Administrative Rule 20:06:47 | South Dakota Legislature

20:06:47:02. Establishment of claims procedures. Any plan providing disability benefits shall establish and maintain reasonable claim procedures. The procedures shall include the following:

(1) A description of all claim procedures including, but not limited to, any procedures for obtaining prior authorization as a prerequisite for obtaining a benefit and adverse determination review procedures;

(2) Applicable time frames;

(3) Administrative processes and safeguards to ensure consistent benefit determinations for similar situations;

(4) In regard to voluntary appeal:

(a) The plan waives any right to assert that a covered person has failed to exhaust administrative remedies because the claimant did not elect to submit a benefit dispute to any such voluntary level of appeal provided by the plan;

(b) The plan agrees that any statute of limitations or other defense based on timeliness is tolled during the time that any such voluntary appeal is pending;

(c) The plan provides that a covered person may elect to submit a benefit dispute to such voluntary level of appeal only after the exhaustion of the appeals; and

(d) The plan provides to any covered person, upon request, sufficient information relating to the voluntary level of appeal to enable the covered person to make an informed judgment about whether to submit a benefit dispute to the voluntary level of appeal, including a statement that the decision of a covered person as to whether or not to submit a benefit dispute to the voluntary level of appeal will have no effect on the covered person's right to representation, the process for selecting the decision maker, and the circumstances, if any, that may affect the impartiality of the decision maker, such as any financial or personal interests in the result or any past or present relationship with any party to the review process.

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.

Rule 20:06:47:03 Unacceptable claims procedures.

20:06:47:03. Unacceptable claims procedures. The claims procedures may not contain any provisions or be administered in a method that unduly inhibits or hampers the initiation or processing of claims for benefits such as:

(1) Denying a claim for lack of prior authorization in circumstances where obtaining authorization could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function;

(2) Precluding an authorized representative from acting on behalf of a covered person;

(3) Requiring the filing of more than two appeals of an adverse benefit determination prior to taking civil action;

(4) Requiring arbitration; and

(5) Imposing fees or costs for voluntary appeals.

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.

Rule 20:06:47:04 Initial benefit determination.

20:06:47:04. Initial benefit determination. 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:

(1) The standards used to determine benefit entitlement;

(2) The issues preventing benefit determination;

(3) Any additional information or materials needed to complete the determination;

(4) 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; and

(5) The date by which the plan expects to render determination.

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.

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.

Rule 20:06:47:05 Adverse benefit notification.

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.

Rule 20:06:47:06 Appeal of adverse benefit determination.

20:06:47:06. Appeal of adverse benefit determination. 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:

(1) The special circumstances requiring an extension of time; and

(2) The date by which the plan expects to render a determination.

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.

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.

Rule 20:06:47:07 Full and fair review.

20:06:47:07. Full and fair review. The plan shall provide full and fair review of an adverse benefit determination. Evidence of a full and fair review consists of the following:

(1) A reasonable opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;

(2) Reasonable access to copies of any documents, records, and other information relevant to the claim for benefits upon request and free of charge;

(3) Consideration of all comments, documents, records, and other information submitted by the covered person relating to the claim for benefits without regard to whether such information was considered or available in the initial determination;

(4) A minimum of 180 days following notification of an adverse determination in which to appeal;

(5) No deference to the initial determination and a review that is conducted by neither the individual who made the adverse determination or a subordinate of that individual;

(6) Consultation by the individual reviewing the appeal with a health care professional of appropriate training and experience in the field of medicine involved when the determination is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate. However, the professional may not be the individual consulted in the initial determination or a subordinate of that individual; and

(7) The identification of medical or vocational experts whose advice was obtained in regard to the determination, regardless if the advice was relied upon in making the determination.

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.

Rule 20:06:47:08 Relevant claim information.

20:06:47:08. Relevant claim information. A document, record, or other information shall be considered relevant to a claim if such document, record, or other information:

(1) Was relied upon in making the benefit determination;

(2) Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;

(3) Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination; and

(4) Constitutes statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the covered person's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

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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