South Dakota Administrative Code

Rule 20:06:53:23 Expedited external review. 20:06:53:23. Expedited external review. 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 di…

Rule 20:06:53:24 Notifications upon request for expedited external review. 20:06:53:24. Notifications upon request for expedited external review. Upon receipt of a request for an expedited external review, the director immediately shall send a copy of the request to the health ca…

Rule 20:06:53:25 Director's determination of eligibility for expedited reviews. 20:06:53:25. Director's determination of eligibility for expedited reviews. The director may determine that a request is eligible for external review and under § 20:06:53:12 notwithstanding a health c…

Rule 20:06:53:26 Director assignment of independent review organization for expedited reviews. 20:06:53:26. Director assignment of independent review organization for expedited reviews. Upon receipt of a notice that the request meets the reviewability requirements, the director i…

Rule 20:06:53:27 Independent review organization decision for expedited reviews. 20:06:53:27. Independent review organization decision for expedited reviews. In reaching a decision in accordance with §§ 20:06:53:29 and 20:06:53:30, the assigned independent review organization is …

Rule 20:06:53:28 Information to be considered by independent review organization for expedited review. 20:06:53:28. Information to be considered by independent review organization for expedited review. In addition to the documents and information provided or transmitted pursuant …

Rule 20:06:53:29 Expedited review decision. 20:06:53:29. Expedited review decision. 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 t…

Rule 20:06:53:30 Health carrier required to approve upon reversal by expedited review. 20:06:53:30. Health carrier required to approve upon reversal by expedited review. Upon receipt of the notice a decision pursuant to § 20:06:53:29 reversing the adverse determination or final a…

Rule 20:06:53:31 Assignment of independent review organization for expedited review. 20:06:53:31. Assignment of independent review organization for expedited reviews. The assignment by the director of an approved independent review organization to conduct an external review in ac…

Rule 20:06:53:32 Applicability of expedited reviews. 20:06:53:32. Applicability of expedited reviews. 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 expedite…

Rule 20:06:53:33 External review of experiment or investigational treatment adverse determinations. 20:06:53:33. External review of experimental or investigational treatment adverse determinations. Within four months after the date of receipt of a notice of an adverse determinati…

Rule 20:06:53:34 Notifications upon request for external review of experimental or investigational treatment adverse determinations. 20:06:53:34. Notifications upon request for external review of experimental or investigational treatment adverse determinations. Upon receipt of a …

Rule 20:06:53:35 Director's determination of eligibility and assignment for external review of experimental or investigational treatment. 20:06:53:35. Director's determination of eligibility and assignment for external review of experimental or investigational treatment. The dire…

Rule 20:06:53:36 Health carrier preliminary review of request for experimental or investigational treatment reviews. 20:06:53:36. Health carrier preliminary review of request for experimental or investigational treatment reviews. Except for a request for an expedited external rev…

Rule 20:06:53:37 Health carrier notification after preliminary review of request for experimental or investigational treatment reviews. 20:06:53:37. Health carrier notification after preliminary review of request for experimental or investigational treatment reviews. Within one b…

Rule 20:06:53:38 Director's determination of request for experimental or investigational treatment reviews. 20:06:53:38. Director's determination of request for experimental or investigational treatment reviews. The director may determine that a request is eligible for external r…

Rule 20:06:53:39 Health carrier notification of eligibility for experimental or investigational treatment reviews. 20:06:53:39. Health carrier notification of eligibility for experimental or investigational treatment reviews. Whenever a request for external review is determined e…

Rule 20:06:53:40 Independent review organization experimental or investigational treatment reviews. 20:06:53:40. Independent review organization experimental or investigational treatment reviews. Within one business day after the receipt of the notice of assignment to conduct the…

Rule 20:06:53:41 Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews. 20:06:53:41. Independent review organization clinical reviewer written opinion for experimental or investigational treatment review. In accord…

Rule 20:06:53:42 Records provided to independent review organization for experimental or investigational treatment reviews. 20:06:53:42. Records provided to independent review organization for experimental or investigational treatment reviews. Within five business days after the …

Rule 20:06:53:43 Review of information by independent review organization for experimental or investigational treatment reviews. 20:06:53:43. Review of information by independent review organization for experimental or investigational treatment reviews. Each clinical reviewer sel…

Rule 20:06:53:44 Reconsideration by health carrier for experimental or investigational treatment reviews. 20:06:53:44. Reconsideration by health carrier for experimental or investigational treatment reviews. Upon receipt of the information required to be forwarded pursuant to § 2…

Rule 20:06:53:45 Clinical review opinion for experimental or investigational treatment reviews. 20:06:53:45. Clinical review opinion for experimental or investigational treatment reviews. Except as provided in § 20:06:53:44, within 20 days after being selected in accordance with …

Rule 20:06:53:46 Expedited review opinions for experimental or investigational treatment reviews. 20:06:53:46. Expedited review opinions for experimental or investigational treatment reviews. For an expedited external review, each clinical reviewer shall provide an opinion orally…

Rule 20:06:53:47 Clinical review criteria for experimental or investigational treatment reviews. 20:06:53:47. Clinical review criteria for experimental or investigational treatment reviews. In addition to the documents and information provided pursuant to §§ 20:06:53:33 to 20:06:…

Rule 20:06:53:48 Independent review organization decision and notice for experimental or investigational treatment reviews. 20:06:53:48. Independent review organization decision and notice for experimental or investigational treatment reviews. Except as provided in § 20:06:53:49,…

Rule 20:06:53:49 Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews. 20:06:53:49. Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews. For an expedited externa…

Rule 20:06:53:50 Decision by independent review organization for experimental or investigational reviews. 20:06:53:50. Decision by independent review organization for experimental or investigational treatment reviews. If a majority of the clinical reviewers recommend that the rec…

Rule 20:06:53:51 Notice of written decision by independent review organization for experimental or investigational treatment reviews. 20:06:53:51. Notice of written decision by independent review organization for experimental or investigational treatment reviews. The independent …

Rule 20:06:53:52 Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational reviews. 20:06:53:52. Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational tre…

Rule 20:06:53:53 Criteria for assignment of independent review organization for experimental or investigational treatment reviews. 20:06:53:53. Criteria for assignment of independent review organization for experimental or investigational treatment reviews. The assignment by the …

Rule 20:06:53:54 Binding nature of external review decision. 20:06:53:54. Binding nature of external review decision. 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 e…

Rule 20:06:53:55 Approval of independent review organizations. 20:06:53:55. Approval of independent review organizations. The director shall approve independent review organizations eligible to be assigned to conduct external reviews pursuant to this chapter. In order to be eligi…

Rule 20:06:53:56 Continuation of approval for independent review organizations. 20:06:53:56. Continuation of approval for independent review organizations. An approval is effective for two years, unless the director determines before its expiration that the independent review org…

Rule 20:06:53:57 Minimum qualifications for independent review organizations. 20:06:53:57. Minimum qualifications for independent review organizations. To be approved under §§ 20:06:53:55 and 20:06:53:56 to conduct external reviews, an independent review organization shall have a…

Rule 20:06:53:58 Requirements for clinical reviewers. 20:06:53:58. Requirements for clinical reviewers. 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 fo…

Rule 20:06:53:59 Subsidiaries of or ownership in independent review organizations. 20:06:53:59. Subsidiaries of or ownership in independent review organizations. In addition to the requirements set forth in § 20:06:53:57, an independent review organization may not own or control,…

Rule 20:06:53:60 Independence of clinical reviewers. 20:06:53:60. Independence of clinical reviewers. 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…

Rule 20:06:53:61 Nationally accredited independent review organizations. 20:06:53:61. Nationally accredited independent review organizations. An independent review organization that is accredited by a nationally recognized private accrediting entity that has independent review ac…

Rule 20:06:53:62 Unbiased independent review organizations. 20:06:53:62. Unbiased independent review organization. An independent review organization must be unbiased. An independent review organization shall establish and maintain written procedures to ensure that it is unbiased…

Rule 20:06:53:63 Hold harmless for independent review organizations. 20:06:53:63. Hold harmless for independent review organizations. No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent, or contract…

Rule 20:06:53:64 External review reporting requirements. 20:06:53:64. External review reporting requirements. 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 aggr…

Rule 20:06:53:65 Independent review organization and health carrier recordkeeping. 20:06:53:65. Independent review organization and health carrier recordkeeping. The independent review organization shall retain the written records required pursuant to § 20:06:53:64 for at least t…

20:06:53:66. Funding of external review. 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. Source: 37 SDR 48, effective September 22, 2010; 37 SD…

Rule 20:06:53:67 Disclosure requirements. 20:06:53:67. Disclosure requirements. 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 p…

Rule 20:06:53:68 Adverse benefit determination -- Defined. 20:06:53:68. Adverse benefit determination -- Defined. 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). Source: 37 SDR 63, effective September 23, …

Rule 20:06:53:69 Urgent care requests -- Timely notification of determination -- Initial benefit determination. 20:06:53:69. Urgent care requests -- Timely notification of determination -- Initial benefit determination. For an urgent care request in the context of an initial bene…

Rule 20:06:53:70 Additional evidence. 20:06:53:70. Additional evidence. 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 conne…

Rule 20:06:53:71 Avoiding conflicts of interest. 20:06:53:71. Avoiding conflicts of interest. The plan or issuer must ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision…

Rule 20:06:53:72 Notice to enrollee. 20:06:53:72. Notice to enrollee. A plan or issuer shall provide notice to enrollees, in a culturally and linguistically appropriate manner, if ten percent or more of the population residing in the claimants county are literate only in the same…