20:06:53:67. Disclosure requirements. Each health carrier shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage it provides to covered persons. The description shall be in a format prescribed by the director. The description shall include a statement that informs the covered person of the right of the covered person to file a request for an external review of an adverse determination or final adverse determination with the director. The statement may explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness. The statement shall include the telephone number and address of the director. The statement shall inform the covered person that, when filing a request for an external review, the covered person is required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on 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.
Commission Note: The provisions of this chapter are effective for plan years beginning after September 22, 2010.
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