South Dakota Administrative Code

Rule 20:06:48:09 Repealed. 20:06:48:09. Appeals (repealed, effective January 1, 2017). Source: 30 SDR 51, effective October 28, 2003; 36 SDR 209, effective July 1, 2010; 39 SDR 100, effective December 6, 2012; SL 2015, ch 249, §§ 34 and 35, effective July 1, 2015; 42 SDR 52, effe…

Rule 20:06:48:10 Repealed. 20:06:48:10. Payment of risk pool premiums. Repealed. Source: 30 SDR 51, effective October 28, 2003; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:11 Repealed. 20:06:48:11. Coverage cancellation for nonpayment of premium. Repealed. Source: 30 SDR 51, effective October 28, 2003; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:12 Repealed. 20:06:48:12. Lifetime benefit limit. Repealed. Source: 30 SDR 51, effective October 28, 2003; 35 SDR 306, effective July 1, 2009; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:13 Repealed. 20:06:48:13. Changing plans. Repealed. Source: 30 SDR 51, effective October 28, 2003; 36 SDR 209, effective July 1, 2010; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:14 Repealed. 20:06:48:14. One-person group ineligible. Repealed. Source: 30 SDR 51, effective October 28, 2003; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:15 Repealed. 20:06:48:15. Cooperation required. Repealed. Source: 30 SDR 51, effective October 28, 2003; 32 SDR 203, effective June 5, 2006; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:16 Repealed. 20:06:48:16. Preexisting condition waiting period prohibited. Repealed. Source: 30 SDR 51, effective October 28, 2003; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:17 Repealed. 20:06:48:17. Eligibility -- Exclusionary rider. Repealed. Source: 30 SDR 51, effective October 28, 2003; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:18 Repealed. 20:06:48:18. Public health plans. Repealed. Source: 31 SDR 214, effective July 6, 2005; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:19 Repealed. 20:06:48:19. Eligibility based upon residence. Repealed. Source: 32 SDR 203, effective June 5, 2006; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:20 Repealed. 20:06:48:20. Termination of coverage due to fraud. Repealed. Source: 33 SDR 226, effective June 25, 2007; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:48:21 Repealed. 20:06:48:21. Claims paid in error -- Debt subject to recovery (repealed, effective January 1, 2017). Source: 33 SDR 226, effective June 25, 2007; SL 2015, ch 249, § 35, July 1, 2015; repealed, effective January 1, 2017.

Rule 20:06:48:22 Repealed. 20:06:48:22. Creditable coverage -- Children's Health Insurance Program. Repealed. Source: 36 SDR 127, effective March 1, 2010; repealed, SL 2015, ch 249, § 33, effective July 1, 2015.

Rule 20:06:49:01 Nominal processing fee. 20:06:49:01. Nominal processing fee. A discount plan subject to the registration provisions of SDCL 58-17E-9 may withhold a nominal processing fee not to exceed $25. Source: 31 SDR 214, effective July 6, 2005; 33 SDR 230, effective July 2,…

20:06:50:01. Permissible policy language and disclosure forms. Appendices A and B are samples of permissible policy language and disclosure forms in reference to coordination of benefits. Source: 32 SDR 232, effective July 10, 2006. General Authority: SDCL 58-18A-61. Law Implemen…

Rule 20:06:51:01 Definitions. 20:06:51:01. Definitions. Terms used in §§ 20:06:51:01 to 20:06:51:06, inclusive, mean: (1) "2001 CSO Mortality Table," that mortality table, consisting of separate rates of mortality for male and female lives, developed by the American Academy of Ac…

Rule 20:06:51:02 Election of Mortality Table. 20:06:51:02. Election of Mortality Table. At the election of the insurer for each calendar year of issue, for any one or more specified plans of insurance and subject to satisfying the conditions stated in this chapter, the 2001 CSO P…

Rule 20:06:51:03 Separate rates for preferred and standard nonsmoker lives. 20:06:51:03. Separate rates for preferred and standard nonsmoker lives. For each plan of insurance with separate rates for preferred and standard nonsmoker lives, an insurer may use the Super Preferred No…

Rule 20:06:51:04 Separate rates for preferred and standard smoker lives. 20:06:51:04. Separate rates for preferred and standard smoker lives. For each plan of insurance with separate rates for preferred and standard smoker lives, an insurer may use the Preferred Smoker and Residu…

Rule 20:06:51:05 Filing of reports. 20:06:51:05. Filing of reports. Unless exempted by the director, every authorized insurer using the 2001 CSO Preferred Class Structure Table shall annually file statistical reports showing mortality and such other information as the director ma…

Rule 20:06:51:06 Minimum valuation mortality standards for preneed insurance policies. 20:06:51:06. Minimum valuation mortality standards for preneed insurance policies. For preneed insurance and similar policies, the minimum mortality standard for determining reserve liabilities…

Rule 20:06:52:01 Definitions. 20:06:52:01. Definitions. Terms used in this chapter mean: (1) "Appeal," any review or appeal before an administrative agency, arbitrator, court or mediator; (2) "Discretionary clause," a provision in a policy that purports to bind the claimant to, o…

Rule 20:06:52:02 Discretionary clauses prohibited. 20:06:52:02. Discretionary clauses prohibited. 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 f…

Rule 20:06:52:03 Application to claims administration services. 20:06:52:03. Application to claims administration services. The provisions of this chapter apply to any health insurer or third party administrator engaged in the business of insurance including any contractual arran…

Rule 20:06:53:01 Definitions. 20:06:53:01. Definitions. 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 …

Rule 20:06:53:02 Applicability. 20:06:53:02. Applicability. 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 …

Rule 20:06:53:03 Notice of right to external review. 20:06:53:03. Notice of right to external review. 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,…

Rule 20:06:53:04 Content of notices. 20:06:53:04. Content of notices. 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 …

Rule 20:06:53:05 Review procedures and authorization to accompany notice. 20:06:53:05. Review procedures and authorization to accompany notice. In addition to the information required by § 20:06:53:04, the health carrier shall include a copy of the description of both the standar…

Rule 20:06:53:06 Request for external review. 20:06:53:06. Request for external review. 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 u…

Rule 20:06:53:07 Exhaustion of internal grievance process required. 20:06:53:07. Exhaustion of internal grievance process required. 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, inclusiv…

Rule 20:06:53:08 When exhaustion of internal grievance occurs. 20:06:53:08. When exhaustion of internal grievance occurs. 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 …

Rule 20:06:53:09 Request for expedited review. 20:06:53:09. Request for expedited review. 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 …

Rule 20:06:53:10 Determination of expedited review. 20:06:53:10. Determination of expedited review. 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 prov…

Rule 20:06:53:11 Waiver of exhaustion requirement. 20:06:53:11. Waiver of exhaustion requirement. 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 SD…

Rule 20:06:53:12 Standard external review. 20:06:53:12. Standard external review. 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 pe…

Rule 20:06:53:13 Notification following preliminary review. 20:06:53:13. Notification following preliminary review. 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 …

Rule 20:06:53:14 Determination by the director and assignment of independent review organization. 20:06:53:14. Determination by the director and assignment of independent review organization. The director may determine that a request is eligible for external review under § 20:06:…

Rule 20:06:53:15 Independence of review decision. 20:06:53:15. Independence of review decision. 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 …

Rule 20:06:53:16 Health carrier required to provide information. 20:06:53:16. Health carrier required to provide information. 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 revie…

Rule 20:06:53:17 Effect of failure to act on external review process. 20:06:53:17. Effect of failure to act on external review process. The failure by the health carrier or its utilization review organization to provide the documents and information within the time specified in §…

Rule 20:06:53:18 Independent review organization review of information. 20:06:53:18. Independent review organization review of information. The assigned independent review organization shall review all of the information and documents received pursuant to § 20:06:53:16 and any ot…

Rule 20:06:53:19 Carrier reconsideration. 20:06:53:19. Carrier reconsideration. 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 subj…

Rule 20:06:53:20 Information to be considered by independent review organization. 20:06:53:20. Information to be considered by independent review organization. In addition to the documents and information provided pursuant to §§ 20:06:53:16 and 20:06:53:17, the assigned independe…

Rule 20:06:53:21 Independent review organization decisions. 20:06:53:21. Independent review organization decisions. 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 dec…

Rule 20:06:53:22 Director assignment of independent review organization. 20:06:53:22. Director assignment of independent review organization. The assignment by the director of an approved independent review organization to conduct an external review in accordance with this sectio…