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          20:06:47:05.  Adverse benefit notification. The plan shall provide a covered person or, if applicable, the person's authorized representative, with written or electronic notification of any adverse benefit determination in a manner calculated to be understood by the covered person. The notification shall include the following:

 

          (1)  The specific reason or reasons for the determination;

 

          (2)  Reference to the specific plan provision on which the determination was based;

 

          (3)  A description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary;

 

          (4)  A description of review procedures and applicable time frames;

 

          (5)  A statement of the person's right to bring a civil action under applicable law;

 

          (6)  The specific rule, guideline, protocol, or other similar criterion used in making the adverse determination, or a statement that such items were relied upon and are available free of charge to the covered person upon request;

 

          (7)  An explanation of the scientific or clinical judgment used in the determination based on medical necessity or experimental treatment or similar exclusion or limitation, or a statement that such explanation will be provided free of charge upon request; and

 

          (8)  The statement "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and the South Dakota Division of Insurance."

 

          Source: 30 SDR 39, effective September 28, 2003; 37 SDR 241, effective July 1, 2011.

          General Authority: SDCL 58-17H-49.

          Law Implemented: SDCL 58-17H-49.

 


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