reglab/statecodes huggingface dataset:
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:35 - Director's determination of eligibility and assignment for external review of experimental or investigational treatment

Current through Register Vol. 51, page 10, July 15, 2024
The director may determine that a request is eligible for external review under §
									20:06:53:36  notwithstanding a health carrier's initial determination 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.
Upon receipt of the notice that the expedited external review request meets the reviewability requirements of §
									20:06:53:36, the director immediately shall assign an independent review organization to review the expedited request 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  and notify the health carrier of the name of the assigned independent review organization.
At the time the health carrier receives the notice of the assigned independent review organization 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 20:06:53:36 - Health carrier preliminary review of request for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Except for a request for an expedited external review made pursuant to §§
									20:06:53:33  to 20:06:53:35, inclusive, within one business day after the date of receipt of the request, the director receives a request for an external review, the director shall notify the health carrier. Within five business days following the date of receipt of the notice sent pursuant to this section, the health carrier shall conduct and 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 or treatment was recommended or 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 or treatment was provided;
(2) The recommended or requested health care service or treatment that is the subject of the adverse determination or final adverse determination:
(a) Is a covered benefit under the covered person's health benefit plan except for the health carrier's determination that the service or treatment is experimental or investigational for a particular medical condition; and
(b) Is not explicitly listed as an excluded benefit under the covered person's health benefit plan with the health carrier;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:37 - Health carrier notification after preliminary review of request for experimental or investigational treatment reviews

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 the covered person and, if applicable, the covered person's authorized representative in writing whether the request is complete and whether the request is eligible for external review.
If the request is not complete, the health carrier shall inform, in writing, the director and the covered person and, if applicable, the covered person's authorized representative 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, the covered person's authorized representative, if applicable, and the director in writing and include in the notice the reasons for its ineligibility.
The notice of initial determination provided under this section must 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 20:06:53:38 - Director's determination of request for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
The director may determine that a request is eligible for external review pursuant to §
									20:06:53:36, 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.
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 20:06:53:39 - Health carrier notification of eligibility for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Whenever a request for external review is determined eligible for external review, the health carrier shall notify the director and the covered person and, if applicable, the covered person's authorized representative. Within one business day after the receipt of the notice from the health carrier that the external review request is eligible for external review pursuant to §
									20:06:53:35  or this section, the director shall:
(1) Assign an independent review organization to conduct the 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  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 within five business days following the date of receipt of the notice provided pursuant to this section 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 20:06:53:40 - Independent review organization experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Within one business day after the receipt of the notice of assignment to conduct the external review pursuant to §
									20:06:53:39, the assigned independent review organization shall:
(1) Select one or more clinical reviewers, as it determines is appropriate, pursuant to this section to conduct the external review; and
(2) Based on the opinion of the clinical reviewer, or opinions if more than one clinical reviewer has been selected to conduct the external review, make a decision to uphold or reverse the adverse determination or final adverse determination.
In selecting clinical reviewers pursuant to this section, the assigned independent review organization shall select physicians or other health care professionals who meet the minimum qualifications described in §§
										20:06:53:57  to 20:06:53:62, inclusive, and, through clinical experience in the past three years, are experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment. Neither the covered person, the covered person's authorized representative, if applicable, nor the health carrier may choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review.
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 20:06:53:41 - Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
In accordance with §§
									20:06:53:45  and 20:06:53:46, each clinical reviewer shall provide a written opinion to the assigned independent review organization on whether the recommended or requested health care service or treatment should be covered. In reaching an opinion, clinical reviewers are 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.
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 20:06:53:43 - Review of information by independent review organization for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Each clinical reviewer selected pursuant to §§
									20:06:53:39  to 20:06:53:41, inclusive, shall review all of the information and documents received pursuant to § 20:06:53:42 and any other information submitted in writing by the covered person or the covered person's authorized representative pursuant to §
									20:06:53:39. Upon receipt of any information submitted by the covered person or the covered person's authorized representative pursuant to §
									20:06:53:39, within one business day after the receipt of the information, the assigned independent review organization shall 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 20:06:53:44 - Reconsideration by health carrier for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of the information required to be forwarded pursuant to §
									20:06:53:43, 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 be terminated only 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 recommended or requested health care service or treatment that is the subject of the adverse determination or final adverse determination.
Immediately upon making the decision to reverse its adverse determination or final adverse determination, as provided in this section, the health carrier shall notify the covered person, the covered person's authorized representative, if applicable, 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 from the health carrier's decision to reverse its 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 20:06:53:45 - Clinical review opinion for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Except as provided in §
									20:06:53:44, within 20 days after being selected in accordance with §§
									20:06:53:39  to 20:06:53:41, inclusive, to conduct the external review, each clinical reviewer shall provide an opinion to the assigned independent review organization pursuant to §
									20:06:53:47  on whether the recommended or requested health care service or treatment should be covered. Except for an opinion provided pursuant to §
									20:06:53:46, each clinical reviewer's opinion shall be in writing and include the following information:
(1) A description of the covered person's medical condition;
(2) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person than any available standard health care services or treatments and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments;
(3) A description and analysis of any medical or scientific evidence, as that term is defined in subdivision 20:06:53:01(28), considered in reaching the opinion;
(4) A description and analysis of any evidence-based standard, as that term is defined in subdivision 20:06:53:01(18); and
(5) Information on whether the reviewer's rationale for the opinion is based on subsection 20:06:53:47(5)(a) or (b).
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 20:06:53:46 - Expedited review opinions for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
For an expedited external review, each clinical reviewer shall provide an opinion orally or in writing to the assigned independent review organization as expeditiously as the covered person's medical condition or circumstances requires, but in no event more than five calendar days after being selected in accordance with §§
									20:06:53:39  to 20:06:53:41, inclusive. If the opinion provided pursuant to this section was not in writing, within 48 hours following the date the opinion was provided, the clinical reviewer shall provide written confirmation of the opinion to the assigned independent review organization and include the information as required under §
									20:06:53:45.
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 20:06:53:47 - Clinical review criteria for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the documents and information provided pursuant to §§
									20:06:53:33  to 20:06:53:35, inclusive, or § 20:06:53:42, each clinical reviewer selected pursuant to §§
									20:06:53:39  to 20:06:53:41, inclusive, to the extent the information or documents are available and the reviewer considers appropriate, shall consider in reaching an opinion pursuant to §§
									20:06:53:45  and 20:06:53:46, the following:
(1) The covered person's pertinent medical records;
(2) The attending physician or 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 physician or health care professional;
(4) The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that, but for the health carrier's determination that the recommended or requested health care service or treatment that is the subject of the opinion is experimental or investigational, the reviewer's opinion is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier; and
(5) Whether:
(a) The recommended or requested health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition; or
(b) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested health care service or treatment is more likely than not to be beneficial to the covered person than any available standard health care service or treatment and the adverse risks of the recommended or requested health care service or treatment would not be substantially increased over those of available standard health care services or treatments.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:48 - Independent review organization decision and notice for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Except as provided in §
									20:06:53:49, within 20 days after the date it receives the opinion of each clinical reviewer pursuant to §
									20:06:53:47, the assigned independent review organization, in accordance with §
									20:06:53:50, shall make a decision and provide written notice of the decision to the covered person, 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 20:06:53:49 - Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
For an expedited external review, within 48 hours after the date it receives the opinion of each clinical reviewer pursuant to §
									20:06:53:47, the assigned independent review organization, in accordance with §
									20:06:53:50, shall make a decision and provide notice of the decision orally or in writing to the persons listed in §
									20:06:53:48.
If the notice provided under this section was not in writing, within 48 hours after the date of providing that notice, the assigned independent review organization shall provide written confirmation of the decision to the persons listed in §
									20:06:53:48  and include the information set forth in §
									20:06:53:51.
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 20:06:53:50 - Decision by independent review organization for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should be covered, the independent review organization shall make a decision to reverse the health carrier's adverse determination or final adverse determination. If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should not be covered, the independent review organization shall make a decision to uphold the health carrier's adverse determination or final adverse determination.
If the clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer in order for the independent review organization to make a decision based on the opinions of a majority of the clinical reviewers.
The additional clinical reviewer selected under this section shall use the same information to reach an opinion as the clinical reviewers who have already submitted their opinions pursuant to §
									20:06:53:47. The selection of the additional clinical reviewer under this section does not extend the time within which the assigned independent review organization is required to make a decision based on the opinions of the clinical reviewers selected under §§
									20:06:53:39  to 20:06:53:41, 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 20:06:53:51 - Notice of written decision by independent review organization for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
The independent review organization shall include in the notice provided pursuant to §§
									20:06:53:48  and 20:06:53:49:
(1) A general description of the reason for the request for external review;
(2) The written opinion of each clinical reviewer, including the recommendation of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for the reviewer's recommendation:
(3) The date the independent review organization was assigned by the director to conduct the external review;
(4) The date the external review was conducted;
(5) The date of its decision;
(6) The principal reason or reasons for its decision; and
(7) The rationale for its decision.
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 20:06:53:52 - Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational treatment reviews

Current through Register Vol. 51, page 10, July 15, 2024
Upon receipt of a notice of a decision pursuant to §§
									20:06:53:48  and 20:06:53:49  reversing the adverse determination or final adverse determination, the health carrier immediately shall approve coverage of the recommended or requested health care service or treatment 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 20:06:53:53 - Criteria for assignment of independent review organization for experimental or investigational treatment 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 §§
									20:06:53:33  to 20:06:53:54, inclusive, 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 20:06:53:54 - Binding nature of external review decision

Current through Register Vol. 51, page 10, July 15, 2024
An external review decision is binding on the health carrier except to the extent the health carrier has other remedies available under applicable state law. An external review decision is binding on the covered person except to the extent the covered person has other remedies available under applicable federal or state law.
A covered person or the covered person's authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to 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 20:06:53:55 - Approval of independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
The director shall approve independent review organizations eligible to be assigned to conduct external reviews pursuant to this chapter. In order to be eligible for approval by the director under this section to conduct external reviews pursuant to this chapter an independent review organization, except as otherwise provided in §§ 20:06:53:55  and 20:06:53:56, shall be accredited by a nationally recognized private accrediting entity that the director has determined has independent review organization accreditation standards that are equivalent to or exceed the minimum qualifications for independent review organizations established pursuant to §§
									20:06:53:57  to 20:06:53:62, inclusive; and
Any independent review organization wishing to be approved to conduct external reviews pursuant to this chapter shall submit an application form as prescribed by the director and include with the form all documentation and information necessary for the director to determine if the independent review organization satisfies the minimum qualifications established pursuant to §§
									20:06:53:57  to 20:06:53:62, inclusive.
The director may approve independent review organizations that are not accredited by a nationally recognized private accrediting entity if there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation.
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 20:06:53:56 - Continuation of approval for independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
An approval is effective for two years, unless the director determines before its expiration that the independent review organization is not satisfying the minimum qualifications established pursuant to §§
									20:06:53:57  to 20:06:53:62, inclusive.
Whenever the director determines that an independent review organization has lost its accreditation or no longer satisfies the minimum requirements established pursuant to §§
									20:06:53:57  to 20:06:53:62, inclusive, the director shall terminate the approval of the independent review organization and remove the independent review organization from the list of independent review organizations approved to conduct external reviews pursuant to this chapter that is maintained by the director pursuant to §
									20:06:53:62.
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 20:06:53:57 - Minimum qualifications for independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
To be approved under §§
									20:06:53:55  and 20:06:53:56  to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in this chapter. The policies and procedures shall include, at a minimum:
(1) A quality assurance mechanism in place that:
(a) Ensures that external reviews are conducted within the specified timeframes and required notices are provided in a timely manner;
(b) Ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization and suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective;
(c) Ensures the confidentiality of medical and treatment records and clinical review criteria; and
(d) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this chapter;
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:58 - Requirements for clinical reviewers

Current through Register Vol. 51, page 10, July 15, 2024
All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who meet the following minimum qualifications:
(1) Be an expert in the treatment of the covered person's medical condition that is the subject of the external review;
(2) Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person;
(3) Hold a non-restricted license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and
(4) Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer's physical, mental, or professional competence or moral character.
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 20:06:53:59 - Subsidiaries of or ownership in independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the requirements set forth in §
									20:06:53:57, an independent review organization may not own or control, be a subsidiary of, or in any way be owned or controlled by, or exercise control with, a health benefit plan, a national, state, or local trade association of health benefit plans, or a national, state, or local trade association of health care providers.
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 20:06:53:60 - Independence of clinical reviewers

Current through Register Vol. 51, page 10, July 15, 2024
In addition to the requirements set forth in §§
									20:06:53:57, 20:06:53:58, and 20:06:53:59, to be approved pursuant to §§ 20:06:52:55 and 20:06:53:56  to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical reviewer assigned by the independent organization to conduct the external review may have a material professional, familial, or financial conflict of interest with any of the following;
(1) The health carrier that is the subject of the external review;
(2) The covered person whose treatment is the subject of the external review or the covered person's authorized representative;
(3) Any officer, director, or management employee of the health carrier that is the subject of the external review;
(4) The health care provider or the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of the external review;
(5) The facility at which the recommended health care service or treatment would be provided; or
(6) The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose treatment is the subject of the external review.
In determining whether an independent review organization or a clinical reviewer of the independent review organization has a material professional, familial, or financial conflict of interest for purposes of this section, the director shall take into consideration situations where the independent review organization to be assigned to conduct an external review of a specified case or a clinical reviewer to be assigned by the independent review organization to conduct an external review of a specified case may have an apparent professional, familial, or financial relationship or connection with a person described in this section, but that the characteristics of that relationship or connection are such that they are not a material professional, familial, or financial conflict of interest that results in the disapproval of the independent review organization or the clinical reviewer from conducting the external review.
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 20:06:53:61 - Nationally accredited independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
An independent review organization that is accredited by a nationally recognized private accrediting entity that has independent review accreditation standards that the director has determined are equivalent to or exceed the minimum qualifications of this section shall be presumed in compliance with this section to be eligible for approval under §§
									20:06:53:55  and 20:06:53:56.
The director shall initially review and periodically review the independent review organization accreditation standards of a nationally recognized private accrediting entity to determine whether the entity's standards are, and continue to be, equivalent to or exceed the minimum qualifications established under this section. The director may accept a review conducted by the NAIC for the purpose of the determination under this section.
Upon request, a nationally recognized private accrediting entity shall make its current independent review organization accreditation standards available to the director or the NAIC in order for the director to determine if the entity's standards are equivalent to or exceed the minimum qualifications established under this section. The director may exclude any private accrediting entity that is not reviewed by the NAIC.
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 20:06:53:62 - Unbiased independent review organization

Current through Register Vol. 51, page 10, July 15, 2024
An independent review organization must be unbiased. An independent review organization shall establish and maintain written procedures to ensure that it is unbiased in addition to any other procedures required pursuant to §§
									20:06:53:57  to 20:06:53:62, 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 20:06:53:63 - Hold harmless for independent review organizations

Current through Register Vol. 51, page 10, July 15, 2024
No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent, or contractor of an independent review organization is liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization's or person's duties under the law during or upon completion of an external review conducted pursuant to this chapter, unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence.
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 20:06:53:64 - External review reporting requirements

Current through Register Vol. 51, page 10, July 15, 2024
An independent review organization assigned pursuant to §§
									20:06:53:12  to 20:06:53:32, inclusive, to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the director, as required under this section. The report must be in the format of Appendix C.
Each independent review organization required to maintain written records on all requests for external review pursuant to this section for which it was assigned to conduct an external review shall submit to the director, upon request, a report in the format specified by the director. The report shall include in the aggregate by state, and for each health carrier, the following:
(1) The total number of requests for external review;
(2) The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;
(3) The average length of time for resolution;
(4) A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director; and
(5) The number of external reviews pursuant to §
									20:06:53:19  that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person's authorized representative.
The director may request additional information to be included within the report or to be provided at an alternate date that relates to the independent review organization's compliance with 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 20:06:53:65 - Independent review organization and health carrier recordkeeping

Current through Register Vol. 51, page 10, July 15, 2024
The independent review organization shall retain the written records required pursuant to §
									20:06:53:64  for at least three years.
Each health carrier shall maintain written records in the aggregate, by state and for each type of health benefit plan offered by the health carrier, on all requests for external review that the health carrier receives notice of from the director pursuant to this chapter. Each health carrier required to maintain written records on all requests for external review pursuant to this section shall submit to the director, upon request, a report in the format of Appendix D. The report shall include in the aggregate, by state, and by type of health benefit plan the following information:
(1) The total number of requests for external review; and
(2) From the total number of requests for external review reported under subdivision (1) of this section, the number of requests determined eligible for a full external review.
The director may request additional information to be included within the report or to be provided at an alternate date that relates to the health carrier's compliance with this chapter.
The health carrier shall retain the written records required pursuant to this section for at least three years.
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 20:06:53:66 - Funding of external review

Current through Register Vol. 51, page 10, July 15, 2024
The health carrier against which a request for any review subject to this chapter is filed shall pay the cost of the independent review organization for conducting the external review.
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 20:06:53:67 - Disclosure requirements

Current through Register Vol. 51, page 10, July 15, 2024
Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons. The description shall be in a format prescribed by the director. The description shall include a statement that informs the covered person of the right of the covered person to file a request for an external review of an adverse determination or final adverse determination with the director. The statement may explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness. The statement shall include the telephone number and address of the director. The statement shall inform the covered person that, when filing a request for an external review, the covered person is required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.
General Authority:
SDCL  58-17-87,  58-17H-49,  58-17I-16,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.
Commission Note:
The provisions of this chapter are effective for plan years beginning after September 22, 2010.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:68 - Adverse benefit determination - Defined

Current through Register Vol. 51, page 10, July 15, 2024
For purposes of §§ 20:06:53:68  to 20:06:53:77, inclusive, an adverse benefit determination is defined in SDCL  58-17H-1(1).
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-17H-1,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:69 - Urgent care requests - Timely notification of determination - Initial benefit determination

Current through Register Vol. 51, page 10, July 15, 2024
For an urgent care request in the context of an initial benefit determination, 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 benefit 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.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87, 58-17C-72,  58-18-79.
South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Section 20:06:53:70 - Additional evidence

Current through Register Vol. 51, page 10, July 15, 2024
The plan or issuer must provide the claimant, free of charge, with any new or additional evidence considered, relied upon, or generated by the plan or issuer or at the direction of the plan or issuer in connection with the claim. Such evidence must be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required to be provided to give the claimant a reasonable opportunity to respond prior to that date. Additionally, before the plan or issuer can issue an adverse benefit determination on review based on a new or additional rationale, the claimant must be provided, free of charge, with the rationale. The rationale must be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination on review is required to be provided to give the claimant a reasonable opportunity to respond prior to that date.
General Authority:
SDCL  58-17-87,  58-18-79.
Law Implemented:
SDCL  58-17-87,  58-18-79.