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