<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns="http://www.w3.org/TR/REC-html40"> <head> <title>Rule 20:06:53:01 Definitions.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:53:01"> <META NAME="Description" Content="Administrative Rules 20:06:53:01 Definitions."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=ProgId content=Word.Document> <meta name=Generator content="Microsoft Word 10"> <meta name=Originator content="Microsoft Word 10"> <link rel=File-List href="2006530000100d_files/filelist.xml"> <!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>lrpr14533</o:Author> <o:LastAuthor>lrpr14296</o:LastAuthor> <o:Revision>2</o:Revision> <o:TotalTime>1</o:TotalTime> <o:Created>2011-07-13T13:58:00Z</o:Created> <o:LastSaved>2011-07-13T13:58:00Z</o:LastSaved> <o:Pages>2</o:Pages> <o:Words>1563</o:Words> <o:Characters>8912</o:Characters> <o:Company>State of South Dakota</o:Company> <o:Lines>74</o:Lines> <o:Paragraphs>20</o:Paragraphs> <o:CharactersWithSpaces>10455</o:CharactersWithSpaces> <o:Version>10.6870</o:Version> </o:DocumentProperties> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:SpellingState>Clean</w:SpellingState> <w:PunctuationKerning/> <w:DrawingGridHorizontalSpacing>5.5 pt</w:DrawingGridHorizontalSpacing> <w:DisplayHorizontalDrawingGridEvery>2</w:DisplayHorizontalDrawingGridEvery> <w:DisplayVerticalDrawingGridEvery>2</w:DisplayVerticalDrawingGridEvery> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:-1610611985 1073750139 0 0 159 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin-top:0in; margin-right:0in; margin-bottom:0in; margin-left:-.7pt; margin-bottom:.0001pt; text-align:justify; mso-pagination:widow-orphan; tab-stops:.4in 40.5pt .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style> <!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:Calibri;} </style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="2050"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--> </head> <body lang=EN-US style='tab-interval:.5in'> <div class=Section1> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>20:06:53:01.&nbsp;&nbsp;Definitions.</b> Terms used in this chapter mean:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(1)&nbsp;&nbsp;&quot;Adverse determination,&quot; a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. A rescission of coverage is an adverse determination;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(2)&nbsp;&nbsp;&quot;Ambulatory review,&quot; utilization review of health care services performed or provided in an outpatient setting;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(3)&nbsp;&nbsp;&quot;Authorized representative,&quot; any person to whom a covered person has given express written consent to represent the covered person in an external review; any person authorized by law to provided substituted consent for a covered person; or any family member of the covered person or the covered person's treating health care professional, but only if the covered person is unable to provide consent;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(4)&nbsp;&nbsp;&quot;Best evidence,&quot; evidence based on:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(a)&nbsp;&nbsp;Randomized clinical trials;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(b)&nbsp;&nbsp;If randomized clinical trials are not available, cohort studies or case-control studies;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(c)&nbsp;&nbsp;If subsections (a) and (b) are not available, case-series; or</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(d)&nbsp;&nbsp;If subsections (a), (b), and (c) are not available, expert opinion;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(5)&nbsp;&nbsp;&quot;Case-control study,&quot; a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(6)&nbsp;&nbsp;&quot;Case management,&quot; a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(7)&nbsp;&nbsp;&quot;Case-series,&quot; an evaluation of a series of patients with a particular outcome, without the use of a control group;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(8)&nbsp;&nbsp;&quot;Certification,&quot; a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(9)&nbsp;&nbsp;&quot;Clinical review criteria,&quot; the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(10)&nbsp;&nbsp;&quot;Cohort study,&quot; a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(11)&nbsp;&nbsp;&quot;Concurrent review,&quot; utilization review conducted during a patient's hospital stay or course of treatment;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(12)&nbsp;&nbsp;&quot;Covered benefits&quot; or &quot;benefits,&quot; those health care services to which a covered person is entitled under the terms of a health benefit plan;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(13)&nbsp;&nbsp;&quot;Covered person,&quot; a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(14)&nbsp;&nbsp;&quot;Discharge planning,&quot; the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(15)&nbsp;&nbsp;&quot;Disclose,&quot; to release, transfer, or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(16)&nbsp;&nbsp;&quot;Emergency medical condition,&quot; the sudden and, at the time, unexpected onset of a health condition or illness that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(17)&nbsp;&nbsp;&quot;Emergency services,&quot; health care items and services furnished or required to evaluate and treat an emergency medical condition;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(18)&nbsp;&nbsp;&quot;Evidence-based standard,&quot; the conscientious, explicit, and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(19)&nbsp;&nbsp;&quot;Expert opinion,&quot; a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(20)&nbsp;&nbsp;&quot;Facility,&quot; an institution providing health care services or a health care setting, including, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation and other therapeutic health settings;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(21)&nbsp;&nbsp;&quot;Final adverse determination,&quot; an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier's internal grievance process procedures as set forth in SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17I-1">58-17I-1</A> to <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17I-16">58-17I-16</A>, inclusive;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(22)&nbsp;&nbsp;&quot;Health benefit plan,&quot; a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(23)&nbsp;&nbsp;'Health care professional,&quot; a physician or other health care practitioner licensed, accredited, or certified to perform specified health care services consistent with state law;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(24)&nbsp;&nbsp;&quot;Health care provider&quot; or &quot;provider,&quot; a health care professional or a facility;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(25)&nbsp;&nbsp;&quot;Health care services,&quot; services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury, or disease;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(26)&nbsp;&nbsp;&quot;Health information,&quot; information or data, whether oral or recorded in any form or medium, and personal facts or information about events or relationships that relates to:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(a)&nbsp;&nbsp;The past, present, or future physical, mental, or behavioral health or condition of an individual or a member of the individual's family;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(b)&nbsp;&nbsp;The provision of health care services to an individual; or</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(c)&nbsp;&nbsp;Payment for the provision of health care services to an individual;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(27)&nbsp;&nbsp;&quot;Independent review organization,&quot; an entity that conducts independent external reviews of adverse determinations and final adverse determinations;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(28)&nbsp;&nbsp;&quot;Medical or scientific evidence,&quot; evidence found in the following sources:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(a)&nbsp;&nbsp;Peer-reviewed scientific studies published in, or accepted for publication by, medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(b)&nbsp;&nbsp;Peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the National Institutes of Health's Library of Medicine for indexing in Index Medicus (Medline) and Elsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE);</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(c)&nbsp;&nbsp;Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the federal Social Security Act;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(d)&nbsp;&nbsp;The following standard reference compendia:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(i)&nbsp;&nbsp;&nbsp;&nbsp;The American Hospital Formulary Service-Drug Information;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(ii)&nbsp;&nbsp;&nbsp;Drug Facts and Comparisons;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(iii)&nbsp;&nbsp;The American Dental Association Accepted Dental Therapeutics; and</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(iv)&nbsp;&nbsp;The United States Pharmacopoeia-Drug Information;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(e)&nbsp;&nbsp;Findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(i)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;The federal Agency for Healthcare Research and Quality;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(ii)&nbsp;&nbsp;&nbsp;&nbsp;The National Institutes of Health;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(iii)&nbsp;&nbsp;&nbsp;The National Cancer Institute;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(iv)&nbsp;&nbsp;&nbsp;The National Academy of Sciences;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(v)&nbsp;&nbsp;&nbsp;&nbsp;The Centers for Medicare &amp; Medicaid Services;</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(vi)&nbsp;&nbsp;&nbsp;The federal Food and Drug Administration; and</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(vii)&nbsp;&nbsp;Any national board recognized by the National Institutes of Health for the purpose of evaluating the medical value of health care services; or</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(f)&nbsp;&nbsp;Any other medical or scientific evidence that the director determines is comparable to the sources listed in subsections (a) to (e), inclusive;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(29)&nbsp;&nbsp;&quot;NAIC,&quot; the National Association of Insurance Commissioners;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(30)&nbsp;&nbsp;&quot;Prospective review,&quot; utilization review conducted prior to an admission or a course of treatment;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(31)&nbsp;&nbsp;&quot;Protected health information,&quot; health information:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(a)&nbsp;&nbsp;That identifies an individual who is the subject of the information; or</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(b)&nbsp;&nbsp;With respect to which there is a reasonable basis to believe that the information could be used to identify an individual;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(32)&nbsp;&nbsp;&quot;Randomized clinical trial,&quot; a controlled, prospective study of patients that have been randomized into an experimental group and a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention, which includes study of the groups for variables and anticipated outcomes over time;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(33)&nbsp;&nbsp;&quot;Retrospective review,&quot; a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(34)&nbsp;&nbsp;&quot;Second opinion,&quot; an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the clinical necessity and appropriateness of the initial proposed health care service;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(35)&nbsp;&nbsp;&quot;Utilization review,&quot; a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(36)&nbsp;&nbsp;&quot;Utilization review organization,&quot; an entity that conducts utilization review, other than a health carrier performing a review of its own health benefit plan.</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Source:</b> 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 1, 2011.</p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17H-49">58-17H-49</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17I-16">58-17I-16</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> </div> </body> </html>