DEPARTMENT OF REVENUE AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

MODEL NOTICE OF APPEAL RIGHTS

 

 

Chapter 20:06:53

 

APPENDIX A

 

SEE: § 20:06:53:03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 37 SDR 48, effective September 22, 2010; 42 SDR 52, effective October 13, 2015.

Appendix A -- Model Notice of Appeal Rights

 

NOTICE OF APPEAL RIGHTS

 

You have a right to appeal any decision we make that denies payment on your claim or your request for coverage of a health care service or treatment.

 

You may request more explanation when your claim or request for coverage of a health care service or treatment is denied or the health care service or treatment you received was not fully covered. Contact¹ us when you:

 

●       Do not understand the reason for the denial;

●       Do not understand why the health care service or treatment was not fully covered;

●       Do not understand why a request for coverage of a health care service or treatment was denied;

●       Cannot find the applicable provision in your Benefit Plan Document;

●       Want a copy (free of charge) of the guidelines, criteria, or clinical rationale that we used to make our decision; or

●       Disagree with the denial or the amount not covered and you want to appeal.

 

If your claim was denied due to missing or incomplete information, you or your health care provider may resubmit the claim to us with the necessary information to complete the claim.^[1]

 

Appeals:  All appeals for claim denials (or any decision that does not cover expenses you believe should have been covered) must be sent to [insert address of where appeals should be sent to the health carrier] within 180 days of the date you receive our denial.^[2] We will provide a full and fair review of your claim by individuals associated with us, but who were not involved in making the initial denial of your claim. You may provide us with additional information that relates to your claim and you may request copies of information that we have that pertains to your claims. We will notify you of our decision in writing within 60 days of receiving your appeal.^[3] If you do not receive our decision within 60 days of receiving your appeal³, you may be entitled to file a request for external review.^[4]

 

External Review⁴:  If we have denied your request for the provision of or payment for a health care service or course of treatment, you may have a right to have our decision reviewed by independent health care professionals who have no association with us. If our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested, you may submit a request for external review within four months after receipt of this notice to the Division of Insurance, 124 South Euclid Avenue, 2^nd Floor, Pierre, South Dakota 57501. For standard external review, a decision will be made within 45 days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review of our denial. If our denial to provide or pay for health care service or course of treatment is based on a determination that the service or treatment is experimental or investigation, you also may be entitled to file a request for external review of our denial. For details, please review your Benefit Plan Document, contact us, or contact your state insurance department.¹