Codified Law 58-17H | South Dakota Legislature

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CHAPTER 58-17H

UTILIZATION REVIEW AND BENEFIT DETERMINATIONS

58-17H-1 Definitions.

58-17H-2 Health benefit plan defined.

58-17H-3 Urgent care request defined.

58-17H-4 Applicability of chapter.

58-17H-5 Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.

58-17H-6 In-network emergency services.

58-17H-7 Cost-sharing requirements for out-of-network emergency services.

58-17H-8 Cost-sharing requirements for covered persons--Payments to out-of-network providers.

58-17H-9 Exceptions for payments by capitated and other plans without negotiated fees.

58-17H-10 Negotiated amounts for in-network providers for a particular emergency service.

58-17H-11 General cost-sharing requirements allowed.

58-17H-12 Access to representative for post-evaluation or post-stabilization services.

58-17H-13 Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.

58-17H-14 Health carrier responsibility for utilization review activities.

58-17H-15 Director to hold health carrier responsible for utilization review performance of contractor.

58-17H-16 Written utilization review program required--Contents of program document.

58-17H-17 Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.

58-17H-18 Program to be administered by qualified licensed health care professionals.

58-17H-19 Determinations to be issued in timely manner--Process to ensure consistency.

58-17H-20 Effectiveness and efficiency of program to be routinely reviewed.

58-17H-21 Data systems to support program activities and generate management reports.

58-17H-22 Health carrier oversight of delegated activities--Requirements.

58-17H-23 Utilization review to be coordinated with other medical management activity of health carrier.

58-17H-24 Health carrier to provide free access to review staff.

58-17H-25 Only information necessary for review or determination to be collected.

58-17H-26 Independence and impartiality required for utilization review.

58-17H-27 Written procedures required for making determinations--Notification.

58-17H-28 Prospective review determinations--Timing--Notification of requirements--Extension of time.

58-17H-29 Concurrent review determinations--Timing--Notification requirements.

58-17H-30 Retrospective review determinations--Timing--Notification requirements.

58-17H-31 Calculation of time period for determination for prospective and retrospective reviews.

58-17H-32 Notification of adverse determination--Contents.

58-17H-33 Information required to be provided to covered persons and prospective covered persons.

58-17H-34 Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.

58-17H-35 Registration of utilization review organizations--Required information.

58-17H-36 Filing changes in registration information.

58-17H-37 Requests for information from utilization review organizations.

58-17H-38 Activities of nonregistered utilization review organizations prohibited.

58-17H-39 Registration fee for utilization review organizations.

58-17H-40 Urgent care requests--Written procedures required for receipt and determination of requests.

58-17H-41 Insufficient information for determination--Notice and statement of necessary information.

58-17H-42 Insufficient information for determination of prospective urgent care requests.

58-17H-43 Urgent care requests--Timely notification of determination.

58-17H-44 Time within which to submit necessary information.

58-17H-45 Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.

58-17H-46 Concurrent review urgent care requests--Extended care requests--Time for determination and notice.

58-17H-47 Calculation of time periods for determination.

58-17H-48 Notification of adverse determination--Requirements.

58-17H-49 Promulgation of rules.

58-17H-50 Coverage for cancer treatment medication.

58-17H-51 Reclassification of benefits with respect to cancer treatment medications.

58-17H-52 Medical management practices complying with chapter.

58-17H-53 Step therapy protocols.

58-17H-54 Step therapy protocols--Process--Transparency.

58-17H-55 Step therapy override exceptions.

58-17H-56 Limitations.

58-17H-1. Definitions.

Terms used in this chapter mean:

(1) "Adverse determination," any of the following:

(a) A determination by a health carrier or the carrier's designee utilization review organization that, based upon the information provided, a request by a covered person for a benefit under the health carrier's health benefit plan upon application of any utilization review technique does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit;

(b) The denial, reduction, termination, or failure to provide or make payment in whole or in part, for a benefit based on a determination by a health carrier or the carrier's designee utilization review organization of a covered person's eligibility to participate in the health carrier's health benefit plan;

(c) Any prospective review or retrospective review determination that denies, reduces, terminates, or fails to provide or make payment, in whole or in part, for a benefit; or

(d) A rescission of coverage determination;

(2) "Ambulatory review," utilization review of health care services performed or provided in an outpatient setting;

(3) "Authorized representative," a person to whom a covered person has given express written consent to represent the covered person for purposes of this chapter, a person authorized by law to provide substituted consent for a covered person, a family member of the covered person or the covered person's treating health care professional if the covered person is unable to provide consent, or a health care professional if the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the health care professional. For any urgent care request, the term includes a health care professional with knowledge of the covered person's medical condition;

(4) "Case management," a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions;

(5) "Certification," a determination by a health carrier or the carrier's designee utilization review organization that a request for a benefit under the health carrier's health benefit plan has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness;

(6) "Clinical practice guidelines," a systematically developed statement to assist decision making by health care professionals and patient decisions about appropriate health care for specific clinical circumstances and conditions;

(7) "Clinical peer," a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review;

(8) "Clinical review criteria," the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of health care services;

(9) "Concurrent review," utilization review conducted during a patient's hospital stay or course of treatment in a facility or other inpatient or outpatient health care setting;

(10) "Covered benefits" or "benefits," those health care services to which a covered person is entitled under the terms of a health benefit plan;

(11) "Covered person," a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;

(12) "Director," the director of the Division of Insurance;

(13) "Discharge planning," the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility;

(14) "Emergency medical condition," a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention, would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;

(15) "Emergency services," with respect to an emergency medical condition:

(a) A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency condition; and

(b) Such further medical examination and treatment, to the extent they are within the capability of the staff and facilities at a hospital to stabilize a patient;

(16) "Facility," an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation, and other therapeutic health settings;

(17) "Health care professional," a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law;

(18) "Health care provider" or "provider," a health care professional or a facility;

(19) "Health care services," services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease;

(20) "Health carrier," an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the director, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services;

(21) "Managed care contractor," a person who establishes, operates, or maintains a network of participating providers; or contracts with an insurance company, a hospital or medical service plan, an employer, an employee organization, or any other entity providing coverage for health care services to operate a managed care plan or health carrier;

(22) "Managed care entity," a licensed insurance company, hospital or medical service plan, health maintenance organization, or an employer or employee organization, that operates a managed care plan or a managed care contractor. The term does not include a licensed insurance company unless it contracts with other entities to provide a network of participating providers;

(23) "Managed care plan," a plan operated by a managed care entity that provides for the financing or delivery of health care services, or both, to persons enrolled in the plan through any of the following:

(a) Arrangements with selected providers to furnish health care services;

(b) Explicit standards for the selection of participating providers; or

(c) Financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the plan;

(24) "Network," the group of participating providers providing services to a health carrier;

(25) "Participating provider," a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly, from the health carrier;

(26) "Pharmaceutical sample," a unit of a prescription drug that is not intended to be sold and is intended to promote the sale of the drug;

(27) "Prospective review," utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health carrier's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision;

(28) "Rescission," a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. The term does not include a cancellation or discontinuance of coverage under a health benefit plan if:

(a) The cancellation or discontinuance of coverage has only a prospective effect; or

(b) The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage;

(29) "Retrospective review," any review of a request for a benefit that is not a prospective review request, which does not include the review of a claim that is limited to veracity of documentation, or accuracy of coding, or adjudication for payment;

(30) "Second opinion," an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the medical necessity and appropriateness of the initial proposed health care service;

(31) "Secretary," the secretary of the Department of Health;

(32) "Stabilized," with respect to an emergency medical condition, that no material deterioration of the condition is likely, with reasonable medical probability, to result from or occur during the transfer of the individual from a facility or, with respect to a pregnant woman, the woman has delivered, including the placenta;

(33) "Utilization review," a set of formal techniques used by a managed care plan or utilization review organization to monitor and evaluate the medical necessity, appropriateness, and efficiency of health care services and procedures including techniques such as ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, and retrospective review;

(34) "Step therapy override exception," a step therapy protocol should be overridden in favor of coverage of the prescription drug selected by a health care professional within the applicable time frames in § 58-17H-55 and in compliance with chapter 58-17H. This determination is based on a review of the covered person's or health care professional's request for an override, along with supporting rationale and documentation;

(35) "Step therapy protocol," a protocol or program that establishes a specific sequence in which prescription drugs are covered under a pharmacy or medical benefit by a health carrier, a health benefit plan, or a utilization review organization for a specified medical condition and medically appropriate for a health carrier, a health benefit plan, or utilization review organization, including self-administered drugs and drugs administered by a health care professional; and

(36) "Utilization review organization," an entity that conducts utilization review other than a health carrier performing utilization review for its own health benefit plans.

Source: SL 2011, ch 219, § 28; SL 2020, ch 209, § 1.

Commission Note: SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed."

58-17H-2. Health benefit plan defined.

For the purposes of this chapter, the term, health benefit plan, means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as otherwise specifically exempted in this definition.

The term does not include coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, specified in federal regulations issued pursuant to Public Law No. 104-191, as amended to January 1, 2011, under which benefits for medical care are secondary or incidental to other insurance benefits.

The term does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or other similar, limited benefits specified in federal regulations issued pursuant to Public Law No. 104-191, as amended to January 1, 2011.

The term does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor: coverage only for a specified disease or illness; or hospital indemnity or other fixed indemnity insurance.

The term does not include the following if offered as a separate policy, certificate, or contract of insurance: medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act, as amended to January 1, 2011; coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)), as amended to January 1, 2011; or similar supplemental coverage provided to coverage under a group health plan.

Source: SL 2011, ch 219, § 91; SL 2021, ch 210, § 14.

58-17H-3. Urgent care request defined.

For the purposes of this chapter, the term, urgent care request means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination:

(1) Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or

(2) In the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.

Except as provided in subdivision (1) of this section, in determining whether a request is to be treated as an urgent care request, an individual acting on behalf of the health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. Any request that a physician with knowledge of the covered person's medical condition determines is an urgent care request within the meaning of subdivisions (1) and (2) of this section shall be treated as an urgent care request.

Source: SL 2011, ch 219, § 92.

58-17H-4. Applicability of chapter.

The provisions of this chapter apply to any health carrier that provides or performs utilization review services. The requirements of this chapter also apply to any designee of the health carrier or utilization review organization that performs utilization review functions on the carrier's behalf.

Source: SL 2011, ch 219, § 29.

58-17H-5. Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.

If conducting utilization review or making a benefit determination for emergency services, a health carrier that provides benefits for services in an emergency department of a hospital shall comply with the provisions of §§ 58-17H-5 to 58-17H-13, inclusive. A health carrier shall cover emergency services necessary to screen and stabilize a covered person and may not require prior authorization of such services if a prudent layperson would have reasonably believed that an emergency medical condition existed even if the emergency services are provided on an out of-network basis. A health carrier shall cover emergency services whether the health care provider furnishing the services is a participating provider with respect to such services. If the emergency services are provided out-of-network, the services shall be covered without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers. Emergency services are provided out-of-network by complying with the cost sharing requirements set forth in §§ 58-17H-7 to 58-17H-10, inclusive, and without regard to any other term or condition of coverage other than the exclusion of or coordination of benefits, an affiliation or waiting periods as permitted under section 2704 of the Public Health Service Act, as amended to January 1, 2011, or cost sharing requirements as set forth in §§ 58-17H-6 to 58-17H-10, inclusive.

Source: SL 2011, ch 219, § 30.

58-17H-6. In-network emergency services.

Coverage of in-network emergency services are subject to applicable copayments, coinsurance, and deductibles.

Source: SL 2011, ch 219, § 31.

58-17H-7. Cost-sharing requirements for out-of-network emergency services.

Cost-sharing requirements for out-of-network emergency services expressed as a copayment amount or coinsurance rate imposed with respect to a covered person cannot exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-network.

Source: SL 2011, ch 219, § 32.

58-17H-8. Cost-sharing requirements for covered persons--Payments to out-of-network providers.

Notwithstanding § 58-17H-7, a covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount the health carrier is required to pay pursuant to this section.

A health carrier complies with the requirements of this section if it provides payment of emergency services provided by an out-of-network provider in an amount not less than the greatest of the following:

(1) The amount negotiated with in-network providers for emergency services, excluding any in-network copayment or coinsurance imposed with respect to the covered person;

(2) The amount of the emergency service calculated using the same method the plan uses to determine payments for out-of-network services, but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or

(3) The amount that would be paid under Medicare for the emergency services, excluding any in-network copayment or coinsurance requirements.

Source: SL 2011, ch 219, § 33.

58-17H-9. Exceptions for payments by capitated and other plans without negotiated fees.

For capitated or other health benefit plans that do not have a negotiated per-service amount for in-network providers, subdivision 58-17H-8(1) does not apply.

Source: SL 2011, ch 219, § 34.

58-17H-10. Negotiated amounts for in-network providers for a particular emergency service.

If a health benefit plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subdivision 58-17H-8(1) is the median of these negotiated amounts.

Source: SL 2011, ch 219, § 35.

58-17H-11. General cost-sharing requirements allowed.

Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible or out-of-pocket maximum, may be imposed with respect to emergency services provided out-of-network if the cost-sharing requirement generally applies to out-of-network benefits. A deductible may be imposed with respect to out-of-network emergency services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum generally applies to out-of-network benefits, that out-of-network maximum applies to out-of-network emergency services.

Source: SL 2011, ch 219, § 36.

58-17H-12. Access to representative for post-evaluation or post-stabilization services.

For immediately required post-evaluation or post-stabilization services, a health carrier shall provide access to a designated representative twenty-four hours a day, seven days a week, to facilitate review, or otherwise provide coverage with no financial penalty to the covered person.

Source: SL 2011, ch 219, § 37.

58-17H-13. Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.

If the director and the secretary find that the requirements of any private accrediting body meet the requirements of coverage of emergency medical services as set forth in §§ 58-17H-4 to 58-17H-12, inclusive, the health carrier may, at the discretion of the director and secretary, be deemed to have met the applicable requirements.

Source: SL 2011, ch 219, § 38.

58-17H-14. Health carrier responsibility for utilization review activities.

A health carrier is responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter and applicable rules are met. The health carrier shall also ensure that appropriate personnel have operational responsibility for the conduct of the health carrier's utilization review program.

Source: SL 2011, ch 219, § 39.

58-17H-15. Director to hold health carrier responsible for utilization review performance of contractor.

If a health carrier contracts to have a utilization review organization or other entity perform the utilization review functions required by this chapter, or applicable rules, the director shall hold the health carrier responsible for monitoring the activities of the utilization review organization or entity with which the health carrier contracts and for ensuring that the requirements of this chapter, and applicable rules, are met.

Source: SL 2011, ch 219, § 40.

58-17H-16. Written utilization review program required--Contents of program document.

A health carrier that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated for the filing of benefit requests, the notification of utilization review and benefit determinations, and the review of adverse determinations in accordance with chapter 58-17I.

The program document shall describe the following:

(1) Procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;

(2) Data sources and clinical review criteria used in decision-making;

(3) Mechanisms to ensure consistent application of review criteria and compatible decisions;

(4) Data collection processes and analytical methods used in assessing utilization of health care services;

(5) Provisions for assuring confidentiality of clinical and proprietary information;

(6) The organizational structure that periodically assesses utilization review activities and reports to the health carrier's governing body; and

(7) The staff position functionally responsible for day-to-day program management.

A health carrier shall prepare an annual summary report in the format specified of its utilization review program activities and file the report, if requested, with the director and the secretary. A health carrier shall maintain records for a minimum of six years of all benefit requests and claims and notices associated with utilization review and benefit determinations made in accordance with §§ 58-17H-27 to 58-17H-32, inclusive, and §§ 58-17H-40 to 58-17H-48, inclusive. The health carrier shall make the records available for examination by covered persons and the director upon request.

Source: SL 2011, ch 219, § 41.

58-17H-17. Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.

A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier may develop its own clinical review criteria, or it may purchase or license clinical review criteria from qualified vendors. A health carrier shall make available its clinical review criteria upon request to authorized government agencies including the Division of Insurance and the Department of Health.

Source: SL 2011, ch 219, § 42.

58-17H-18. Program to be administered by qualified licensed health care professionals.

Qualified licensed health care professionals shall administer the utilization review program and oversee review decisions. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care provider.

Source: SL 2011, ch 219, § 43.

58-17H-19. Determinations to be issued in timely manner--Process to ensure consistency.

A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§ 58-17H-27 to 58-17H-32, inclusive, and §§ 58-17H-40 to 58-17H-48, inclusive. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.

If a health carrier fails to strictly adhere to the requirements of §§ 58-17H-27 to 58-17H-32, inclusive, and §§ 58-17H-40 to 58-17H-48, inclusive, with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the provisions of chapters 58-17G and 58-17H, and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§ 58-17H-27 to 58-17H-32, inclusive, and §§ 58-17H-40 to 58-17H-48, inclusive, as applicable, or that any error it committed was de minimus.

Any covered person may file a request for external review in accordance with rules promulgated by the director. In addition to the external review rights a covered person is entitled to pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim.

Source: SL 2011, ch 219, § 44.

58-17H-20. Effectiveness and efficiency of program to be routinely reviewed.

Any health carrier shall routinely assess the effectiveness and efficiency of its utilization review program.

Source: SL 2011, ch 219, § 45.

58-17H-21. Data systems to support program activities and generate management reports.

Any health carrier's data system shall be sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively.

Source: SL 2011, ch 219, § 46.

58-17H-22. Health carrier oversight of delegated activities--Requirements.

If a health carrier delegates any utilization review activities to a utilization review organization, the health carrier shall maintain adequate oversight, which shall include:

(1) A written description of the utilization review organization's activities and responsibilities, including reporting requirements;

(2) Evidence of formal approval of the utilization review organization program by the health carrier; and

(3) A process by which the health carrier evaluates the performance of the utilization review organization.

Source: SL 2011, ch 219, § 47.

58-17H-23. Utilization review to be coordinated with other medical management activity of health carrier.

Each health carrier shall coordinate the utilization review program with other medical management activity conducted by the carrier, such as quality assurance, credentialing, provider contracting data reporting, grievance procedures, processes for assessing member satisfaction, and risk management.

Source: SL 2011, ch 219, § 48.

58-17H-24. Health carrier to provide free access to review staff.

Each health carrier shall provide covered persons and participating providers with access to its review staff by a toll-free number or collect call telephone line.

Source: SL 2011, ch 219, § 49.

58-17H-25. Only information necessary for review or determination to be collected.

If conducting a utilization review, the health carrier shall collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination.

Source: SL 2011, ch 219, § 50.

58-17H-26. Independence and impartiality required for utilization review.

In conducting utilization review, the health carrier shall ensure that the review is conducted in a manner to ensure the independence and impartiality of the individuals involved in making the utilization review or benefit determination.

In ensuring the independence and impartially of individuals involved in making the utilization review or benefit determination, no health carrier may make decisions regarding hiring, compensation, termination, promotion, or other similar matters based upon the likelihood that the individual will support the denial of benefits.

Source: SL 2011, ch 219, § 51.

58-17H-27. Written procedures required for making determinations--Notification.

A health carrier shall maintain written procedures pursuant to this chapter, for making standard utilization review and benefit determinations on requests submitted to the health carrier by covered persons or their authorized representatives for benefits and for notifying covered persons and their authorized representatives of its determinations with respect to these requests within the specified time frames required under this chapter. If a period of time is extended as permitted by this chapter due to a claimant's failure to submit information necessary to decide a prospective, retrospective, or disability claim, the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

Source: SL 2011, ch 219, § 52.

58-17H-28. Prospective review determinations--Timing--Notification of requirements--Extension of time.

For any prospective review determination, other than allowed by this section, a health carrier shall make the determination and notify the covered person or, if applicable, the covered person's authorized representative of the determination, whether the carrier certifies the provision of the benefit or not, within a reasonable period of time appropriate to the covered person's medical condition, but in no event later than fifteen days after the date the health carrier receives the request. If the determination is an adverse determination, the health carrier shall make the notification of the adverse determination in accordance with § 58-17H-32.

The time period for making a determination and notifying the covered person or, if applicable, the covered person's authorized representative, of the determination pursuant to this section may be extended once by the health carrier for up to fifteen days, if the health carrier:

(1) Determines that an extension is necessary due to matters beyond the health carrier's control; and

(2) Notifies the covered person or, if applicable, the covered person's authorized representative, prior to the expiration of the initial fifteen-day time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.

If the extension is necessary due to the failure of the covered person or the covered person's authorized representative to submit information necessary to reach a determination on the request, the notice of extension shall specifically describe the required information necessary to complete the request and give the covered person or, if applicable, the covered person's authorized representative at least forty-five days from the date of receipt of the notice to provide the specified information.

If the health carrier receives a prospective review request from a covered person or the covered person's authorized representative that fails to meet the health carrier's filing procedures, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative of this failure and provide in the notice information on the proper procedures to be followed for filing a request. This notice shall be provided as soon as possible, but in no event later than five days following the date of the failure. The health carrier may provide the notice orally or, if requested by the covered person or the covered person's authorized representative, in writing. The provisions only apply in a case of failure that is a communication by a covered person or the covered person's authorized representative that is received by a person or organizational unit of the health carrier responsible for handling benefit matters and is a communication that refers to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment, or provider for which certification is being requested.

Source: SL 2011, ch 219, § 53.

58-17H-29. Concurrent review determinations--Timing--Notification requirements.

For concurrent review determinations, if a health carrier has certified an ongoing course of treatment to be provided over a period of time or number of treatments:

(1) Any reduction or termination by the health carrier during the course of treatment before the end of the period or number treatments, other than by health benefit plan amendment or termination of the health benefit plan, shall constitute an adverse determination; and

(2) The health carrier shall notify the covered person of the adverse determination in accordance with § 58-17H-32 at a time sufficiently in advance of the reduction or termination to allow the covered person or, if applicable, the covered person's authorized representative, to file a grievance to request a review of the adverse determination pursuant to chapter 58-17I, and obtain a determination with respect to that review of the adverse determination before the benefit is reduced or terminated.

The health care service or treatment that is the subject of the adverse determination shall be continued without liability to the covered person until the covered person has been notified of the determination by the health carrier with respect to the internal review request made pursuant to chapter 58-17I.

Source: SL 2011, ch 219, § 54.

58-17H-30. Retrospective review determinations--Timing--Notification requirements.

For retrospective review determinations, the health carrier shall make the determination within a reasonable period of time, but in no event later than thirty days after the date of receiving the benefit request.

In the case of a certification, the health carrier may notify in writing the covered person and the provider rendering the service.

If the determination is an adverse determination, the health carrier shall provide notice of the adverse determination to the covered person or, if applicable, the covered person's authorized representative, in accordance with § 58-17H-32. The time period for making a determination and notifying the covered person or, if applicable, the covered person's authorized representative, of the determination pursuant to this section may be extended once by the health carrier for up to fifteen days, if the health carrier:

(1) Determines that an extension is necessary due to matters beyond the health carrier's control; and

(2) Notifies the covered person or, if applicable, the covered person's authorized representative, prior to the expiration of the initial thirty-day time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.

If the extension under this section is necessary due to the failure of the covered person or, if applicable, the covered person's authorized representative to submit information necessary to reach a determination on the request, the notice of extension shall specifically describe the required information necessary to complete the request and give the covered person or, if applicable, the covered person's authorized representative at least forty-five days from the date of receipt of the notice to provide the specified information.

Source: SL 2011, ch 219, § 55.

58-17H-31. Calculation of time period for determination for prospective and retrospective reviews.

For purposes of calculating the time periods within which a determination is required to be made for prospective and retrospective reviews, the time period within which the determination is required to be made begins on the date the request is received by the health carrier in accordance with the health carrier's procedures established pursuant to § 58-17H-16. If the time period for making the determination for a prospective or retrospective review is extended due to the covered person or, if applicable, the covered person's authorized representative's failure to submit the information necessary to make the determination, the time period for making the determination shall be tolled from the date on which the health carrier sends the notification of the extension to the covered person or, if applicable, the covered person's authorized representative, until the earlier of: the date on which the covered person or, if applicable, the covered person's authorized representative, responds to the request for additional information or the date on which the specified information was to have been submitted. If the covered person or the covered person's authorized representative fails to submit the information before the end of the period of the extension, as specified in §§ 58-17H-28 and 58-17H-30, the health carrier may deny the certification of the requested benefit.

Source: SL 2011, ch 219, § 56.

58-17H-32. Notification of adverse determination--Contents.

Any notification of an adverse determination under this section shall, in a manner which is designed to be understood by the covered person, set forth:

(1) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care provider, the claim amount, if applicable, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning;

(2) The specific reason or reasons for the adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in denying the benefit request or claim;

(3) A reference to the specific plan provision on which the determination is based;

(4) A description of additional material or information necessary for the covered person to complete the benefit request, including an explanation of why the material or information is necessary to complete the request;

(5) A description of the health carrier's grievance procedures established pursuant to chapter 58-17I, including time limits applicable to those procedures;

(6) If the health carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that a specific rule, guideline, protocol, or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the covered person upon request;

(7) If the adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances or a statement that an explanation will be provided to the covered person free of charge upon request;

(8) If applicable, instructions for requesting:

(a) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination, as provided in subdivision (6) of this section; or

(b) The written statement of the scientific or clinical rationale for the adverse determination, as provided in subdivision (7) of this section; and

(9) A statement explaining the availability of and the right of the covered person, as appropriate, to contact the Division of Insurance at any time for assistance or, upon completion of the health carrier's grievance procedure process as provided under chapter 58-17I, to file a civil suit in a court of competent jurisdiction.

If the adverse determination is a rescission, the health carrier shall provide, in addition to any applicable disclosures required under § 58-17H-32, clear identification of the alleged fraudulent practice or omission or the intentional misrepresentation of material fact, an explanation as to why the act, practice, or omission was fraudulent or was an intentional misrepresentation of a material fact, and the effective date of the rescission.

A health carrier may provide the notice required under this section in writing or electronically.

If the adverse determination is a rescission, the health carrier shall provide advance notice of the rescission determination required by rules promulgated by the director, in addition to any applicable disclosures required under this section.

The health carrier shall provide clear identification of the alleged fraudulent act, practice, or omission or the intentional misrepresentation of material fact.

The health carrier shall provide an explanation as to why the act, practice, or omission was fraudulent or was an intentional misrepresentation of a material fact.

The health carrier shall provide notice that the covered person or the covered person's authorized representative, prior to the date the advance notice of the proposed rescission ends, may immediately file a grievance to request a review of the adverse determination to rescind coverage pursuant to chapter 58-17I.

The health carrier shall provide a description of the health carrier's grievance procedures established pursuant to chapter 58-17I, including any time limits applicable to those procedures.

The health carrier shall provide the date when the advance notice ends and the date back to which the coverage will be retroactively rescinded.

Source: SL 2011, ch 219, § 57.

58-17H-33. Information required to be provided to covered persons and prospective covered persons.

In the certificate of coverage or member handbook provided to covered persons, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of covered persons with respect to those procedures. A health carrier shall include a summary of its utilization review and benefit determination procedures in materials intended for prospective covered persons. A health carrier shall print on its membership cards a toll-free telephone number to call for utilization review and benefit decisions.

Source: SL 2011, ch 219, § 58.

58-17H-34. Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.

If the director and the secretary find that the requirements of any private accrediting body meet the requirements of utilization review as set forth in this chapter, the health carrier may, at the discretion of the director and secretary, be deemed to have met the applicable requirements.

Source: SL 2011, ch 219, § 59.

58-17H-35. Registration of utilization review organizations--Required information.

Any utilization review organization which engages in utilization review activities in this state shall register with the Division of Insurance prior to conducting business in this state. The registration shall be in a format prescribed by the director. In prescribing the form or in carrying out other functions required by §§ 58-17H-35 to 58-17H-39, inclusive, the director shall consult with the secretary if applicable. The director or the secretary may require that the following information be submitted:

(1) Information relating to its actual or anticipated activities in this state;

(2) The status of any accreditation designation it holds or has sought;

(3) Information pertaining to its place of business, officers, and directors;

(4) Qualifications of review staff; and

(5) Any other information reasonable and necessary to monitor its activities in this state.

Source: SL 2011, ch 219, § 60.

58-17H-36. Filing changes in registration information.

Any utilization review organization which has previously registered in this state shall, on or before July first of each year, file with the Division of Insurance any changes to the initial or subsequent annual registration for the utilization review organization.

Source: SL 2011, ch 219, § 61.

58-17H-37. Requests for information from utilization review organizations.

The director or the secretary may request information from any utilization review organization at any time pertaining to its activities in this state. The utilization review organization shall respond to all requests for information within twenty days.

Source: SL 2011, ch 219, § 62.

58-17H-38. Activities of nonregistered utilization review organizations prohibited.

A utilization review organization may not engage in utilization review in this state unless the utilization review organization is properly registered. The director may issue a cease and desist order against any utilization review organization which fails to comply with the requirements of §§ 58-17H-35 to 58-17H-39, inclusive, prohibiting the utilization review organization from engaging in utilization review activities in this state.

Source: SL 2011, ch 219, § 63.

58-17H-39. Registration fee for utilization review organizations.

The director may require the payment of a fee in conjunction with the initial or annual registration of a utilization review organization not to exceed two hundred fifty dollars per registration. The fee shall be established by rules promulgated pursuant to chapter 1-26.

Source: SL 2011, ch 219, § 64.

58-17H-40. Urgent care requests--Written procedures required for receipt and determination of requests.

Each health carrier shall establish written procedures, in accordance with §§ 58-17H-40 to 58-17H-48, inclusive, for receiving benefit requests from covered persons or their authorized representatives and for making and notifying covered persons or their authorized representatives of expedited utilization review and benefit determinations with respect to urgent care requests and concurrent review urgent care requests.

Source: SL 2011, ch 219, § 65.

58-17H-41. Insufficient information for determination--Notice and statement of necessary information.

If the covered person or, if applicable, the covered person's authorized representative has failed to provide sufficient information for the health carrier to make a determination, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, either orally or, if requested by the covered person or the covered person's authorized representative, in writing of this failure and state what specific information is needed as soon as possible, but in no event later than twenty-four hours after receipt of the request.

Source: SL 2011, ch 219, § 66.

58-17H-42. Insufficient information for determination of prospective urgent care requests.

If the benefit request involves a prospective review urgent care request, the provisions of § 58-17H-41 apply only in the case of a failure that:

(1) Is a communication by a covered person or, if applicable, the covered person's authorized representative, that is received by a person or organizational unit of the health carrier responsible for handling benefit matters; and

(2) Is a communication that refers to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment, or provider for which approval is being requested.

Source: SL 2011, ch 219, § 67.

58-17H-43. Urgent care requests--Timely notification of determination.

For an urgent care request, unless the covered person or the covered person's authorized representative has failed to provide sufficient information for the health carrier to determine whether, or to what extent, the benefits requested are covered benefits or payable under the health carrier's health benefit plan, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative of the health carrier's determination with respect to the request, whether or not the determination is an adverse determination, as soon as possible, taking into account the medical condition of the covered person, but in no event later than twenty-four hours after the date of the receipt of the request by the health carrier. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with § 58-17H-48.

Source: SL 2011, ch 219, § 68.

58-17H-44. Time within which to submit necessary information.

The health carrier shall provide the covered person or, if applicable, the covered person's authorized representative, a reasonable period of time to submit the necessary information, taking into account the circumstances, but in no event less than forty-eight hours after the date of notifying the covered person or the covered person's authorized representative of the failure to submit sufficient information, as provided in §§ 58-17H-41 and 58-17H-42.

Source: SL 2011, ch 219, § 69.

58-17H-45. Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.

The health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, of its determination with respect to the urgent care request as soon as possible, but in no event more than forty-eight hours after the earlier of:

(1) The health carrier's receipt of the requested specified information; or

(2) The end of the period provided for the covered person or, if applicable, the covered person's authorized representative, to submit the requested specified information.

If the covered person or the covered person's authorized representative fails to submit the information before the end of the period of the extension, as specified in § 58-17H-44, the health carrier may deny the certification of the requested benefit. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with § 58-17H-32.

Source: SL 2011, ch 219, § 70.

58-17H-46. Concurrent review urgent care requests--Extended care requests--Time for determination and notice.

For concurrent review urgent care requests involving a request by the covered person or the covered person's authorized representative to extend the course of treatment beyond the initial period of time or the number of treatments, if the request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments, the health carrier shall make a determination with respect to the request and notify the covered person or, if applicable, the covered person's authorized representative, of the determination, whether it is an adverse determination or not, as soon as possible, taking into account the covered person's medical condition but in no event more than twenty-four hours after the date of the health carrier's receipt of the request. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with § 58-17H-48.

Source: SL 2011, ch 219, § 71.

58-17H-47. Calculation of time periods for determination.

For purposes of calculating the time periods within which a determination is required to be made under §§ 58-17H-43 to 58-17H-45, inclusive, the time period within which the determination is required to be made shall begin on the date the request is filed with the health carrier in accordance with the health carrier's procedures established pursuant to § 58-17H-16 for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.

Source: SL 2011, ch 219, § 72.

58-17H-48. Notification of adverse determination--Requirements.

If a health carrier's determination with respect to §§ 58-17H-40 to 58-17H-47, inclusive, is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with this section. A notification of an adverse determination under this section shall, in a manner calculated to be understood by the covered person, set forth:

(1) Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care provider, the claim amount, if applicable, the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning;

(3) A reference to the specific plan provisions on which the determination is based;

(4) A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;

(5) A description of the health carrier's internal review procedures established pursuant to chapter 58-17I, including any time limits applicable to those procedures;

(6) A description of the health carrier's expedited review procedures established pursuant to §§ 58-17I-12 to 58-17I-16, inclusive;

(7) If the health carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that a specific rule, guideline, protocol, or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the covered person upon request;

(8) If the adverse determination is based on a medical necessity or experimental or investigation treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances, or a statement that an explanation will be provided to the covered person free of charge upon request;

(9) If applicable, instructions for requesting:

(a) A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination in accordance with subdivision (7) of this section; or

(b) The written statement of the scientific or clinical rationale for the adverse determination in accordance with subdivision (8) of this section; and

(10) A statement explaining the availability of and the right of the covered person, as appropriate, to contact the Division of Insurance at any time for assistance or, upon completion of the health carrier's grievance procedure process as provided under chapter 58-17I, to file a civil suit in a court of competent jurisdiction.

A health carrier may provide the notice required under this section orally, in writing or electronically. If notice of the adverse determination is provided orally, the health carrier shall provide written or electronic notice of the adverse determination within three days following the oral notification.

Source: SL 2011, ch 219, § 73.

58-17H-49. Promulgation of rules.

The director may, after consultation with the secretary, promulgate rules, pursuant to chapter 1-26, to carry out the provisions of this chapter. The rules shall provide for a timely administration of utilization review by the public and assure that utilization review decisions are made in a fair and clinically acceptable manner. The rules may include the following:

(1) Definition of terms;

(2) Timing, form, and content of reports;

(3) Application of clinical criteria as it relates to utilization review;

(4) Written determinations; and

(5) Utilization review procedures.

The director may promulgate rules, pursuant to chapter 1-26, pertaining to claims for group disability income plans. The rules shall be consistent with applicable federal requirements included in 29 CFR Part 2560 as amended to January 1, 2011.

Source: SL 2011, ch 219, § 74.

58-17H-50. Coverage for cancer treatment medication.

Any health benefit plan as defined in § 58-17H-2 that provides benefits for injected or intravenously administered cancer treatment medication used to kill or slow the growth of cancerous cells shall provide no less favorable benefits for prescribed, orally administered anticancer medication covered by the plan, regardless of the formulation or benefit category determination by the health plan.

Source: SL 2015, ch 252, § 1, eff. Jan. 1, 2016.

58-17H-51. Reclassification of benefits with respect to cancer treatment medications.

A health carrier may not reclassify benefits with respect to cancer treatment medications or increase a copayment, deductible, or coinsurance amount for covered cancer treatment medications that are injected or intravenously administered unless:

(1) The increase is applied generally to other medical or pharmaceutical benefits covered under the plan and is not done to circumvent § 58-17H-50;

(2) The reclassification of benefits with respect to cancer treatment medications is done in a manner that is consistent with §§ 58-17H-50 to 58-17H-52, inclusive; or

(3) A health carrier is applying cost-sharing increases consistent with the annual increases in the cost of health care.

Source: SL 2015, ch 252, § 2, eff. Jan. 1, 2016.

58-17H-52. Medical management practices complying with chapter.

Nothing in §§ 58-17H-50 and 58-17H-51 prohibits a health carrier from performing medical management practices that comply with the provisions of this chapter.

Source: SL 2015, ch 252, § 3, eff. Jan. 1, 2016.

58-17H-53 . Step therapy protocols.

A health carrier, health benefit plan, or utilization review organization shall consider available recognized evidence-based and peer-reviewed clinical practice guidelines when establishing a step therapy protocol. Upon written request of a covered person, a health carrier, health benefit plan, or utilization review organization shall provide any clinical review criteria applicable to a specific prescription drug covered by the health carrier, health benefit plan, or utilization review organization.

Source: SL 2020, ch 209, § 2.

58-17H-54 . Step therapy protocols--Process--Transparency.

When coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization through the use of a step therapy protocol, the covered person and the prescribing health care professional shall have access to a clear, readily accessible, and convenient process to request a step therapy override exception. A health carrier, health benefit plan, or utilization review organization may use its existing medical exceptions process to satisfy this requirement. The process used shall be easily accessible on the internet site of the health carrier, health benefit plan, or utilization review organization.

Source: SL 2020, ch 209, § 3.

58-17H-55 . Step therapy override exceptions.

A step therapy override exception shall be approved by a health carrier, health benefit plan, or utilization review organization if any of the following circumstances apply:

(1) The prescription drug required under the step therapy protocol is contraindicated pursuant to the drug manufacturer's prescribing information for the drug or, due to a documented adverse event with a previous use or a documented medical condition, including a comorbid condition, is likely to do any of the following:

(a) Cause an adverse reaction to a covered person;

(b) Decrease the ability of a covered person to achieve or maintain reasonable functional ability in performing daily activities;

(2) The prescription drug required under the step therapy protocol is expected to be ineffective based on the known clinical characteristics of the covered person, such as the covered person's adherence to or compliance with the covered person's individual plan of care, and any of the following:

(a) The known characteristics of the prescription drug regimen as described in peer-reviewed literature or in the manufacturer's prescribing information for the drug;

(b) The health care professional's medical judgment based on clinical practice guidelines or peer-reviewed journals;

(3) The covered person has had a trial of a therapeutically equivalent dose of the prescription drug under the step therapy protocol while under the covered person's current or previous health benefit plan for a period of time to allow for a positive treatment outcome, and such prescription drug was discontinued by the covered person's health care professional due to lack of effectiveness;

(4) The covered person is currently receiving a positive therapeutic outcome on a prescription drug selected by the covered person's health care professional for the medical condition under consideration while under the covered person's current or previous health benefit plan. This subdivision may not be construed to encourage the use of a pharmaceutical sample for the sole purpose of meeting the requirements for a step therapy override exception.

Upon approval of a step therapy override exception, the health carrier, health benefit plan, or utilization review organization shall authorize coverage for the prescription drug selected by the covered person's prescribing health care professional if the prescription drug is a covered prescription drug under the covered person's health benefit plan.

Except in the case of an urgent care request, a health carrier, health benefit plan, or utilization review organization shall make a determination to approve or deny a request for a step therapy override exception within five calendar days after receipt of complete, clinically relevant written documentation supporting a step therapy override exception under subdivisions (1) through (4) of this section. In the case of an urgent care request, a health carrier, health benefit plan, or utilization review organization shall approve or deny a request for a step therapy override exception within seventy-two hours after receipt of such documentation. If a request for a step therapy override exception is incomplete or additional clinically relevant information is required, the health carrier, health benefit plan, or utilization review organization may request such information within the applicable time period provided in this section. Once the information is submitted, the applicable time period for approval or denial shall begin again. If a health carrier, health plan, or utilization review organization fails to respond to the request for a step override exception within the applicable time, the step therapy override exception shall be deemed granted.

If a nonurgent care request for a step therapy override exception is denied, the denial is an adverse determination and the health carrier, health benefit plan, or utilization review organization shall provide notification of adverse determination pursuant to § 58-17H-32 . If an urgent care request is denied, the health carrier, health benefit plan, or utilization review organization shall provide notification of adverse determination pursuant to § 58-17H-48 . Any denial of a request for a step therapy override exception is subject to the grievance procedures under chapter 58-17I .

Source: SL 2020, ch 209, § 4.

58-17H-56 . Limitations.

Nothing in §§ 58-17H-53 to 55-17H-56 shall be construed to prevent:

(1) A health carrier, health benefit plan, or utilization review organization from requiring a covered person to try a prescription drug with the same generic name and demonstrated bioavailability or biological product that is an interchangeable biological product pursuant to §§ 36-11-46.1 and 36-11-46.9 before providing coverage for the equivalent branded prescription drug;

(2) A health care professional from prescribing a prescription drug that is determined to be medically appropriate.

Source: SL 2020, ch 209, § 5.