<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 20:06:47:04 Initial benefit determination.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:47:04"> <META NAME="Description" Content="Administrative Rules 20:06:47:04 Initial benefit determination."> <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="2006470000400d_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>1</o:Pages> <o:Words>301</o:Words> <o:Characters>1719</o:Characters> <o:Company>State of South Dakota</o:Company> <o:Lines>14</o:Lines> <o:Paragraphs>4</o:Paragraphs> <o:CharactersWithSpaces>2016</o:CharactersWithSpaces> <o:Version>10.6870</o:Version> </o:DocumentProperties> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <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:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; font-family:Calibri; mso-fareast-font-family:Calibri; mso-bidi-font-family:"Times New Roman";} p.MsoFooter, li.MsoFooter, div.MsoFooter {mso-style-link:" Char"; 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 center 3.0in left 3.1in 3.4in 3.6in 3.9in 4.1in right 6.0in; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} span.Char {mso-style-name:" Char"; mso-style-link:Footer; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; font-family:"Times New Roman"; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-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=MsoFooter 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'>20:06:47:04.&nbsp;&nbsp;Initial benefit determination.</b> Any plan providing disability benefits shall notify a covered person, or if applicable, the covered person's authorized representative, of a benefit determination within a reasonable time period, but not later than 45 days after receipt of the claim. This time period for making a determination and notifying the covered person or their authorized representative may be extended for up to 30 days when necessary due to matters beyond the control of the plan. If the plan is unable to render a determination within 45 days, the plan must notify the covered person in writing, prior to the end of the initial 45-day period of that fact, and include the following:</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(1)&nbsp;&nbsp;The standards used to determine benefit entitlement;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(2)&nbsp;&nbsp;The issues preventing benefit determination;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(3)&nbsp;&nbsp;Any additional information or materials needed to complete the determination;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(4)&nbsp;&nbsp;The time period, which may not be less than 45 days, that the covered person or the person's authorized representative has to submit additional information;<span style='mso-spacerun:yes'>&nbsp; </span>and</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(5)&nbsp;&nbsp;The date by which the plan expects to render determination.</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>If the plan is unable to render a determination, due to matters beyond its control, the time period may be extended for a second 30-day period, providing the plan notifies the covered person in writing, prior to the end of the initial 30-day extension and includes the notification requirements listed above. The toll of the time periods begins at the time the claim is filed in accordance with plan procedures without regard to whether all the information necessary accompanies the filing. In regard to time period extensions, the time is tolled from the date on which notice of the extension is sent to the covered person until the date on which the covered person responds to the request for additional information.</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter 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> 30 SDR 39, effective September 28, 2003; 37 SDR 241, effective July 1, 2011.</p> <p class=MsoFooter 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=58-17H-49">58-17H-49.</A></p> <p class=MsoFooter 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=58-17H-49">58-17H-49.</A></p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> </div> </body> </html>