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

Universal Citation: SD Admin Rules 20:06:53:36

Current through Register Vol. 50, page 114, March 25, 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;

(3) The covered person's treating physician has certified that one of the following situations is applicable:

(a) Standard health care services or treatments have not been effective in improving the condition of the covered person;

(b) Standard health care services or treatments are not medically appropriate for the covered person; or

(c) There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the recommended or requested health care service or treatment described in subdivision (4) of this section;

(4) The covered person's treating physician:

(a) Has recommended a health care service or treatment that the physician certifies, in writing, is likely to be more beneficial to the covered person, in the physician's opinion, than any available standard health care services or treatments; or

(b) Who is a licensed, board certified or board eligible physician qualified to practice in the area of medicine appropriate to treat the covered person's condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested by the covered person that is the subject of the adverse determination or final adverse determination is likely to be more beneficial to the covered person than any available standard health care services or treatments;

(5) The covered person has exhausted the health carrier's internal grievance process as set forth in SDCL 58-17I-1 to 58-17I-16, inclusive, unless the covered person is not required to exhaust the health carrier's internal grievance process pursuant to §§ 20:06:53:07 to 20:06:53:21, inclusive; and

(6) The covered person has provided all the information and forms required by the director that are necessary to process an external review, including the release form provided under §§ 20:06:53:04 and 20:06:53:05.

General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.

Law Implemented: SDCL 58-17-87, 58-18-79.

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.
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