20:06:53:40. Independent review organization experimental or investigational treatment reviews. Within one business day after the receipt of the notice of assignment to conduct the external review pursuant to § 20:06:53:39, the assigned independent review organization shall:
(1) Select one or more clinical reviewers, as it determines is appropriate, pursuant to this section to conduct the external review; and
(2) Based on the opinion of the clinical reviewer, or opinions if more than one clinical reviewer has been selected to conduct the external review, make a decision to uphold or reverse the adverse determination or final adverse determination.
In selecting clinical reviewers pursuant to this section, the assigned independent review organization shall select physicians or other health care professionals who meet the minimum qualifications described in §§ 20:06:53:57 to 20:06:53:62, inclusive, and, through clinical experience in the past three years, are experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment. Neither the covered person, the covered person's authorized representative, if applicable, nor the health carrier may choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review.
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.
Back to 20:06:53