Title 58 — INSURANCE
79 chapters · 3,532 sections in this title.
SDCL § 58-17I-1 Definitions
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Terms used in this chapter mean: (1) "Adverse determination," any of the following: (a) A determination by a health carrier or the carrier's designee utilization review organization that, based upon the information provided, a request by a covered person for a benefit under the h…
SDCL § 58-17I-10 Procedures for providing new or additional evidence
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Prior to issuing a decision in accordance with the timeframes provided in § 58-17I-9 , the health carrier shall provide free of charge to covered person, or the covered person's authorized representative, any new or additional evidence, relied upon or generated by the health carr…
SDCL § 58-17I-11 Issuance of decision--Required contents
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The decision issued pursuant to § 58-17I-9 shall set forth in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative and include the following: (1) The titles and qualifying credentials of any person participat…
SDCL § 58-17I-12 Expedited review for adverse determinations involving urgent care requests--Appointment of peers for review
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Each health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. In addition, a health carrier shall provide expedited review of a grievance involving an adverse determination with respect to…
SDCL § 58-17I-13 Transmission of necessary information for certain expedited reviews
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In an expedited review that is not an initial determination for benefits, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or, if applicable, the covered person's authorized representative, …
SDCL § 58-17I-14 Expedited review decision not initial determination for benefits--Notification--Time periods--Continuation of service involving concurrent review urgent care requests
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An expedited review decision, that is not an initial determination for benefits, shall be made and the covered person or, if applicable, the covered person's authorized representative, shall be notified of the decision in accordance with § 58-17I-15 as expeditiously as the covere…
SDCL § 58-17I-15 Expedited review decision--Notification--Required contents
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A notification of a decision under §§ 58-17I-12 to 58-17I-15 , inclusive, shall, in a manner calculated to be understood by the covered person or, if applicable, the covered person's authorized representative, set forth the following: (1) The titles and qualifying credentials of …
SDCL § 58-17I-16 Promulgation of rules
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The director, in consultation with the secretary, shall promulgate rules, pursuant to chapter 1-26 , to establish time frames relative to the filing of grievances, the disposition of grievances, and the response to the aggrieved person. Rules may also be promulgated covering defi…
SDCL § 58-17I-2 Health benefit plan defined
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For the purposes of this chapter, the term, health benefit plan, means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term inc…
SDCL § 58-17I-3 Urgent care request defined
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For the purposes of this chapter, the term, urgent care request, means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination: (1) Could seriously jeopardize the life or health of the cov…
SDCL § 58-17I-4 Register of grievances required--Information to be compiled--Maintenance
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Each health carrier shall maintain in a register written records to document all grievances received including the notices and claims associated with the grievances during a calendar year. A request for a first level review of a grievance involving an adverse determination shall …
SDCL § 58-17I-5 Repealed
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Source: SL 2011, ch 219 , § 77; SL 2023, ch 165 , § 1.
SDCL § 58-17I-6 Grievance procedures--Filing--Certificate of compliance--Contact information
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Except as specified in this chapter, each health carrier shall use written procedures for receiving and resolving grievances from covered persons, as provided in §§ 58-17I-7 to 58-17I-11 , inclusive. If a health carrier fails to strictly adhere to the requirements of §§ 58-17I-7 …
SDCL § 58-17I-7 Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review
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Within one hundred eighty days after the date of receipt of a notice of an adverse determination sent pursuant to chapter 58-17H , any covered person or the covered person's authorized representative may file a grievance with the health carrier requesting a first level review of …
SDCL § 58-17I-8 Rights of covered person or authorized representative on review--Access to documentation
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No covered person has the right to attend, or to have a representative in attendance, at the first level review. However, the covered person or, if applicable, the covered person's authorized representative may: (1) Submit written comments, documents, records, and other material …
SDCL § 58-17I-9 Time for decision and notice--Calculation of time periods
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A health carrier shall notify and issue a decision in writing or electronically to the covered person or, if applicable, the covered person's authorized representative, within the following time frames: (1) With respect to a grievance requesting a first level review of an adverse…