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
- Section 20:06:53:02 - Applicability
- Section 20:06:53:03 - Notice of right to external review
- Section 20:06:53:04 - Content of notices
- Section 20:06:53:05 - Review procedures and authorization to accompany notice
- Section 20:06:53:06 - Request for external review
- Section 20:06:53:07 - Exhaustion of internal grievance process required
- Section 20:06:53:08 - When exhaustion of internal grievance occurs
- Section 20:06:53:09 - Request for expedited review
- Section 20:06:53:10 - Determination of expedited review
- Section 20:06:53:11 - Waiver of exhaustion requirement
- Section 20:06:53:12 - Standard external review
- Section 20:06:53:13 - Notification following preliminary review
- Section 20:06:53:14 - Determination by the director and assignment of independent review organization
- Section 20:06:53:15 - Independence of review decision
- Section 20:06:53:16 - Health carrier required to provide information
- Section 20:06:53:17 - Effect of failure to act on external review process
- Section 20:06:53:18 - Independent review organization review of information
- Section 20:06:53:19 - Carrier reconsideration
- Section 20:06:53:20 - Information to be considered by independent review organization
- Section 20:06:53:21 - Independent review organization decisions
- Section 20:06:53:22 - Director assignment of independent review organization
- Section 20:06:53:23 - Expedited external review
- Section 20:06:53:24 - Notifications upon request for expedited external review
- Section 20:06:53:25 - Director's determination of eligibility for expedited reviews
- Section 20:06:53:26 - Director assignment of independent review organization for expedited reviews
- Section 20:06:53:27 - Independent review organization decision for expedited reviews
- Section 20:06:53:28 - Information to be considered by independent review organization for expedited review
- Section 20:06:53:29 - Expedited review decision
- Section 20:06:53:30 - Health carrier required to approve upon reversal by expedited review
- Section 20:06:53:31 - Assignment of independent review organization for expedited reviews
- Section 20:06:53:32 - Applicability of expedited reviews
- Section 20:06:53:33 - External review of experimental or investigational treatment adverse determinations
- Section 20:06:53:34 - Notifications upon request for external review of experimental or investigational treatment adverse determinations
- Section 20:06:53:35 - Director's determination of eligibility and assignment for external review of experimental or investigational treatment
- Section 20:06:53:36 - Health carrier preliminary review of request for experimental or investigational treatment reviews
- Section 20:06:53:37 - Health carrier notification after preliminary review of request for experimental or investigational treatment reviews
- Section 20:06:53:38 - Director's determination of request for experimental or investigational treatment reviews
- Section 20:06:53:39 - Health carrier notification of eligibility for experimental or investigational treatment reviews
- Section 20:06:53:40 - Independent review organization experimental or investigational treatment reviews
- Section 20:06:53:41 - Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews
- Section 20:06:43:42 - Records provided to independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:43 - Review of information by independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:44 - Reconsideration by health carrier for experimental or investigational treatment reviews
- Section 20:06:53:45 - Clinical review opinion for experimental or investigational treatment reviews
- Section 20:06:53:46 - Expedited review opinions for experimental or investigational treatment reviews
- Section 20:06:53:47 - Clinical review criteria for experimental or investigational treatment reviews
- Section 20:06:53:48 - Independent review organization decision and notice for experimental or investigational treatment reviews
- Section 20:06:53:49 - Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews
- Section 20:06:53:50 - Decision by independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:51 - Notice of written decision by independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:52 - Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational treatment reviews
- Section 20:06:53:53 - Criteria for assignment of independent review organization for experimental or investigational treatment reviews
- Section 20:06:53:54 - Binding nature of external review decision
- Section 20:06:53:55 - Approval of independent review organizations
- Section 20:06:53:56 - Continuation of approval for independent review organizations
- Section 20:06:53:57 - Minimum qualifications for independent review organizations
- Section 20:06:53:58 - Requirements for clinical reviewers
- Section 20:06:53:59 - Subsidiaries of or ownership in independent review organizations
- Section 20:06:53:60 - Independence of clinical reviewers
- Section 20:06:53:61 - Nationally accredited independent review organizations
- Section 20:06:53:62 - Unbiased independent review organization
- Section 20:06:53:63 - Hold harmless for independent review organizations
- Section 20:06:53:64 - External review reporting requirements
- Section 20:06:53:65 - Independent review organization and health carrier recordkeeping
- Section 20:06:53:66 - Funding of external review
- Section 20:06:53:67 - Disclosure requirements
- Section 20:06:53:68 - Adverse benefit determination - Defined
- Section 20:06:53:69 - Urgent care requests - Timely notification of determination - Initial benefit determination
- Section 20:06:53:70 - Additional evidence
- Section 20:06:53:71 - Avoiding conflicts of interest
- Section 20:06:53:72 - Notice to enrollee
- Section 20:06:53:73 - Failure to comply with internal claims and appeal process
- Section 20:06:53:74 - Continued coverage and ongoing treatment
- Section 20:06:53:75 - One level of internal appeals
- Section 20:06:53:76 - Record keeping
- Section 20:06:53:77 - Applicability
- Section 20:06:53:78 - Strictly adhere - Defined
- Section 20:06:53:79 - Written explanation of violation
- Section 20:06:53:80 - Procedure when immediate review request denied
- Appendix A - Model notice of appeal rights
- Appendix B - Model external review request form
- Appendix C - Independent review organization external review annual report form
- Appendix D - Model health carrier external review annual report form
Disclaimer: These regulations may not be the most recent version. South Dakota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.