20:06:53:57. Minimum qualifications for independent review organizations. To be approved under §§ 20:06:53:55 and 20:06:53:56 to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in this chapter. The policies and procedures shall include, at a minimum:
(1) A quality assurance mechanism in place that:
(a) Ensures that external reviews are conducted within the specified timeframes and required notices are provided in a timely manner;
(b) Ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization and suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective;
(c) Ensures the confidentiality of medical and treatment records and clinical review criteria; and
(d) Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this chapter;
(2) A toll-free telephone service to receive information on a 24-hour-day, 7-day-a-week basis related to external reviews that is capable of accepting, recording, or providing appropriate instruction to incoming telephone callers during other than normal business hours; and
(3) An agreement to maintain and provide to the director the information set out in §§ 20:06:53:64 and 20:06:53:65.
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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