DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
MODEL EXTERNAL REVIEW REQUEST FORM
Chapter 20:06:53
APPENDIX B
SEE: § 20:06:53:06
Source: 37 SDR 48, effective September 22, 2010; 42 SDR 52, effective October 13, 2015.
Appendix B - Model External Review Request Form
This EXTERNAL REVIEW REQUEST FORM must be filed with the Division of Insurance within FOUR MONTHS after receipt from your insurer of a denial of payment on a claim or request for coverage of a health care service or treatment.
EXTERNAL REVIEW REQUEST FORM
APPLICANT NAME _______________________________ □ Covered person/Patient □ Provider □ Authorized Representative
COVERED PERSON/PATIENT INFORMATION
Covered Person Name: ________________________________
Patient Name: _______________________________________
Address: ________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________
Covered Person Phone #: Home (_____)_________________
Work: (_____)_____________________________________
INSURANCE INFORMATION
Insurer/HMO Name
_______________________________________________________________________________
Covered Person Insurance
ID#:____________________________________________________________________________
Insurance Claim/Reference
#:______________________________________________________________________________
Insurer/HMO Mailing Address:
________________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Insurer Telephone #:
(_____)_________________________________________________________________________
EMPLOYER INFORMATION
Employer's Name:
_______________________________________________________________________________
Employer's Phone #:
(_____)_________________________________________________________________________
Is the health coverage you have through your employer a self-funded plan? ______. If you are not certain please check with your employer. Most self-funded plans are not eligible for external review. However, some self-funded plans may voluntarily provide external review, but may have different procedures. You should check with your employer.
HEALTH CARE PROVIDER INFORMATION
Treating Physician/Health Care Provider:
__________________________________________________________________________________
Address:___________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________
Contact Person: _______________________________
Phone: ( ) _________________________________
Medical Record #: _____________________________
REASON FOR HEALTH CARRIER DENIAL (Please check one)
□ The health care service or treatment is not medically necessary.
□ The health care service or treatment is experimental or investigational.
SUMMARY OF EXTERNAL REVIEW REQUEST (Enter a brief description of the claim, the request for health care service or treatment that was denied, and/or attach a copy of the denial from your health carrier)*
________________________________________________________________________________________________________________________________________________________________________________________________________
*You may also describe in your own words the health care service or treatment in dispute and why you are appealing this denial using the attached pages below.
EXPEDITED REVIEW
If you need a fast decision, you may request that your external appeal be handled on an expedited basis. To complete this request, your treating health care provider must fill out the attached form stating that a delay would seriously jeopardize the life or health of the patient or would jeopardize the patient's ability to regain maximum function.
Is this a request for an expedited appeal? Yes ______ No _______
SIGNATURE AND RELEASE OF MEDICAL RECORDS
To appeal your health carrier's denial, you must sign and date this external review request form and consent to the release of medical records.
I, _______________________, hereby request an external appeal. I attest that the information provided in this application is true and accurate to the best of my knowledge. I authorize my insurance company and my health care providers to release all relevant medical or treatment records to the independent review organization and the South Dakota Division of Insurance. I understand that the independent review organization and the South Dakota Division of Insurance will use this information to make a determination on my external appeal and that the information will be kept confidential and not be released to anyone else. This release is valid for one year.
_______________________________________________ ____________________
Signature of Covered Person (or legal representative)* Date
*(Parent, Guardian, Conservator or Other - Please Specify)
APPOINTMENT OF AUTHORIZED REPRESENTATIVE
(Fill out this section only if someone else will be representing you in this appeal.)
You can represent yourself, or you may ask another person, including your treating health care provider, to act as your authorized representative. You may revoke this authorization at any time.
I hereby authorize ____________________________________ to pursue my appeal on my behalf.
________________________________________________ ______________
Signature of Covered Person (or legal representative)* Date
*(Parent, Guardian, Conservator or Other - Please Specify)
Address of Authorized Representative:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Phone #.
Daytime (_____)___________________
Evening (_____)___________________
_______________________________________________________________________________
HEALTH CARE SERVICE OR TREATMENT DECISION IN DISPUTE
DESCRIBE IN YOUR OWN WORDS THE DISAGREEMENT WITH YOUR HEALTH CARRIER. INDICATE CLEARLY THE SERVICE(S) BEING DENIED AND THE SPECIFIC DATE(S) BEING DENIED. EXPLAIN WHY YOU DISAGREE. ATTACH ADDITIONAL PAGES IF NECESSARY AND INCLUDE AVAILABLE PERTINENT MEDICAL RECORDS, ANY INFORMATION YOU RECEIVED FROM YOUR HEALTH CARRIER CONCERNING THE DENIAL, ANY PERTINENT PEER LITERATURE OR CLINICAL STUDIES, AND ANY ADDITIONAL INFORMATION FROM YOUR PHYSICIAN/HEALTH CARE PROVIDER THAT YOU WANT THE INDEPENDENT REVIEW ORGANIZATION REVIEWER TO CONSIDER.
__________________________________________________________________________________
WHAT TO SEND AND WHERE TO SEND IT
PLEASE CHECK BELOW (NOTE: YOUR REQUEST WILL NOT BE ACCEPTED FOR FULL REVIEW UNLESS ALL FOUR ITEMS BELOW ARE INCLUDED*)
1. □ YES, I have included this completed application form signed and dated;
2. □ YES, I have included a photocopy of my insurance identification card or other evidence showing that I am insured by the health insurance company named in this application;
3. □ YES**, I have enclosed the letter from my health carrier or utilization review company that states:
(a) Their decision is final and that I have exhausted all internal review procedures; or
(b) They have waived the requirement to exhaust all of the health carrier's internal review procedures.
**You may make a request for external review without exhausting all internal review procedures under certain circumstances. You should contact the Division of Insurance, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501.
4. □ YES, I have included a copy of my certificate of coverage or my insurance policy benefit booklet, which lists the benefits under my health benefit plan.
*Call the Division of Insurance at 605.773.3563 if you need help in completing this application or if you do not have one or more of the above items and would like information on alternative ways to complete your request for external review.
If you are requesting a standard external review, send all paperwork to:
South Dakota Division of Insurance
124 South Euclid Avenue, 2nd Floor
Pierre, SD 57501
If you are requesting an expedited external review, call the Division of Insurance before sending your paperwork, and you will receive instructions on the quickest way to submit the application and supporting information.
CERTIFICATON OF TREATING HEALTH CARE PROVIDER
FOR EXPEDITED CONSIDERATION OF A PATIENT'S EXTERNAL REVIEW
APPEAL
NOTE TO THE TREATING HEALTH CARE PROVIDER
Patients can request an external review when a health center has denied a health care service or course of treatment on the basis of a utilization review determination that the requested health care service or course of treatment does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested. The South Dakota Division of Insurance oversees external appeals. The standard external review process can take up to 45 days from the date the patient's request for external review is received by our division. Expedited external review is available only if the patient's treating health care provider certifies that adherence to the timeframe for the standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function. An expedited external review must be completed within 72 hours. This form is for the purpose of providing the certification necessary to trigger expedited review.
GENERAL INFORMATION
Name of Treating Health Care Provider:
__________________________________________________________________________________
Mailing Address:
__________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________
Phone Number: (_____)_______________________
Fax Number: (_____)_______________________
Licensure and Area of Clinical Specialty:
_________________________________________________________________________________
________________________________________________________________________________
Name of Patient:
__________________________________________________________________________________
Patient's Insurer Member ID#:
__________________________________________________________________________________
CERTIFICATION
I hereby certify that: I am a treating health care provider for
_________________________________________________
(hereafter referred to as "the patient"); that adherence to the timeframe of conducting a standard external review of the patient's appeal would, in my professional judgment, seriously jeopardize the life or health of the patient or would jeopardize the patient's ability to regain maximum function; and that, for this reason, the patient's appeal of the denial by the patient's health carrier of the requested health care service or course of treatment should be processed on an expedited basis.
___________________________________________
Treating Health Care Provider's Name (Please Print)
___________________________________________ _________________
Signature Date
PHYSICIAN CERTIFICATION
EXPERIMENTAL/INVESTIGATIONAL DENIALS
(To Be Completed by Treating Physician)
I hereby certify that I am the treating physician for ______________________ (insured's name) and that I have requested the authorization for a drug, device, procedure, or therapy denied for coverage due to the insurance company's determination that the proposed therapy is experimental and/or investigational. I understand that in order for the covered person to obtain the right to an external review of this denial, as treating physician I must certify that the insured's medical condition meets certain requirements:
In my medical opinion as the Insured's treating physician, I hereby certify to the following:
(Please check all that apply) (NOTE: Requirements #1 - #3 below must all apply for the covered person to qualify for an external review).
□ 1) The covered person has a terminal medical condition, life threatening condition, or a seriously debilitating condition.
□ 2) The covered person has a condition that qualifies under one or more of the following:
[please indicate which description(s) apply]:
□ Standard health care services or treatments have not been effective in improving the covered person's condition;
□ Standard health care services or treatments are not medically appropriate for the covered person; or
□ There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the requested or recommended health care service or treatment.
□ 3) The health care service or treatment I have recommended and which has been denied, in my medical opinion, is likely to be more beneficial to the covered person than any available standard health care services or treatments.
□ 4) The health care service or treatment recommended would be significantly less effective if not promptly initiated.
Explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
□ 5) It is my medical opinion based on scientifically valid studies using accepted protocols that the health care service or treatment requested by the covered person and which has been denied is likely to be more beneficial to the covered person than any available standard health care services or treatments.
Explain:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please provide a description of the recommended or requested health care service or treatment that is the subject of the denial. (Attach additional sheets as necessary)
____________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________________
Physician's Signature Date
