasons for its decision, including what applicable, if any, evidence-based standards were a basis for its decision;
(6) The rationale for its decision; and
(7) References to the evidence or documentation, including the evidence-based standards, considered in reaching its decision.
Upon receipt of a notice of a decision pursuant to this section reversing the adverse determination or final adverse determination, the health carrier immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:22 - Director assignment of independent review organization

Current through Register Vol. 51, page 10, July 15, 2024
The assignment by the director of an approved independent review organization to conduct an external review in accordance with this section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstances, including conflict of interest concerns pursuant to §
									20:06:53:60.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:23 - Expedited external review

Current through Register Vol. 51, page 10, July 15, 2024
Except for retrospective adverse or final adverse determinations, a covered person or the covered person's authorized representative may make a request for an expedited external review with the director at the time the covered person receives:
(1) An adverse determination if:
(a) The adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal review of a grievance involving an adverse determination set forth in SDCL  58-17I-12 to  58-17I-15, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; and
(b) The covered person or the covered person's authorized representative has filed a request for an expedited review of a grievance involving an adverse determination as set forth in SDCL  58-17H-1 to  58-17H-16, inclusive; or
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:24 - Notifications upon request for expedited external review

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of a request for an expedited external review, the director immediately shall send a copy of the request to the health carrier. Immediately upon receipt of the request from the director, the health carrier shall determine whether the request meets the reviewability requirements set forth in §
									20:06:53:12. The health carrier shall immediately notify the director and the covered person and, if applicable, the covered person's authorized representative of its eligibility determination.
The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that an external review request is ineligible for review may be appealed to the director.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:25 - Director's determination of eligibility for expedited reviews

Current through Register Vol. 51, page 10, July 15, 2024
The director may determine that a request is eligible for external review and under §
									20:06:53:12  notwithstanding a health carrier's initial determination that the request is ineligible and require that it be referred for external review. In making a determination under this section, the director's decision is made in accordance with the terms of the covered person's health benefit plan and is subject to all applicable provisions of this chapter.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:26 - Director assignment of independent review organization for expedited reviews

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of a notice that the request meets the reviewability requirements, the director immediately shall assign an independent review organization to conduct the expedited external review from the list of approved independent review organizations compiled and maintained by the director pursuant to §§
									20:06:53:55  and 20:06:53:56. The director shall immediately notify the health carrier of the name of the assigned independent review organization.
Upon receipt of the notice from the director of the name of the independent review organization assigned to conduct the expedited external review pursuant to this section, the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:27 - Independent review organization decision for expedited reviews

Current through Register Vol. 51, page 10, July 15, 2024
In reaching a decision in accordance with §§
									20:06:53:29  and 20:06:53:30, the assigned independent review organization is not bound by any decisions or conclusions reached during the health carrier's utilization review process as set forth in SDCL  58-17H-1 to  58-17H-49, inclusive, or the health carrier's internal grievance process as set forth in SDCL  58-17I-1 to  58-17I-16, inclusive.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:28 - Information to be considered by independent review organization for expedited review

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the documents and information provided or transmitted pursuant to §
									20:06:53:26, the assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:
(1) The covered person's pertinent medical records;
(2) The attending health care professional's recommendation;
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person's authorized representative, or the covered person's treating provider;
(4) The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that the independent review organization's decision is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier;
(5) The most appropriate practice guidelines, which shall include evidence-based standards, and may include any other practice guidelines developed by the federal government, or national or professional medical societies, boards, and associations;
(6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization in making adverse determinations; and
(7) The opinion of the independent review organization's clinical reviewer or reviewers after considering subdivisions (1) to (6), inclusive, to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:29 - Expedited review decision

Current through Register Vol. 51, page 10, July 15, 2024
As expeditiously as the covered person's medical condition or circumstances requires, but in no event more than 72 hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements set forth in §
									20:06:53:12, the assigned independent review organization shall:
(1) Make a decision to uphold or reverse the adverse determination or final adverse determination; and
(2) Notify the covered person, if applicable, the covered person's authorized representative, the health carrier, and the director of the decision. If the notice provided was not in writing, within 48 hours after the date of providing that notice, the assigned independent review organization shall:
(a) Provide written confirmation of the decision to the covered person, if applicable, the covered person's authorized representative, the health carrier, and the director; and
(b) Include the information set forth in §
										20:06:53:21.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:30 - Health carrier required to approve upon reversal by expedited review

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of the notice a decision pursuant to §
									20:06:53:29  reversing the adverse determination or final adverse determination, the health carrier immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:31 - Assignment of independent review organization for expedited reviews

Current through Register Vol. 51, page 10, July 15, 2024
The assignment by the director of an approved independent review organization to conduct an external review in accordance with this section shall be done on a random basis among those approved independent review organizations qualified to conduct the particular external review based on the nature of the health care service that is the subject of the adverse determination or final adverse determination and other circumstance, including conflict of interest concerns pursuant to §
									20:06:53:60.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:32 - Applicability of expedited reviews

Current through Register Vol. 51, page 10, July 15, 2024
An expedited external review may not be provided for retrospective adverse or final adverse determinations. Sections 20:06:53:23 to 20:06:53:31, inclusive, only apply to expedited reviews.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:33 - External review of experimental or investigational treatment adverse determinations

Current through Register Vol. 51, page 10, July 15, 2024
Within four months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to §§
									20:06:53:03  to 20:06:53:05, inclusive, that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or the covered person's authorized representative may file a request for external review with the director.
A covered person or the covered person's authorized representative may make an oral request for an expedited external review of the adverse determination or final adverse determination pursuant to this section if the covered person's treating physician certifies, in writing, that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:34 - Notifications upon request for external review of experimental or investigational treatment adverse determinations

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of a request for an expedited external review, the director immediately shall notify the health carrier. Upon notice of the request for expedited external review, the health carrier immediately shall determine whether the request meets the reviewability requirements of §
									20:06:53:36. The health carrier shall immediately notify the director and the covered person and, if applicable, the covered person's authorized representative of its eligibility determination.
The notice of initial determination by the health carrier under this section shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the director.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.