20:06:53:42.  Records provided to independent review organization for experimental or investigational treatment reviews. Within five business days after the date of receipt of the notice provided pursuant to § 20:06:53:39, the health carrier or its designee utilization review organization shall provide to the assigned independent review organization, the documents and any information considered in making the adverse determination or the final adverse determination. Except as provided in this section, failure by the health carrier or its designee utilization review organization to provide the documents and information within the five day timeframe may not delay the conduct of the external review.

          If the health carrier or its designee utilization review organization has failed to provide the documents and information within the time specified in this section, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination. Immediately upon making the decision under this section, the independent review organization shall notify the covered person, the covered person's authorized representative, if applicable, the health carrier, and the director.

          Source: 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 1, 2011.

          General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.

          Law Implemented: SDCL 58-17-87, 58-18-79.