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          20:06:53:33.  External review of experimental or investigational treatment adverse determinations. Within four months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to ยงยง 20:06:53:03 to 20:06:53:05, inclusive, that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational, a covered person or the covered person's authorized representative may file a request for external review with the director.

 

          A covered person or the covered person's authorized representative may make an oral request for an expedited external review of the adverse determination or final adverse determination pursuant to this section if the covered person's treating physician certifies, in writing, that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated.

 

          Source: 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 1, 2011.

          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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