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          20:06:53:03.  Notice of right to external review. A health carrier shall notify the covered person in writing of the covered person's right to request an external review to be conducted pursuant to ยงยง 20:06:53:12 to 20:06:53:53, inclusive, and include the appropriate statements and information set forth in this section at the same time the health carrier sends written notice of:

 

          (1)  An adverse determination upon completion of the health carrier's utilization review process set forth in SDCL 58-17H-1 to 58-17H-49, inclusive; and

          (2)  A final adverse determination.

 

          As part of the written notice required by this section, a health carrier includes the following, or substantially equivalent, language: "We have denied your request for the provision of, or payment for, a health care service or course of treatment. You may have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested by submitting a request for external review to the South Dakota Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, South Dakota 57501." The notice as contained in Appendix A, or a substantially similar form as may be approved by the director, must be used.

 

          Source: 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 1, 2011; 42 SDR 52, effective October 13, 2015.

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

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

 


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