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          20:06:53:58.  Requirements for clinical reviewers. All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who meet the following minimum qualifications:

 

          (1)  Be an expert in the treatment of the covered person's medical condition that is the subject of the external review;

 

          (2)  Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person;

 

          (3)  Hold a non-restricted license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and

 

          (4)  Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer's physical, mental, or professional competence or moral character.

 

          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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