20:06:53:28. Information to be considered by independent review organization for expedited review. In addition to the documents and information provided or transmitted pursuant to § 20:06:53:26, the assigned independent review organization, to the extent the information or documents are available and the independent review organization considers them appropriate, shall consider the following in reaching a decision:
(1) The covered person's pertinent medical records;
(2) The attending health care professional's recommendation;
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health carrier, covered person, the covered person's authorized representative, or the covered person's treating provider;
(4) The terms of coverage under the covered person's health benefit plan with the health carrier to ensure that the independent review organization's decision is not contrary to the terms of coverage under the covered person's health benefit plan with the health carrier;
(5) The most appropriate practice guidelines, which shall include evidence-based standards, and may include any other practice guidelines developed by the federal government, or national or professional medical societies, boards, and associations;
(6) Any applicable clinical review criteria developed and used by the health carrier or its designee utilization review organization in making adverse determinations; and
(7) The opinion of the independent review organization's clinical reviewer or reviewers after considering subdivisions (1) to (6), inclusive, to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.
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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