<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 20:06:47:06 Appeal of adverse benefit determination.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:47:06"> <META NAME="Description" Content="Administrative Rules 20:06:47:06 Appeal of adverse 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="2006470000600d_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>0</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>224</o:Words> <o:Characters>1283</o:Characters> <o:Company>State of South Dakota</o:Company> <o:Lines>10</o:Lines> <o:Paragraphs>3</o:Paragraphs> <o:CharactersWithSpaces>1504</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'>20:06:47:06.&nbsp;&nbsp;Appeal of adverse benefit determination.</b> Any plan providing disability benefits, upon receipt of an appeal of an adverse benefit determination, shall notify a covered person or, if applicable, the covered person's authorized representative, of the benefit determination within a reasonable time period, but not later than 45 days after receipt of the request, without regard to whether all the information necessary to make a benefit determination accompanies the filing. This time period for making a determination and notifying the covered person of the covered person's authorized representative may be extended for up to 45 days when necessary due to matters beyond the control of the plan. If the plan is unable to render a determination within the 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 special circumstances requiring an extension of time; and</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 date by which the plan expects to render a 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>The time period for extensions due to the covered person's failure to submit information necessary to decide a claim shall be tolled from the date on which the notification of the extension is sent 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>