Rule 20:06:33 UTILIZATION REVIEW ORGANIZATIONS AND MANAGED CARE ENTITIES

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CHAPTER 20:06:33

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UTILIZATION REVIEW ORGANIZATIONS AND\r\nMANAGED CARE ENTITIES

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Section

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20:06:33:01 Registration fee.

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20:06:33:02 Form and content of access plans.

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20:06:33:03 Annual filing of access plans.

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20:06:33:04 Centers of Excellence -- Access plans.

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\r\n\r\n\r\nRule 20:06:33:01 Registration fee.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

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20:06:33:01. Registration fee.\r\nThe fee for initial or annual registration of a utilization review organization\r\nor a managed care contractor is $250.

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Source: 23 SDR 2, effective July 1,\r\n1996; 25 SDR 167, effective July 1, 1999; 37 SDR 241, effective July 1, 2011.

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General Authority: SDCL 58-17F-16, 58-17F-20, 58-17H-35, 58-17H-39.

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Law Implemented: SDCL 58-17F-16, 58-17H-35, 58-18-75.

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\r\n\r\n\r\nRule 20:06:33:02 Form and content of access plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

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20:06:33:02. Form and content of access plans.\r\nEach initial filing of an access plan pursuant to SDCL 58-17F-10 must contain the following:

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(1) A complete copy of the entire access plan;

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(2) A complete copy of the current provider\r\nnetwork in place listed by specialty and location;

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(3) Any formalized steps that a covered person\r\nmust utilize to obtain a referral;

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(4) An annual survey, or other method approved\r\nby the director, to assess the satisfaction of covered persons that includes,\r\nat a minimum, questions designed to elicit how the covered person is generally\r\nsatisfied and how the covered person feels the managed care plan meets the\r\ncovered person's health care needs;

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(5) In addition to the description of the method\r\nfor informing covered persons required pursuant to SDCL subdivision 58-17F-10(5), a copy of the disclosure required by SDCL 58-17F-4, a copy of the health carrier's grievance procedures, a summary of utilization review procedures provided to prospective covered persons, and a copy of the membership card pursuant to SDCL 58-17H-33;

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(6) A copy of any written materials provided to\r\ncovered persons that would generally inform such persons of the systems or\r\nprocesses that may be used to change primary care professionals as required by\r\nSDCL subdivision 58-17F-10(7);

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(7) In conjunction with the plan for providing\r\ncontinuity of care as required by SDCL subdivision 58-17F-10(8), a copy of the language used in any provider contract that pertains to continuity of care; and

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(8) A specimen copy of all provider contracts.

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Discounted fee for service plans are not required to comply\r\nwith subdivisions (3), (4), and (7). Discounted fee for service plans are not\r\nrequired to comply with subdivision (6) if the plan does not use or require the\r\nuse of primary care professionals. Stand-alone dental plans are not required to\r\ncomply with subdivisions (3), (4), (6), and (7).

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Source: 26 SDR\r\n64, effective November 14, 1999; 37 SDR 241, effective July 1, 2011; 38 SDR 59,\r\neffective October 19, 2011; 39 SDR 203, effective June 10, 2013.

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General Authority:\r\nSDCL 58-17F-10, 58-17F-21.

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Law Implemented:\r\nSDCL 58-17F-4, 58-17F-10, 58-17F-21.

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\r\n\r\n\r\nRule 20:06:33:03 Annual filing of access plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

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20:06:33:03. Annual filing of access plans. A health insurance issuer\r\nis required to either file any changes or an attestation stating no changes\r\nhave been made, annually on or before September 30^th of each year of\r\ntheir access plan filing.

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Source: 26 SDR\r\n64, effective November 14, 1999; 37 SDR 241, effective July 1, 2011; 39 SDR\r\n203, effective June 20, 2013.

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General Authority:\r\nSDCL 58-17F-10, 58-17F-21.

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Law Implemented:\r\nSDCL 58-17F-4, 58-17F-10, 58-17F-21.

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\r\n\r\n\r\nRule 20:06:33:04 Centers of Excellence -- Access plans.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n

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20:06:33:04. Centers of\r\nExcellence -- Access plans. Each contracted Center of Excellence and each\r\ncontracted network of a Center of Excellence must be included in a health\r\ncarrier's access plan. For purposes of network adequacy pursuant to\r\n§§ 58-17F-5 to 58-17F-9, inclusive, the health carrier's entire Center of\r\nExcellence network including both direct contracted Centers of Excellence and\r\ncontracted networks shall be considered. A health carrier may not contract with\r\na Center of Excellence network or any other network that is not registered\r\npursuant to § 58-17F-16. Nothing in this section affects the ability of\r\ncarriers to select network providers as permitted by SDCL subdivision 58-17F-11(3). For purposes of this section a Center of Excellence means a provider of transplant services that is medically recognized as having special expertise to perform a particular transplant or transplants. Transplant providers that separately contract with a health carrier do not constitute a network pursuant to this section.

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Source: 36 SDR 96, effective December\r\n9, 2009; 37 SDR 241, effective July 1, 2011.

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General Authority: SDCL 58-17F-10, 58-17F-21(4)(5).

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Law Implemented: SDCL 58-17F-5, 58-17F-6, 58-17F-7, 58-17F-8, 58-17F-9.

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