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DEPARTMENT\r\nOF REVENUE AND REGULATION
\r\n\r\n\r\n\r\n
DIVISION\r\nOF INSURANCE
\r\n\r\n\r\n\r\n
\r\n\r\n
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\r\n\r\n
MODEL\r\nNOTICE OF APPEAL RIGHTS
\r\n\r\n\r\n\r\n
\r\n\r\n
Chapter\r\n20:06:53
\r\n\r\n\r\n\r\n
APPENDIX\r\nA
\r\n\r\n\r\n\r\n
SEE:\r\n§ 20:06:53:03
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Source: 37\r\nSDR 48, effective September 22, 2010; 42 SDR 52, effective October 13, 2015.
\r\n\r\nAppendix\r\nA -- Model Notice of Appeal Rights
\r\n\r\n\r\n\r\n
NOTICE\r\nOF APPEAL RIGHTS
\r\n\r\n\r\n\r\n
You\r\nhave a right to appeal any decision we make that denies payment on your claim\r\nor your request for coverage of a health care service or treatment.
\r\n\r\n\r\n\r\n
You\r\nmay request more explanation when your claim or request for coverage of a\r\nhealth care service or treatment is denied or the health care service or\r\ntreatment you received was not fully covered. Contact1 us when\r\nyou:
\r\n\r\n\r\n\r\n
● Do\r\nnot understand the reason for the denial;
\r\n\r\n● Do\r\nnot understand why the health care service or treatment was not fully covered;
\r\n\r\n● Do\r\nnot understand why a request for coverage of a health care service or treatment\r\nwas denied;
\r\n\r\n● Cannot\r\nfind the applicable provision in your Benefit Plan Document;
\r\n\r\n● Want\r\na copy (free of charge) of the guidelines, criteria, or clinical rationale that\r\nwe used to make our decision; or
\r\n\r\n● Disagree\r\nwith the denial or the amount not covered and you want to appeal.
\r\n\r\n\r\n\r\n
If\r\nyour claim was denied due to missing or incomplete information, you or your\r\nhealth care provider may resubmit the claim to us with the necessary\r\ninformation to complete the claim.
\r\n\r\n
Appeals: All\r\nappeals for claim denials (or any decision that does not cover expenses you\r\nbelieve should have been covered) must be sent to [insert address of where\r\nappeals should be sent to the health carrier] within 180 days of the\r\ndate you receive our denial.
\r\n\r\n
External\r\nReview4: If we have denied your request for the\r\nprovision of or payment for a health care service or course of treatment, you\r\nmay have a right to have our decision reviewed by independent health care\r\nprofessionals who have no association with us. If our decision involved making\r\na judgment as to the medical necessity, appropriateness, health care setting,\r\nlevel of care, or effectiveness of the health care service or treatment you\r\nrequested, you may submit a request for external review within four months\r\nafter receipt of this notice to the Division of Insurance, 124 South Euclid\r\nAvenue, 2nd Floor, Pierre, South Dakota 57501. For standard external\r\nreview, a decision will be made within 45 days of receiving your request. If\r\nyou have a medical condition that would seriously jeopardize your life or\r\nhealth or would jeopardize your ability to regain maximum function if treatment\r\nis delayed, you may be entitled to request an expedited external review of our\r\ndenial. If our denial to provide or pay for health care service or course of\r\ntreatment is based on a determination that the service or treatment is\r\nexperimental or investigation, you also may be entitled to file a request for\r\nexternal review of our denial. For details, please review your Benefit Plan\r\nDocument, contact us, or contact your state insurance department.1
\r\n\r\n\r\n\r\n
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DEPARTMENT OF LABOR\r\nAND REGULATION
\r\n\r\n\r\n\r\n
DIVISION OF INSURANCE
\r\n\r\n\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
MODEL EXTERNAL REVIEW\r\nREQUEST FORM
\r\n\r\n\r\n\r\n
\r\n\r\n
Chapter 20:06:53
\r\n\r\n\r\n\r\n
APPENDIX B
\r\n\r\n\r\n\r\n
SEE:\r\n§ 20:06:53:06
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Source: 37 SDR 48, effective September 22, 2010;\r\n42 SDR 52, effective October 13, 2015.
\r\n\r\n\r\n\r\n
Appendix B - Model External\r\nReview Request Form
\r\n\r\n\r\n\r\n
This EXTERNAL REVIEW\r\nREQUEST FORM must be filed with the Division of Insurance within FOUR\r\nMONTHS after receipt from your insurer of a denial of payment on a claim or\r\nrequest for coverage of a health care service or treatment.
\r\n\r\n\r\n\r\n
EXTERNAL REVIEW REQUEST\r\nFORM
\r\n\r\n\r\n\r\n
APPLICANT NAME
\r\n\r\n
COVERED PERSON/PATIENT\r\nINFORMATION
\r\n\r\n\r\n\r\n
Covered Person Name:\r\n________________________________
\r\n\r\nPatient Name:\r\n_______________________________________
\r\n\r\n\r\n\r\n
Address:\r\n________________________________________________________________________
\r\n\r\n__________________________________________________________________________________
\r\n\r\n________________________________________________________________________________
\r\n\r\n\r\n\r\n
Covered Person Phone #: Home\r\n(_____)_________________
\r\n\r\nWork:\r\n(_____)_____________________________________
\r\n\r\n\r\n\r\n
INSURANCE INFORMATION
\r\n\r\n\r\n\r\n
Insurer/HMO Name
\r\n\r\n_______________________________________________________________________________
\r\n\r\n\r\n\r\n
Covered Person Insurance
\r\n\r\nID#:____________________________________________________________________________
\r\n\r\n\r\n\r\n
Insurance Claim/Reference
\r\n\r\n#:______________________________________________________________________________
\r\n\r\n\r\n\r\n
Insurer/HMO Mailing Address:
\r\n\r\n________________________________________________________________________________
\r\n\r\n_______________________________________________________________________________
\r\n\r\n_______________________________________________________________________________
\r\n\r\n\r\n\r\n
Insurer Telephone #:
\r\n\r\n(_____)_________________________________________________________________________
\r\n\r\n\r\n\r\n
EMPLOYER INFORMATION
\r\n\r\n\r\n\r\n
Employer's Name:
\r\n\r\n_______________________________________________________________________________
\r\n\r\n\r\n\r\n
Employer's Phone #:
\r\n\r\n(_____)_________________________________________________________________________
\r\n\r\n\r\n\r\n
Is the health coverage you\r\nhave through your employer a self-funded plan? ______. If you are not certain\r\nplease check with your employer. Most self-funded plans are not eligible for\r\nexternal review. However, some self-funded plans may voluntarily provide\r\nexternal review, but may have different procedures. You should check with your\r\nemployer.
\r\n\r\n\r\n\r\n
HEALTH CARE PROVIDER\r\nINFORMATION
\r\n\r\n\r\n\r\n
Treating Physician/Health\r\nCare Provider:
\r\n\r\n__________________________________________________________________________________
\r\n\r\n\r\n\r\n
Address:___________________________________________________________________________
\r\n\r\n__________________________________________________________________________________
\r\n\r\n________________________________________________________________________________
\r\n\r\n\r\n\r\n
Contact Person:\r\n_______________________________
\r\n\r\nPhone: ( ) \r\n_________________________________
\r\n\r\n\r\n\r\n
Medical Record #:\r\n_____________________________
\r\n\r\nREASON FOR HEALTH CARRIER\r\nDENIAL (Please check one)
\r\n\r\n□
□
\r\n\r\n
SUMMARY OF EXTERNAL REVIEW\r\nREQUEST (Enter a brief description of\r\nthe claim, the request for health care service or treatment that was denied,\r\nand/or attach a copy of the denial from your health carrier)*
\r\n\r\n________________________________________________________________________________________________________________________________________________________________________________________________________
\r\n\r\n*You
\r\n\r\n
EXPEDITED REVIEW
\r\n\r\nIf you need a fast\r\ndecision, you may request that your\r\nexternal appeal be handled on an expedited basis. To complete this request,\r\nyour treating health care provider must fill out the attached form stating that\r\na delay would seriously jeopardize the life or health of the patient or would\r\njeopardize the patient's ability to regain maximum function.
\r\n\r\nIs this a request for an\r\nexpedited appeal? Yes\r\n______ No _______
\r\n\r\n\r\n\r\n
SIGNATURE AND RELEASE OF\r\nMEDICAL RECORDS
\r\n\r\nTo appeal your health\r\ncarrier's denial, you must sign and date this external review request form and\r\nconsent to the release of medical records.
\r\n\r\nI, _______________________,\r\nhereby request an external appeal. I attest that the information provided in\r\nthis application is true and accurate to the best of my knowledge. I authorize\r\nmy insurance company and my health care providers to release all relevant\r\nmedical or treatment records to the independent review organization and the\r\nSouth Dakota Division of Insurance. I understand that the independent review\r\norganization and the South Dakota Division of Insurance will use this\r\ninformation to make a determination on my external appeal and that the\r\ninformation will be kept confidential and not be released to anyone else. This\r\nrelease is valid for one year.
\r\n\r\n_______________________________________________ \r\n____________________
\r\n\r\nSignature of Covered Person\r\n(or legal representative)* Date
\r\n\r\n*(Parent, Guardian, Conservator\r\nor Other - Please Specify)
\r\n\r\n\r\n\r\n
APPOINTMENT OF\r\nAUTHORIZED\r\nREPRESENTATIVE
\r\n\r\nYou can represent yourself,\r\nor you may ask another person, including your treating health care provider, to\r\nact as your authorized representative. You may revoke this authorization at any\r\ntime.
\r\n\r\nI hereby authorize\r\n____________________________________ to pursue my appeal on my behalf.
\r\n\r\n________________________________________________ \r\n______________
\r\n\r\nSignature of Covered Person\r\n(or legal representative)* Date
\r\n\r\n*(Parent, Guardian,\r\nConservator or Other - Please Specify)
\r\n\r\nAddress of Authorized\r\nRepresentative:
\r\n\r\n_______________________________________________________________________
\r\n\r\n_______________________________________________________________________
\r\n\r\n_______________________________________________________________________
\r\n\r\nPhone #.
\r\n\r\nDaytime \r\n(_____)___________________
\r\n\r\nEvening \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
DESCRIBE IN YOUR OWN WORDS\r\nTHE DISAGREEMENT WITH YOUR HEALTH CARRIER. INDICATE CLEARLY THE SERVICE(S)\r\nBEING DENIED AND THE SPECIFIC DATE(S) BEING DENIED. EXPLAIN WHY YOU DISAGREE.\r\nATTACH ADDITIONAL PAGES IF NECESSARY AND INCLUDE AVAILABLE PERTINENT MEDICAL\r\nRECORDS, ANY INFORMATION YOU RECEIVED FROM YOUR HEALTH CARRIER CONCERNING THE\r\nDENIAL, ANY PERTINENT PEER LITERATURE OR CLINICAL STUDIES, AND ANY ADDITIONAL\r\nINFORMATION FROM YOUR PHYSICIAN/HEALTH CARE PROVIDER THAT YOU WANT THE\r\nINDEPENDENT REVIEW ORGANIZATION REVIEWER TO CONSIDER.
\r\n\r\n\r\n\r\n
__________________________________________________________________________________
\r\n\r\n\r\n\r\n
\r\n\r\n
PLEASE CHECK BELOW (NOTE:\r\nYOUR REQUEST WILL NOT BE ACCEPTED FOR FULL REVIEW UNLESS ALL FOUR ITEMS BELOW\r\nARE INCLUDED*)
\r\n\r\n\r\n\r\n
1.
\r\n\r\n
2.
\r\n\r\n
3.
(a) Their\r\ndecision is final and that I have exhausted all internal review procedures; or
\r\n\r\n(b) They\r\nhave waived the requirement to exhaust all of the health carrier's internal\r\nreview procedures.
\r\n\r\n\r\n\r\n
**You may make a request for\r\nexternal review without exhausting all internal review procedures under certain\r\ncircumstances. You should contact the Division of Insurance, 124 South Euclid\r\nAvenue, 2nd Floor, Pierre, SD 57501.
\r\n\r\n\r\n\r\n
4.
\r\n\r\n
*Call the Division of\r\nInsurance at 605.773.3563 if you need help in completing this application or if\r\nyou do not have one or more of the above items and would like information on\r\nalternative ways to complete your request for external review.
\r\n\r\n\r\n\r\n
If you are requesting a\r\nstandard external review, send all paperwork to:
\r\n\r\n\r\n\r\n
South Dakota Division of\r\nInsurance
\r\n\r\n124 South Euclid Avenue, 2nd\r\nFloor
\r\n\r\nPierre, SD 57501
\r\n\r\n\r\n\r\n
If you are requesting an\r\nexpedited external review, call the Division of Insurance before sending your\r\npaperwork, and you will receive instructions on the quickest way to submit the\r\napplication and supporting information.
\r\n\r\n\r\n\r\n
\r\n\r\n
NOTE TO THE TREATING\r\nHEALTH CARE PROVIDER
\r\n\r\n\r\n\r\n
Patients can request an\r\nexternal review when a health center has denied a health care service or course\r\nof treatment on the basis of a utilization review determination that the\r\nrequested health care service or course of treatment does not meet the health\r\ncarrier's requirements for medical necessity, appropriateness, health care\r\nsetting, level of care, or effectiveness of the health care service or\r\ntreatment you requested. The South Dakota Division of Insurance oversees\r\nexternal appeals. The standard external review process can take up to 45 days\r\nfrom the date the patient's request for external review is received by our\r\ndivision. Expedited external review is available only if the patient's treating\r\nhealth care provider certifies that adherence to the timeframe for the standard\r\nexternal review would seriously jeopardize the life or health of the covered\r\nperson or would jeopardize the covered person's ability to regain maximum\r\nfunction. An expedited external review must be completed within 72 hours. This\r\nform is for the purpose of providing the certification necessary to trigger\r\nexpedited review.
\r\n\r\n\r\n\r\n
GENERAL INFORMATION
\r\n\r\n\r\n\r\n
Name of Treating Health Care\r\nProvider:
\r\n\r\n__________________________________________________________________________________
\r\n\r\n\r\n\r\n
Mailing Address:
\r\n\r\n__________________________________________________________________________________
\r\n\r\n__________________________________________________________________________________________________________________________________________________________________
\r\n\r\n\r\n\r\n
Phone Number:\r\n(_____)_______________________
\r\n\r\nFax Number: \r\n(_____)_______________________
\r\n\r\n\r\n\r\n
Licensure and Area of\r\nClinical Specialty:
\r\n\r\n_________________________________________________________________________________
\r\n\r\n________________________________________________________________________________
\r\n\r\n\r\n\r\n
Name of Patient:
\r\n\r\n__________________________________________________________________________________
\r\n\r\n\r\n\r\n
Patient's Insurer Member ID#:
\r\n\r\n__________________________________________________________________________________
\r\n\r\n\r\n\r\n
CERTIFICATION
\r\n\r\n\r\n\r\n
I hereby certify that: I am a\r\ntreating health care provider for
\r\n\r\n_________________________________________________
\r\n\r\n(hereafter referred to as\r\n"the patient"); that adherence to the timeframe of conducting a\r\nstandard external review of the patient's appeal would, in my professional\r\njudgment, seriously jeopardize the life or health of the patient or would\r\njeopardize the patient's ability to regain maximum function; and that, for this\r\nreason, the patient's appeal of the denial by the patient's health carrier of\r\nthe requested health care service or course of treatment should be processed on\r\nan expedited basis.
\r\n\r\n\r\n\r\n
___________________________________________
\r\n\r\nTreating Health Care\r\nProvider's Name (Please Print)
\r\n\r\n___________________________________________ _________________
\r\n\r\nSignature Date
\r\n\r\n\r\n\r\n
\r\n\r\n
\r\n\r\n
I hereby certify that I am\r\nthe treating physician for ______________________ (insured's name) and that I\r\nhave requested the authorization for a drug, device, procedure, or therapy\r\ndenied for coverage due to the insurance company's determination that the\r\nproposed therapy is experimental and/or investigational. I understand that in\r\norder for the covered person to obtain the right to an external review of this\r\ndenial, as treating physician I must certify that the insured's medical condition\r\nmeets certain requirements:
\r\n\r\n\r\n\r\n
In my medical opinion as\r\nthe Insured's treating physician, I hereby certify to the following:
\r\n\r\n(Please check all that\r\napply) (NOTE: Requirements #1 - #3\r\nbelow must all apply for the covered person to qualify for an external review).
\r\n\r\n\r\n\r\n
\r\n\r\n
□
\r\n\r\n
Explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
\r\n\r\n\r\n\r\n
Explain:
\r\n\r\n____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
\r\n\r\n\r\n\r\n
Please provide a description\r\nof the recommended or requested health care service or treatment that is the\r\nsubject of the denial. (Attach additional sheets as necessary)
\r\n\r\n\r\n\r\n
____________________________________________________________________________________________________________________________________________________________________
\r\n\r\n________________________________________________________________________________
\r\n\r\n\r\n\r\n
__________________________________________________________________________________
\r\n\r\nPhysician's Signature Date
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Source: 37 SDR\r\n48, effective September 22, 2010.
\r\n\r\n\r\n\r\n
Appendix C - Independent\r\nReview Organization External Review Annual Report Form
\r\n\r\n\r\n\r\n
\r\n\r\n
\r\n\r\n
| \r\n | \r\n ||||||||
| \r\n Due on\r\n [________] for previous calendar year. \r\n\r\n | \r\n ||||||||
| \r\n Each independent review\r\n organization (IRO) shall submit an annual report with information for each\r\n health carrier in the aggregate on external reviews performed in South Dakota\r\n only. \r\n | \r\n ||||||||
| \r\n \r\n | \r\n ||||||||
| \r\n 1. IRO\r\n name: \r\n | \r\n \r\n \r\n | \r\n \r\n Filing \r\nDate: \r\n | \r\n \r\n \r\n | \r\n |||||
| \r\n 2. IRO\r\n License/ \r\nCertification\r\n no.: \r\n | \r\n \r\n \r\n | \r\n |||||||
| \r\n 3. IRO\r\n address: \r\n\r\n | \r\n \r\n \r\n | \r\n |||||||
| \r\n City, State, Zip: \r\n\r\n | \r\n \r\n \r\n | \r\n |||||||
| \r\n 4. IRO\r\n Web site: \r\n\r\n | \r\n \r\n \r\n | \r\n |||||||
| \r\n 5. Name,\r\n email address, phone and fax number of the person completing this form: \r\n_____________________________________________________________________________ \r\n_____________________________________________________________________________ \r\n_____________________________________________________________________________ \r\n_____________________________________________________________________________ \r\n | \r\n ||||||||
| \r\n 6. Name and\r\n title of the person responsible for regulatory compliance and quality of \r\nexternal reviews: \r\n | \r\n ||||||||
| \r\n Name: \r\n | \r\n \r\n _______________________ \r\n | \r\n \r\n Title: \r\n | \r\n \r\n _______________________ \r\n | \r\n |||||
| \r\n 7. Total\r\n number of requests for external review \r\nreceived from\r\n South Dakota Division of \r\nInsurance during\r\n the reporting period: \r\n | \r\n \r\n \r\n \r\n _____________________ \r\n | \r\n |||||||
| \r\n 8. Number\r\n of standard \r\nexternal reviews. \r\n | \r\n \r\n \r\n | \r\n \r\n \r\n \r\n | \r\n ||||||
| \r\n 9. Average\r\n number of days IRO required \r\nto reach a final\r\n decision in standard \r\nreviews: \r\n | \r\n \r\n \r\n | \r\n \r\n \r\n \r\n \r\n | \r\n ||||||
| \r\n 10. Number of\r\n expedited reviews \r\ncompleted to a\r\n final decision: \r\n | \r\n \r\n \r\n | \r\n \r\n \r\n \r\n | \r\n ||||||
| \r\n 11. Average number\r\n of days IRO required to reach a final \r\ndecision in\r\n expedited reviews: \r\n | \r\n \r\n _____________________ \r\n | \r\n |||||||
| \r\n 12. Number of\r\n medical necessity reviews decided in favor \r\nof the health\r\n carrier: \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\r\n
| \r\n Briefly list procedures \r\ndenied: \r\n | \r\n \r\n ________________________________________________________________________________________________________ \r\n | \r\n ||||
| \r\n 13. Number of\r\n medical necessity reviews decided in favor of \r\nthe covered person: \r\n | \r\n \r\n _____________________ \r\n | \r\n ||||
| \r\n Briefly list procedures\r\n \r\napproved: \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 14. Number of\r\n experimental/investigational reviews decided in favor \r\nof the health\r\n carrier: \r\n | \r\n \r\n _______________ \r\n | \r\n ||||
| \r\n Briefly list procedures\r\n denied: \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 15. Number of\r\n experimental/investigational reviews decided in favor \r\nof the covered\r\n person: \r\n | \r\n \r\n _______________ \r\n | \r\n ||||
| \r\n Briefly list procedures \r\napproved: \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 16. Number of\r\n reviews terminated as the result of a \r\nreconsideration\r\n by the health carrier: \r\n | \r\n \r\n _________________ \r\n | \r\n ||||
| \r\n 17. Number of\r\n reviews terminated by the covered \r\nperson: \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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| \r\n 18. Number of reviews\r\n declined due to \r\npossible conflict\r\n with: \r\n | \r\n \r\n \r\n | \r\n
| \r\n ||||||
| \r\n Health carrier \r\n | \r\n \r\n __________ \r\n | \r\n \r\n Covered person \r\n | \r\n \r\n __________ \r\n | \r\n \r\n Health care \r\nprovider \r\n | \r\n \r\n __________ \r\n | \r\n |||
| \r\n Describe possible\r\n conflicts(s) of \r\ninterest: \r\n | \r\n \r\n ______________________________________________ \r\n______________________________________________ \r\n | \r\n |||||||
| \r\n 19. Number of reviews\r\n declined due to other reasons not reflected \r\n | \r\n \r\n \r\n | \r\n |||||||
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Source: 37 SDR\r\n48, effective September 22, 2010.
\r\n\r\nAppendix D - Model Health\r\nCarrier External Review Annual Report Form
\r\n\r\n\r\n\r\n
\r\n\r\n
| \r\n External\r\n Review Annual Summary for 20_____ \r\n | \r\n |||||
| \r\n \r\n | \r\n |||||
| \r\n Due on\r\n ___________for previous calendar \r\nyear. \r\n | \r\n \r\n \r\n | \r\n ||||
| \r\n Each health carrier\r\n shall submit an annual report with information in the aggregate by state and\r\n by type of health benefit plan. \r\n | \r\n |||||
| \r\n \r\n | \r\n |||||
| \r\n 1. Health\r\n carrier name: \r\n | \r\n \r\n \r\n | \r\n \r\n Filing Date: \r\n | \r\n \r\n \r\n | \r\n ||
| \r\n 2. Health\r\n carrier \r\naddress: \r\n | \r\n \r\n \r\n | \r\n ||||
| \r\n City, State, ZIP: \r\n\r\n | \r\n \r\n \r\n | \r\n ||||
| \r\n 3. Health\r\n carrier Web \r\nsite: \r\n | \r\n \r\n \r\n | \r\n ||||
| \r\n 4. Name, email\r\n address, phone and fax number of the person completing this form: \r\n______________________________________________________________________________ \r\n______________________________________________________________________________ \r\n______________________________________________________________________________ \r\n______________________________________________________________________________ \r\n______________________________________________________________________________ \r\n\r\n | \r\n |||||
| \r\n 5. Total\r\n number of external review requests received from the South Dakota Division \r\nof Insurance\r\n during the reporting period: \r\n | \r\n \r\n _______ \r\n | \r\n ||||
| \r\n 6. From the\r\n total number of external review requests provided in Question 5, the \r\nnumber of requests\r\n determined eligible for a full external review: \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
CHAPTER 20:06:53
EXTERNAL AND INTERNAL REVIEW
20:06:53:01Â Â Â Â Â Â Â Â Definitions.
20:06:53:02Â Â Â Â Â Â Â Â Applicability.
20:06:53:03Â Â Â Â Â Â Â Â Notice of right to external review.
20:06:53:04Â Â Â Â Â Â Â Â Content of notices.
20:06:53:05Â Â Â Â Â Â Â Â Review procedures and authorization to accompany notice.
20:06:53:06Â Â Â Â Â Â Â Â Request for external review.
20:06:53:07Â Â Â Â Â Â Â Â Exhaustion of internal grievance process required.
20:06:53:08Â Â Â Â Â Â Â Â When exhaustion of internal grievance occurs.
20:06:53:09Â Â Â Â Â Â Â Â Request for expedited review.
20:06:53:10Â Â Â Â Â Â Â Â Determination of expedited review.
20:06:53:11Â Â Â Â Â Â Â Â Waiver of exhaustion requirement.
20:06:53:12Â Â Â Â Â Â Â Â Standard external review.
20:06:53:13Â Â Â Â Â Â Â Â Notification following preliminary review.
20:06:53:14Â Â Â Â Â Â Â Â Determination by the director and assignment of independent review organization.
20:06:53:15Â Â Â Â Â Â Â Â Independence of review decision.
20:06:53:16Â Â Â Â Â Â Â Â Health carrier required to provide information.
20:06:53:17Â Â Â Â Â Â Â Â Effect of failure to act on external review process.
20:06:53:18Â Â Â Â Â Â Â Â Independent review organization review of information.
20:06:53:19Â Â Â Â Â Â Â Â Carrier reconsideration.
20:06:53:20Â Â Â Â Â Â Â Â Information to be considered by independent review organization.
20:06:53:21Â Â Â Â Â Â Â Â Independent review organization decisions.
20:06:53:22Â Â Â Â Â Â Â Â Director assignment of independent review organization.
20:06:53:23Â Â Â Â Â Â Â Â Expedited external review.
20:06:53:24Â Â Â Â Â Â Â Â Notifications upon request for expedited external review.
20:06:53:25Â Â Â Â Â Â Â Â Director's determination of eligibility for expedited reviews.
20:06:53:26Â Â Â Â Â Â Â Â Director assignment of independent review organization for expedited reviews.
20:06:53:27Â Â Â Â Â Â Â Â Independent review organization decision for expedited reviews.
20:06:53:28Â Â Â Â Â Â Â Â Information to be considered by independent review organization for expedited review.
20:06:53:29Â Â Â Â Â Â Â Â Expedited review decision.
20:06:53:30Â Â Â Â Â Â Â Â Health carrier required to approve upon reversal by expedited review.
20:06:53:31Â Â Â Â Â Â Â Â Assignment of independent review organization for expedited reviews.
20:06:53:32Â Â Â Â Â Â Â Â Applicability of expedited reviews.
20:06:53:33Â Â Â Â Â Â Â Â External review of experimental or investigational treatment adverse determinations.
20:06:53:34Â Â Â Â Â Â Â Â Notifications upon request for external review of experimental or investigational treatment adverse determinations.
20:06:53:35Â Â Â Â Â Â Â Â Director's determination of eligibility and assignment for external review of experimental or investigational treatment.
20:06:53:36Â Â Â Â Â Â Â Â Health carrier preliminary review of request for experimental or investigational treatment reviews.
20:06:53:37Â Â Â Â Â Â Â Â Health carrier notification after preliminary review of request for experimental or investigational treatment reviews.
20:06:53:38Â Â Â Â Â Â Â Â Director's determination of request for experimental or investigational treatment reviews.
20:06:53:39Â Â Â Â Â Â Â Â Health carrier notification of eligibility for experimental or investigational treatment reviews.
20:06:53:40Â Â Â Â Â Â Â Â Independent review organization experimental or investigational treatment reviews.
20:06:53:41Â Â Â Â Â Â Â Â Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews.
20:06:53:42Â Â Â Â Â Â Â Â Records provided to independent review organization for experimental or investigational treatment reviews.
20:06:53:43Â Â Â Â Â Â Â Â Review of information by independent review organization for experimental or investigational treatment reviews.
20:06:53:44Â Â Â Â Â Â Â Â Reconsideration by health carrier for experimental or investigational treatment reviews.
20:06:53:45Â Â Â Â Â Â Â Â Clinical review opinion for experimental or investigational treatment reviews.
20:06:53:46Â Â Â Â Â Â Â Â Expedited review opinions for experimental or investigational treatment reviews.
20:06:53:47Â Â Â Â Â Â Â Â Clinical review criteria for experimental or investigational treatment reviews.
20:06:53:48Â Â Â Â Â Â Â Â Independent review organization decision and notice for experimental or investigational treatment reviews.
20:06:53:49Â Â Â Â Â Â Â Â Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews.
20:06:53:50Â Â Â Â Â Â Â Â Decision by independent review organization for experimental or investigational treatment reviews.
20:06:53:51Â Â Â Â Â Â Â Â Notice of written decision by independent review organization for experimental or investigational treatment reviews.
20:06:53:52Â Â Â Â Â Â Â Â Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational treatment reviews.
20:06:53:53Â Â Â Â Â Â Â Â Criteria for assignment of independent review organization for experimental or investigational treatment reviews.
20:06:53:54Â Â Â Â Â Â Â Â Binding nature of external review decision.
20:06:53:55Â Â Â Â Â Â Â Â Approval of independent review organizations.
20:06:53:56Â Â Â Â Â Â Â Â Continuation of approval for independent review organizations.
20:06:53:57Â Â Â Â Â Â Â Â Minimum qualifications for independent review organizations.
20:06:53:58Â Â Â Â Â Â Â Â Requirements for clinical reviewers.
20:06:53:59Â Â Â Â Â Â Â Â Subsidiaries of or ownership in independent review organizations.
20:06:53:60Â Â Â Â Â Â Â Â Independence of clinical reviewers.
20:06:53:61Â Â Â Â Â Â Â Â Nationally accredited independent review organizations.
20:06:53:62Â Â Â Â Â Â Â Â Unbiased independent review organization.
20:06:53:63Â Â Â Â Â Â Â Â Hold harmless for independent review organizations.
20:06:53:64Â Â Â Â Â Â Â Â External review reporting requirements.
20:06:53:65Â Â Â Â Â Â Â Â Independent review organization and health carrier recordkeeping.
20:06:53:66Â Â Â Â Â Â Â Â Funding of external review.
20:06:53:67Â Â Â Â Â Â Â Â Disclosure requirements.
20:06:53:68Â Â Â Â Â Â Â Â Adverse benefit determination -- Defined.
20:06:53:69Â Â Â Â Â Â Â Â Urgent care requests -- Timely notification of determination -- Initial benefit determination.
20:06:53:70Â Â Â Â Â Â Â Â Additional evidence.
20:06:53:71Â Â Â Â Â Â Â Â Avoiding conflicts of interest.
20:06:53:72Â Â Â Â Â Â Â Â Notice to enrollee.
20:06:53:73Â Â Â Â Â Â Â Â Failure to comply with internal claims and appeal process.
20:06:53:74Â Â Â Â Â Â Â Â Continued coverage and ongoing treatment.
20:06:53:75Â Â Â Â Â Â Â Â One level of internal appeals.
20:06:53:76Â Â Â Â Â Â Â Â Record keeping.
20:06:53:77Â Â Â Â Â Â Â Â Applicability.
20:06:53:78Â Â Â Â Â Â Â Â Strictly adhere -- Defined.
20:06:53:79Â Â Â Â Â Â Â Â Written explanation of violation.
20:06:53:80Â Â Â Â Â Â Â Â Procedure when immediate review request denied.
Appendix AÂ Â Â Â Model notice of appeal rights.
Appendix BÂ Â Â Â Model external review request form.
Appendix CÂ Â Â Â Independent review organization external review annual report form.
Appendix DÂ Â Â Â Model health carrier external review annual report form.
(1) "Adverse\r\ndetermination," a determination by a health carrier or its designee\r\nutilization review organization that an admission, availability of care,\r\ncontinued stay, or other health care service that is a covered benefit has been\r\nreviewed and, based upon the information provided, does not meet the health\r\ncarrier's requirements for medical necessity, appropriateness, health care\r\nsetting, level of care, or effectiveness, and the requested service or payment\r\nfor the service is therefore denied, reduced, or terminated. A rescission of\r\ncoverage is an adverse determination;
\r\n\r\n(2) "Ambulatory\r\nreview," utilization review of health care services performed or provided\r\nin an outpatient setting;
\r\n\r\n(3) "Authorized\r\nrepresentative," any person to whom a covered person has given express\r\nwritten consent to represent the covered person in an external review; any\r\nperson authorized by law to provided substituted consent for a covered person;\r\nor any family member of the covered person or the covered person's treating\r\nhealth care professional, but only if the covered person is unable to provide\r\nconsent;
\r\n\r\n(4) "Best\r\nevidence," evidence based on:
\r\n\r\n(a) Randomized\r\nclinical trials;
\r\n\r\n(b) If\r\nrandomized clinical trials are not available, cohort studies or case-control\r\nstudies;
\r\n\r\n(c) If\r\nsubsections (a) and (b) are not available, case-series; or
\r\n\r\n(d) If\r\nsubsections (a), (b), and (c) are not available, expert opinion;
\r\n\r\n(5) "Case-control\r\nstudy," a retrospective evaluation of two groups of patients with\r\ndifferent outcomes to determine which specific interventions the patients\r\nreceived;
\r\n\r\n(6) "Case\r\nmanagement," a coordinated set of activities conducted for individual\r\npatient management of serious, complicated, protracted, or other health\r\nconditions;
\r\n\r\n(7) "Case-series,"\r\nan evaluation of a series of patients with a particular outcome, without the\r\nuse of a control group;
\r\n\r\n(8) "Certification,"\r\na determination by a health carrier or its designee utilization review organization\r\nthat an admission, availability of care, continued stay, or other health care\r\nservice has been reviewed and, based on the information provided, satisfies the\r\nhealth carrier's requirements for medical necessity, appropriateness, health\r\ncare setting, level of care, and effectiveness;
\r\n\r\n(9) "Clinical\r\nreview criteria," the written screening procedures, decision abstracts,\r\nclinical protocols, and practice guidelines used by a health carrier to\r\ndetermine the necessity and appropriateness of health care services;
\r\n\r\n(10) "Cohort\r\nstudy," a prospective evaluation of two groups of patients with only one\r\ngroup of patients receiving a specific intervention;
\r\n\r\n(11) "Concurrent\r\nreview," utilization review conducted during a patient's hospital stay or\r\ncourse of treatment;
\r\n\r\n(12) "Covered\r\nbenefits" or "benefits," those health care services to which a\r\ncovered person is entitled under the terms of a health benefit plan;
\r\n\r\n(13) "Covered\r\nperson," a policyholder, subscriber, enrollee, or other individual\r\nparticipating in a health benefit plan;
\r\n\r\n(14) "Discharge\r\nplanning," the formal process for determining, prior to discharge from a\r\nfacility, the coordination and management of the care that a patient receives\r\nfollowing discharge from a facility;
\r\n\r\n(15) "Disclose,"\r\nto release, transfer, or otherwise divulge protected health information to any\r\nperson other than the individual who is the subject of the protected health\r\ninformation;
\r\n\r\n(16) "Emergency\r\nmedical condition," the sudden and, at the time, unexpected onset of a\r\nhealth condition or illness that requires immediate medical attention, where\r\nfailure to provide medical attention would result in a serious impairment to\r\nbodily functions, serious dysfunction of a bodily organ or part, or would place\r\nthe person's health in serious jeopardy;
\r\n\r\n(17) "Emergency\r\nservices," health care items and services furnished or required to\r\nevaluate and treat an emergency medical condition;
\r\n\r\n(18) "Evidence-based\r\nstandard," the conscientious, explicit, and judicious use of the current\r\nbest evidence based on the overall systematic review of the research in making\r\ndecisions about the care of individual patients;
\r\n\r\n(19) "Expert\r\nopinion," a belief or an interpretation by specialists with experience in\r\na specific area about the scientific evidence pertaining to a particular\r\nservice, intervention, or therapy;
\r\n\r\n(20) "Facility,"\r\nan institution providing health care services or a health care setting,\r\nincluding, hospitals and other licensed inpatient centers, ambulatory surgical\r\nor treatment centers, skilled nursing centers, residential treatment centers,\r\ndiagnostic, laboratory, and imaging centers, and rehabilitation and other\r\ntherapeutic health settings;
\r\n\r\n(21) "Final\r\nadverse determination," an adverse determination involving a covered\r\nbenefit that has been upheld by a health carrier, or its designee utilization\r\nreview organization, at the completion of the health carrier's internal\r\ngrievance process procedures as set forth in SDCL 58-17I-1 to 58-17I-16, inclusive;
\r\n\r\n(22) "Health\r\nbenefit plan," a policy, contract, certificate, or agreement offered or\r\nissued by a health carrier to provide, deliver, arrange for, pay for, or\r\nreimburse any of the costs of health care services;
\r\n\r\n(23) 'Health\r\ncare professional," a physician or other health care practitioner\r\nlicensed, accredited, or certified to perform specified health care services\r\nconsistent with state law;
\r\n\r\n(24) "Health\r\ncare provider" or "provider," a health care professional or a\r\nfacility;
\r\n\r\n(25) "Health\r\ncare services," services for the diagnosis, prevention, treatment, cure or\r\nrelief of a health condition, illness, injury, or disease;
\r\n\r\n(26) "Health\r\ninformation," information or data, whether oral or recorded in any form or\r\nmedium, and personal facts or information about events or relationships that\r\nrelates to:
\r\n\r\n(a) The\r\npast, present, or future physical, mental, or behavioral health or condition of\r\nan individual or a member of the individual's family;
\r\n\r\n(b) The\r\nprovision of health care services to an individual; or
\r\n\r\n(c) Payment\r\nfor the provision of health care services to an individual;
\r\n\r\n(27) "Independent\r\nreview organization," an entity that conducts independent external reviews\r\nof adverse determinations and final adverse determinations;
\r\n\r\n(28) "Medical\r\nor scientific evidence," evidence found in the following sources:
\r\n\r\n(a) Peer-reviewed\r\nscientific studies published in, or accepted for publication by, medical\r\njournals that meet nationally recognized requirements for scientific\r\nmanuscripts and that submit most of their published articles for review by\r\nexperts who are not part of the editorial staff;
\r\n\r\n(b) Peer-reviewed\r\nmedical literature, including literature relating to therapies reviewed and\r\napproved by a qualified institutional review board, biomedical compendia, and\r\nother medical literature that meet the criteria of the National Institutes of\r\nHealth's Library of Medicine for indexing in Index Medicus (Medline) and\r\nElsevier Science Ltd. for indexing in Excerpta Medicus (EMBASE);
\r\n\r\n(c) Medical\r\njournals recognized by the Secretary of Health and Human Services under Section\r\n1861(t)(2) of the federal Social Security Act;
\r\n\r\n(d) The\r\nfollowing standard reference compendia:
\r\n\r\n(i) The\r\nAmerican Hospital Formulary Service-Drug Information;
\r\n\r\n(ii) Drug\r\nFacts and Comparisons;
\r\n\r\n(iii) The\r\nAmerican Dental Association Accepted Dental Therapeutics; and
\r\n\r\n(iv) The\r\nUnited States Pharmacopoeia-Drug Information;
\r\n\r\n(e) Findings,\r\nstudies, or research conducted by or under the auspices of federal government\r\nagencies and nationally recognized federal research institutes, including:
\r\n\r\n(i) The\r\nfederal Agency for Healthcare Research and Quality;
\r\n\r\n(ii) The\r\nNational Institutes of Health;
\r\n\r\n(iii) The\r\nNational Cancer Institute;
\r\n\r\n(iv) The\r\nNational Academy of Sciences;
\r\n\r\n(v) The\r\nCenters for Medicare & Medicaid Services;
\r\n\r\n(vi) The\r\nfederal Food and Drug Administration; and
\r\n\r\n(vii) Any\r\nnational board recognized by the National Institutes of Health for the purpose\r\nof evaluating the medical value of health care services; or
\r\n\r\n(f) Any\r\nother medical or scientific evidence that the director determines is comparable\r\nto the sources listed in subsections (a) to (e), inclusive;
\r\n\r\n(29) "NAIC,"\r\nthe National Association of Insurance Commissioners;
\r\n\r\n(30) "Prospective\r\nreview," utilization review conducted prior to an admission or a course of\r\ntreatment;
\r\n\r\n(31) "Protected\r\nhealth information," health information:
\r\n\r\n(a) That\r\nidentifies an individual who is the subject of the information; or
\r\n\r\n(b) With\r\nrespect to which there is a reasonable basis to believe that the information\r\ncould be used to identify an individual;
\r\n\r\n(32) "Randomized\r\nclinical trial," a controlled, prospective study of patients that have\r\nbeen randomized into an experimental group and a control group at the beginning\r\nof the study with only the experimental group of patients receiving a specific\r\nintervention, which includes study of the groups for variables and anticipated\r\noutcomes over time;
\r\n\r\n(33) "Retrospective\r\nreview," a review of medical necessity conducted after services have been\r\nprovided to a patient, but does not include the review of a claim that is\r\nlimited to an evaluation of reimbursement levels, veracity of documentation,\r\naccuracy of coding, or adjudication for payment;
\r\n\r\n(34) "Second\r\nopinion," an opportunity or requirement to obtain a clinical evaluation by\r\na provider other than the one originally making a recommendation for a proposed\r\nhealth care service to assess the clinical necessity and appropriateness of the\r\ninitial proposed health care service;
\r\n\r\n(35) "Utilization\r\nreview," a set of formal techniques designed to monitor the use of, or\r\nevaluate the clinical necessity, appropriateness, efficacy, or efficiency of,\r\nhealth care services, procedures, or settings. Techniques may include\r\nambulatory review, prospective review, second opinion, certification,\r\nconcurrent review, case management, discharge planning, or retrospective\r\nreview;
\r\n\r\n(36) "Utilization\r\nreview organization," an entity that conducts utilization review, other\r\nthan a health carrier performing a review of its own health benefit plan.
\r\n\r\n
20:06:53:03. Notice\r\nof right to external review. A health carrier shall notify the covered\r\nperson in writing of the covered person's right to request an external review\r\nto be conducted pursuant to §§ 20:06:53:12 to 20:06:53:53, inclusive, and\r\ninclude the appropriate statements and information set forth in this section at\r\nthe same time the health carrier sends written notice of:
\r\n\r\n\r\n\r\n
(1) An adverse determination upon\r\ncompletion of the health carrier's utilization review process set forth in SDCL 58-17H-1 to 58-17H-49, inclusive; and
\r\n\r\n(2) A final adverse determination.
\r\n\r\n\r\n\r\n
As part of the written notice required by this\r\nsection, a health carrier includes the following, or substantially equivalent,\r\nlanguage: "We have denied your request for the provision of, or payment\r\nfor, a health care service or course of treatment. You may have the right to\r\nhave our decision reviewed by health care professionals who have no association\r\nwith us if our decision involved making a judgment as to the medical necessity,\r\nappropriateness, health care setting, level of care, or effectiveness of the\r\nhealth care service or treatment you requested by submitting a request for\r\nexternal review to the South Dakota Division of Insurance, 124 South Euclid\r\nAvenue, 2nd Floor, Pierre, South Dakota 57501." The notice as\r\ncontained in Appendix A, or a substantially similar form as may be approved by\r\nthe director, must be used.
\r\n\r\n\r\n\r\n
Source: 37 SDR 48, effective September 22,\r\n2010; 37 SDR 241, effective July 1, 2011; 42 SDR 52, effective October 13,\r\n2015.
\r\n\r\nGeneral Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.
\r\n\r\nLaw Implemented: SDCL 58-17-87, 58-18-79.
\r\n\r\n\r\n\r\n
(1) For\r\na notice related to an adverse determination, a statement informing the covered\r\nperson that:
\r\n\r\n(a) If\r\nthe covered person has a medical condition where the timeframe for completion\r\nof an expedited review of a grievance involving an adverse determination set\r\nforth in SDCL 58-17I-12 to 58-17I-15, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function, the covered person or the covered person's authorized representative may file a request for an expedited external review to be conducted pursuant to §§ 20:06:53:23 to 20:06:53:32, inclusive, or §§ 20:06:53:33 to 20:06:53:54, inclusive;
\r\n\r\n(b) If:
\r\n\r\n(i) The\r\nadverse determination involves a denial of coverage based on a determination\r\nthat the recommended or requested health care service or treatment is\r\nexperimental or investigational and the covered person's treating physician\r\ncertifies in writing that the recommended or requested health care service or\r\ntreatment that is the subject of the adverse determination would be\r\nsignificantly less effective if not promptly initiated; and
\r\n\r\n(ii) At\r\nthe same time the covered person or the covered person's authorized\r\nrepresentative files a request for an expedited review of a grievance involving\r\nan adverse determination as set forth in SDCL 58-17I-12 to 58-17I-15, inclusive, then the independent review organization assigned to conduct the expedited external review will determine whether the covered person is required to complete the expedited review of the grievance prior to conducting the expedited external review; and
\r\n\r\n(c) The\r\ncovered person or the covered person's authorized representative may file a\r\ngrievance under the health carrier's internal grievance process as set forth in\r\nSDCL 58-17I-1 to 58-17I-16, inclusive, but if the health carrier has not issued a written decision to the covered person or the covered person's authorized representative within 30 days following the date the covered person or the covered person's authorized representative files the grievance with the health carrier and the covered person or the covered person's authorized representative has not requested or agreed to a delay, the covered person or the covered person's authorized representative may file a request for external review pursuant to § 20:06:53:06 and shall be considered to have exhausted the health carrier's internal grievance process for purposes of §§ 20:06:53:07 to 20:06:53:11, inclusive; and
\r\n\r\n(2) For\r\na notice related to a final adverse determination, a statement informing the\r\ncovered person that:
\r\n\r\n(a) If\r\nthe covered person has a medical condition where the timeframe for completion\r\nof a standard external review pursuant to §§ 20:06:53:12 to 20:06:53:22,\r\ninclusive, would seriously jeopardize the life or health of the covered person\r\nor would jeopardize the covered person's ability to regain maximum function,\r\nthe covered person or the covered person's authorized representative may file a\r\nrequest for an expedited external review pursuant to §§ 20:06:53:23 to\r\n20:06:53:32, inclusive; or
\r\n\r\n(b) If\r\nthe final adverse determination concerns:
\r\n\r\n(i) An\r\nadmission, availability of care, continued stay, or health care service for\r\nwhich the covered person received emergency services, but has not been\r\ndischarged from a facility, the covered person or the covered person's\r\nauthorized representative may request an expedited external review pursuant to\r\n§§ 20:06:53:23 to 20:06:53:32, inclusive; or
\r\n\r\n(ii) A\r\ndenial of coverage based on a determination that the recommended or requested\r\nhealth care service or treatment is experimental or investigational, the\r\ncovered person or the covered person's authorized representative may file a\r\nrequest for a standard external review to be conducted pursuant to\r\n§§ 20:06:53:33 to 20:06:53:53, inclusive, or if the covered person's\r\ntreating physician certifies in writing that the recommended or requested\r\nhealth care service or treatment that is the subject of the request would be\r\nsignificantly less effective if not promptly initiated, the covered person or\r\nthe covered person's authorized representative may request an expedited\r\nexternal review to be conducted under §§ 20:06:53:33 to 20:06:53:53,\r\ninclusive.
\r\n\r\n
As\r\npart of any forms provided under this section, the health carrier shall include\r\nan authorization form, or other document approved by the director that complies\r\nwith the requirements of 45 C.F.R § 164.508, by which the covered person, for\r\npurposes of conducting an external review under this chapter, authorizes the\r\nhealth carrier and the covered person's treating health care provider to\r\ndisclose protected health information, including medical records, concerning\r\nthe covered person that are pertinent to the external review, as provided in\r\n§ 20:06:45:27.
\r\n\r\n
The\r\nform to be used for external review requests is in Appendix B. A covered person\r\nor the covered person's authorized representative may make a request for an\r\nexternal review of an adverse determination or final adverse determination.
\r\n\r\n
(1) Has\r\nfiled a grievance involving an adverse determination pursuant to SDCL 58-17I-7 to 58-17I-11, inclusive; and
\r\n\r\n(2) Except\r\nto the extent the covered person or the covered person's authorized\r\nrepresentative requested or agreed to a delay, has not received a written\r\ndecision on the grievance from the health carrier within 30 days following the\r\ndate the covered person or the covered person's authorized representative filed\r\nthe grievance with the health carrier. However, a covered person or the covered\r\nperson's authorized representative may not make a request for an external\r\nreview of an adverse determination involving a retrospective review\r\ndetermination made pursuant to SDCL 58-17I-7 to 58-17I-11, inclusive, until the covered person has exhausted the health carrier's internal grievance process.
\r\n\r\n
(1) Under\r\n§§ 20:06:53:23 to 20:06:53:32, inclusive, if the covered person has a\r\nmedical condition where the timeframe for completion of an expedited review of\r\nthe grievance involving an adverse determination set forth in SDCL 58-17I-12 to 58-17I-15, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; or
\r\n\r\n(2) Under\r\n§§ 20:06:53:33 to 20:06:53:53, inclusive, if the adverse determination\r\ninvolves a denial of coverage based on a determination that the recommended or\r\nrequested health care service or treatment is experimental or investigational\r\nand the covered person's treating physician certifies in writing that the\r\nrecommended or requested health care service or treatment that is the subject\r\nof the adverse determination would be significantly less effective if not\r\npromptly initiated.
\r\n\r\n
Upon\r\na determination made pursuant to this section, the independent review\r\norganization immediately shall notify the covered person and, if applicable,\r\nthe covered person's authorized representative of this determination and that\r\nit will not proceed with the expedited external review set forth in\r\n§§ 20:06:53:23 to 20:06:53:32, inclusive, until completion of the\r\nexpedited grievance review process and the covered person's grievance at the\r\ncompletion of the expedited grievance review process remains unresolved.
\r\n\r\n
Within\r\nfive business days following the date of receipt of the copy of the external\r\nreview request from the director under this section, the health carrier shall\r\ncomplete a preliminary review of the request to determine whether:
\r\n\r\n(1) The\r\nindividual is or was a covered person in the health benefit plan at the time\r\nthe health care service was requested or, in the case of a retrospective\r\nreview, was a covered person in the health benefit plan at the time the health\r\ncare service was provided;
\r\n\r\n(2) The\r\nhealth care service that is the subject of the adverse determination or the\r\nfinal adverse determination is a covered service under the covered person's\r\nhealth benefit plan, but for a determination by the health carrier that the\r\nhealth care service is not covered because it does not meet the health\r\ncarrier's requirements for medical necessity, appropriateness, health care\r\nsetting, level of care, or effectiveness;
\r\n\r\n(3) The\r\ncovered person has exhausted the health carrier's internal grievance process as\r\nset forth in SDCL 58-17I-1 to 58-17I-16, inclusive, unless the covered person is not required to exhaust the health carrier's internal grievance process pursuant to §§ 20:06:53:07 to 20:06:53:11, inclusive; and
\r\n\r\n(4) The\r\ncovered person has provided all the information and forms required to process\r\nan external review, including the release form provided under\r\n§§ 20:06:53:04 and 20:06:53:05.
\r\n\r\n
(1) The\r\nrequest is complete; and
\r\n\r\n(2) The\r\nrequest is eligible for external review.
\r\n\r\nIf\r\nthe request is not complete, the health carrier shall inform the covered person\r\nand, if applicable, the covered person's authorized representative and the\r\ndirector in writing and include in the notice what information or materials are\r\nneeded to make the request complete. If the request is not eligible for\r\nexternal review, the health carrier shall inform the covered person, if\r\napplicable, the covered person's authorized representative and the director in\r\nwriting and include in the notice the reasons for its ineligibility.
\r\n\r\nThe\r\nnotice of initial determination shall include a statement informing the covered\r\nperson and, if applicable, the covered person's authorized representative that\r\na health carrier's initial determination that the external review request is\r\nineligible for review may be appealed to the director.
\r\n\r\n
Whenever\r\nthe director receives a notice that a request is eligible for external review\r\nfollowing the preliminary review conducted pursuant to § 20:06:53:13,\r\nwithin one business day after the date of receipt of the notice, the director\r\nshall:
\r\n\r\n(1) Assign\r\nan independent review organization from the list of approved independent review\r\norganizations compiled and maintained by the director pursuant to\r\n§§ 20:06:53:55 and 20:06:53:56, to conduct the external review and notify\r\nthe health carrier of the name of the assigned independent review organization;\r\nand
\r\n\r\n(2) Notify\r\nin writing the covered person and, if applicable, the covered person's\r\nauthorized representative of the request's eligibility and acceptance for\r\nexternal review. The director shall include in the notice provided to the\r\ncovered person and, if applicable, the covered person's authorized\r\nrepresentative a statement that the covered person or the covered person's\r\nauthorized representative may submit in writing to the assigned independent\r\nreview organization at any time during the five business days following the\r\ndate of receipt of the notice provided pursuant to § 20:06:53:14\r\nadditional information that the independent review organization shall consider\r\nwhen conducting the external review. The independent review organization is not\r\nrequired to, but may, accept and consider additional information submitted\r\nafter five business days.
\r\n\r\n
(1) If\r\nthe health carrier or its utilization review organization fails to provide the\r\ndocuments and information within the time specified in § 20:06:53:16, the\r\nassigned independent review organization may terminate the external review and\r\nmake a decision to reverse the adverse determination or final adverse\r\ndetermination; or
\r\n\r\n(2) Within\r\none business day after making the decision under subdivision (1), the\r\nindependent review organization shall notify the covered person, if applicable,\r\nthe covered person's authorized representative, the health carrier, and the\r\ndirector.
\r\n\r\n
The\r\nexternal review may only be terminated if the health carrier decides, upon\r\ncompletion of its reconsideration, to reverse its adverse determination or\r\nfinal adverse determination and provide coverage or payment for the health care\r\nservice that is the subject of the adverse determination or final adverse\r\ndetermination. Within one business day after making a decision to reverse its\r\nadverse determination or final adverse determination, as provided in this\r\nsection, the health carrier shall notify the covered person, if applicable, the\r\ncovered person's authorized representative, the assigned independent review\r\norganization, and the director in writing of its decision.
\r\n\r\nThe\r\nassigned independent review organization shall terminate the external review\r\nupon receipt of the notice of a reversal from the health carrier sent pursuant\r\nto this section.
\r\n\r\n
(1) The\r\ncovered person's medical records;
\r\n\r\n(2) The\r\nattending health care professional's recommendation;
\r\n\r\n(3) Consulting\r\nreports from appropriate health care professionals and other documents\r\nsubmitted by the health carrier, covered person, the covered person's\r\nauthorized representative, or the covered person's treating provider;
\r\n\r\n(4) The\r\nterms of coverage under the covered person's health benefit plan with the\r\nhealth carrier to ensure that the independent review organization's decision is\r\nnot contrary to the terms of coverage under the covered person's health benefit\r\nplan with the health carrier;
\r\n\r\n(5) The\r\nmost appropriate practice guidelines, which shall include applicable\r\nevidence-based standards and may include any other practice guidelines\r\ndeveloped by the federal government, national or professional medical\r\nsocieties, boards, and associations;
\r\n\r\n(6) Any\r\napplicable clinical review criteria developed and used by the health carrier or\r\nits designee utilization review organization; and
\r\n\r\n(7) The\r\nopinion of the independent review organization's clinical reviewer or reviewers\r\nafter considering subdivisions (1) to (6), inclusive, to the extent the\r\ninformation or documents are available and the clinical reviewer or reviewers\r\nconsider appropriate.
\r\n\r\n
The\r\nindependent review organization shall include in the notice sent pursuant to\r\nthis section the following:
\r\n\r\n(1) A\r\ngeneral description of the reason for the request for external review;
\r\n\r\n(2) The\r\ndate the independent review organization received the assignment from the\r\ndirector to conduct the external review;
\r\n\r\n(3) The\r\ndate the external review was conducted;
\r\n\r\n(4) The\r\ndate of its decision;
\r\n\r\n(5) The\r\nprincipal reason or reasons for its decision, including what applicable, if\r\nany, evidence-based standards were a basis for its decision;
\r\n\r\n(6) The\r\nrationale for its decision; and
\r\n\r\n(7) References\r\nto the evidence or documentation, including the evidence-based standards,\r\nconsidered in reaching its decision.
\r\n\r\nUpon\r\nreceipt of a notice of a decision pursuant to this section reversing the\r\nadverse determination or final adverse determination, the health carrier\r\nimmediately shall approve the coverage that was the subject of the adverse\r\ndetermination or final adverse determination.
\r\n\r\n
(1) An\r\nadverse determination if:
\r\n\r\n(a) The\r\nadverse determination involves a medical condition of the covered person for\r\nwhich the timeframe for completion of an expedited internal review of a\r\ngrievance involving an adverse determination set forth in SDCL 58-17I-12 to 58-17I-15, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; and
\r\n\r\n(b) The\r\ncovered person or the covered person's authorized representative has filed a\r\nrequest for an expedited review of a grievance involving an adverse\r\ndetermination as set forth in SDCL 58-17H-1 to 58-17H-16, inclusive; or
\r\n\r\n(2) A\r\nfinal adverse determination:
\r\n\r\n(a) If\r\nthe covered person has a medical condition where the timeframe for completion\r\nof a standard external review pursuant to §§ 20:06:53:12 to 20:06:53:22,\r\ninclusive, would seriously jeopardize the life or health of the covered person\r\nor would jeopardize the covered person's ability to regain maximum function; or
\r\n\r\n(b) If\r\nthe final adverse determination concerns an admission, availability of care,\r\ncontinued stay, or health care service for which the covered person received\r\nemergency services, but has not been discharged from a facility.
\r\n\r\n
The\r\nnotice of initial determination shall include a statement informing the covered\r\nperson and, if applicable, the covered person's authorized representative that\r\na health carrier's initial determination that an external review request is\r\nineligible for review may be appealed to the director.
\r\n\r\n
Upon\r\nreceipt of the notice from the director of the name of the independent review\r\norganization assigned to conduct the expedited external review pursuant to this\r\nsection, the health carrier or its designee utilization review organization\r\nshall provide or transmit all necessary documents and information considered in\r\nmaking the adverse determination or final adverse determination to the assigned\r\nindependent review organization electronically or by telephone or facsimile or\r\nany other available expeditious method.
\r\n\r\n
(1) The\r\ncovered person's pertinent medical records;
\r\n\r\n(2) The\r\nattending health care professional's recommendation;
\r\n\r\n(3) Consulting\r\nreports from appropriate health care professionals and other documents\r\nsubmitted by the health carrier, covered person, the covered person's\r\nauthorized representative, or the covered person's treating provider;
\r\n\r\n(4) The\r\nterms of coverage under the covered person's health benefit plan with the\r\nhealth carrier to ensure that the independent review organization's decision is\r\nnot contrary to the terms of coverage under the covered person's health benefit\r\nplan with the health carrier;
\r\n\r\n(5) The\r\nmost appropriate practice guidelines, which shall include evidence-based\r\nstandards, and may include any other practice guidelines developed by the\r\nfederal government, or national or professional medical societies, boards, and\r\nassociations;
\r\n\r\n(6) Any\r\napplicable clinical review criteria developed and used by the health carrier or\r\nits designee utilization review organization in making adverse determinations;\r\nand
\r\n\r\n(7) The\r\nopinion of the independent review organization's clinical reviewer or reviewers\r\nafter considering subdivisions (1) to (6), inclusive, to the extent the\r\ninformation or documents are available and the clinical reviewer or reviewers\r\nconsider appropriate.
\r\n\r\n
(1) Make\r\na decision to uphold or reverse the adverse determination or final adverse\r\ndetermination; and
\r\n\r\n(2) Notify\r\nthe covered person, if applicable, the covered person's authorized\r\nrepresentative, the health carrier, and the director of the decision. If the\r\nnotice provided was not in writing, within 48 hours after the date of providing\r\nthat notice, the assigned independent review organization shall:
\r\n\r\n(a) Provide\r\nwritten confirmation of the decision to the covered person, if applicable, the\r\ncovered person's authorized representative, the health carrier, and the\r\ndirector; and
\r\n\r\n(b) Include\r\nthe information set forth in § 20:06:53:21.
\r\n\r\n
A\r\ncovered person or the covered person's authorized representative may make an\r\noral request for an expedited external review of the adverse determination or\r\nfinal adverse determination pursuant to this section if the covered person's\r\ntreating physician certifies, in writing, that the recommended or requested\r\nhealth care service or treatment that is the subject of the request would be\r\nsignificantly less effective if not promptly initiated.
\r\n\r\n
The\r\nnotice of initial determination by the health carrier under this section shall\r\ninclude a statement informing the covered person and, if applicable, the covered\r\nperson's authorized representative that a health carrier's initial\r\ndetermination that the external review request is ineligible for review may be\r\nappealed to the director.
\r\n\r\n
Upon\r\nreceipt of the notice that the expedited external review request meets the\r\nreviewability requirements of § 20:06:53:36, the director immediately\r\nshall assign an independent review organization to review the expedited request\r\nfrom the list of approved independent review organizations compiled and\r\nmaintained by the director pursuant to §§ 20:06:53:55 and 20:06:53:56 and\r\nnotify the health carrier of the name of the assigned independent review\r\norganization.
\r\n\r\nAt\r\nthe time the health carrier receives the notice of the assigned independent\r\nreview organization pursuant to this section, the health carrier or its\r\ndesignee utilization review organization shall provide or transmit all necessary\r\ndocuments and information considered in making the adverse determination or\r\nfinal adverse determination to the assigned independent review organization\r\nelectronically or by telephone or facsimile or any other available expeditious\r\nmethod.
\r\n\r\n
(1) The\r\nindividual is or was a covered person in the health benefit plan at the time\r\nthe health care service or treatment was recommended or requested or, in the case\r\nof a retrospective review, was a covered person in the health benefit plan at\r\nthe time the health care service or treatment was provided;
\r\n\r\n(2) The\r\nrecommended or requested health care service or treatment that is the subject\r\nof the adverse determination or final adverse determination:
\r\n\r\n(a) Is\r\na covered benefit under the covered person's health benefit plan except for the\r\nhealth carrier's determination that the service or treatment is experimental or\r\ninvestigational for a particular medical condition; and
\r\n\r\n(b) Is\r\nnot explicitly listed as an excluded benefit under the covered person's health\r\nbenefit plan with the health carrier;
\r\n\r\n(3) The\r\ncovered person's treating physician has certified that one of the following\r\nsituations is applicable:
\r\n\r\n(a) Standard\r\nhealth care services or treatments have not been effective in improving the\r\ncondition of the covered person;
\r\n\r\n(b) Standard\r\nhealth care services or treatments are not medically appropriate for the\r\ncovered person; or
\r\n\r\n(c) There\r\nis no available standard health care service or treatment covered by the health\r\ncarrier that is more beneficial than the recommended or requested health care\r\nservice or treatment described in subdivision (4) of this section;
\r\n\r\n(4) The\r\ncovered person's treating physician:
\r\n\r\n(a) Has\r\nrecommended a health care service or treatment that the physician certifies, in\r\nwriting, is likely to be more beneficial to the covered person, in the\r\nphysician's opinion, than any available standard health care services or\r\ntreatments; or
\r\n\r\n(b) Who\r\nis a licensed, board certified or board eligible physician qualified to\r\npractice in the area of medicine appropriate to treat the covered person's\r\ncondition, has certified in writing that scientifically valid studies using\r\naccepted protocols demonstrate that the health care service or treatment\r\nrequested by the covered person that is the subject of the adverse\r\ndetermination or final adverse determination is likely to be more beneficial to\r\nthe covered person than any available standard health care services or\r\ntreatments;
\r\n\r\n(5) The\r\ncovered person has exhausted the health carrier's internal grievance process as\r\nset forth in SDCL 58-17I-1 to 58-17I-16, inclusive, unless the covered person is not required to exhaust the health carrier's internal grievance process pursuant to §§ 20:06:53:07 to 20:06:53:21, inclusive; and
\r\n\r\n(6) The\r\ncovered person has provided all the information and forms required by the\r\ndirector that are necessary to process an external review, including the\r\nrelease form provided under §§ 20:06:53:04 and 20:06:53:05.
\r\n\r\n
If\r\nthe request is not complete, the health carrier shall inform, in writing, the\r\ndirector and the covered person and, if applicable, the covered person's\r\nauthorized representative and include in the notice what information or\r\nmaterials are needed to make the request complete.
\r\n\r\nIf\r\nthe request is not eligible for external review, the health carrier shall\r\ninform the covered person, the covered person's authorized representative, if\r\napplicable, and the director in writing and include in the notice the reasons\r\nfor its ineligibility.
\r\n\r\nThe\r\nnotice of initial determination provided under this section must include a\r\nstatement informing the covered person and, if applicable, the covered person's\r\nauthorized representative that a health carrier's initial determination that\r\nthe external review request is ineligible for review may be appealed to the\r\ndirector.
\r\n\r\n
(1) Assign\r\nan independent review organization to conduct the external review from the list\r\nof approved independent review organizations compiled and maintained by the\r\ndirector pursuant to §§ 20:06:53:55 and 20:06:53:56 and notify the health\r\ncarrier of the name of the assigned independent review organization; and
\r\n\r\n(2) Notify\r\nin writing the covered person and, if applicable, the covered person's\r\nauthorized representative of the request's eligibility and acceptance for\r\nexternal review.
\r\n\r\nThe\r\ndirector shall include in the notice provided to the covered person and, if\r\napplicable, the covered person's authorized representative a statement that the\r\ncovered person or the covered person's authorized representative may submit in\r\nwriting to the assigned independent review organization within five business\r\ndays following the date of receipt of the notice provided pursuant to this\r\nsection additional information that the independent review organization shall\r\nconsider when conducting the external review. The independent review\r\norganization is not required to, but may, accept and consider additional\r\ninformation submitted after five business days.
\r\n\r\n
(1) Select\r\none or more clinical reviewers, as it determines is appropriate, pursuant to\r\nthis section to conduct the external review; and
\r\n\r\n(2) Based\r\non the opinion of the clinical reviewer, or opinions if more than one clinical\r\nreviewer has been selected to conduct the external review, make a decision to\r\nuphold or reverse the adverse determination or final adverse determination.
\r\n\r\nIn\r\nselecting clinical reviewers pursuant to this section, the assigned independent\r\nreview organization shall select physicians or other health care professionals\r\nwho meet the minimum qualifications described in §§ 20:06:53:57 to\r\n20:06:53:62, inclusive, and, through clinical experience in the past three\r\nyears, are experts in the treatment of the covered person's condition and\r\nknowledgeable about the recommended or requested health care service or\r\ntreatment. Neither the covered person, the covered person's authorized\r\nrepresentative, if applicable, nor the health carrier may choose or control the\r\nchoice of the physicians or other health care professionals to be selected to\r\nconduct the external review.
\r\n\r\n
If\r\nthe health carrier or its designee utilization review organization has failed\r\nto provide the documents and information within the time specified in this\r\nsection, the assigned independent review organization may terminate the\r\nexternal review and make a decision to reverse the adverse determination or\r\nfinal adverse determination. Immediately upon making the decision under this\r\nsection, the independent review organization shall notify the covered person,\r\nthe covered person's authorized representative, if applicable, the health\r\ncarrier, and the director.
\r\n\r\n
Immediately\r\nupon making the decision to reverse its adverse determination or final adverse\r\ndetermination, as provided in this section, the health carrier shall notify the\r\ncovered person, the covered person's authorized representative, if applicable,\r\nthe assigned independent review organization, and the director, in writing, of\r\nits decision.
\r\n\r\nThe\r\nassigned independent review organization shall terminate the external review\r\nupon receipt of the notice from the health carrier's decision to reverse its\r\nadverse determination or final adverse determination.
\r\n\r\n
(1) The\r\ncovered person's pertinent medical records;
\r\n\r\n(2) The\r\nattending physician or health care professional's recommendation;
\r\n\r\n(3) Consulting\r\nreports from appropriate health care professionals and other documents\r\nsubmitted by the health carrier, covered person, the covered person's\r\nauthorized representative, or the covered person's treating physician or health\r\ncare professional;
\r\n\r\n(4) The\r\nterms of coverage under the covered person's health benefit plan with the\r\nhealth carrier to ensure that, but for the health carrier's determination that\r\nthe recommended or requested health care service or treatment that is the\r\nsubject of the opinion is experimental or investigational, the reviewer's\r\nopinion is not contrary to the terms of coverage under the covered person's health\r\nbenefit plan with the health carrier; and
\r\n\r\n(5) Whether:
\r\n\r\n(a) The\r\nrecommended or requested health care service or treatment has been approved by\r\nthe federal Food and Drug Administration, if applicable, for the condition; or
\r\n\r\n(b) Medical\r\nor scientific evidence or evidence-based standards demonstrate that the\r\nexpected benefits of the recommended or requested health care service or\r\ntreatment is more likely than not to be beneficial to the covered person than\r\nany available standard health care service or treatment and the adverse risks\r\nof the recommended or requested health care service or treatment would not be\r\nsubstantially increased over those of available standard health care services\r\nor treatments.
\r\n\r\n
If\r\nthe notice provided under this section was not in writing, within 48 hours\r\nafter the date of providing that notice, the assigned independent review\r\norganization shall provide written confirmation of the decision to the persons\r\nlisted in § 20:06:53:48 and include the information set forth in § 20:06:53:51.
\r\n\r\n
If\r\nthe clinical reviewers are evenly split as to whether the recommended or\r\nrequested health care service or treatment should be covered, the independent\r\nreview organization shall obtain the opinion of an additional clinical reviewer\r\nin order for the independent review organization to make a decision based on\r\nthe opinions of a majority of the clinical reviewers.
\r\n\r\nThe\r\nadditional clinical reviewer selected under this section shall use the same\r\ninformation to reach an opinion as the clinical reviewers who have already\r\nsubmitted their opinions pursuant to § 20:06:53:47. The selection of the\r\nadditional clinical reviewer under this section does not extend the time within\r\nwhich the assigned independent review organization is required to make a\r\ndecision based on the opinions of the clinical reviewers selected under\r\n§§ 20:06:53:39 to 20:06:53:41, inclusive.
\r\n\r\n
(1) A\r\ngeneral description of the reason for the request for external review;
\r\n\r\n(2) The\r\nwritten opinion of each clinical reviewer, including the recommendation of each\r\nclinical reviewer as to whether the recommended or requested health care\r\nservice or treatment should be covered and the rationale for the reviewer's\r\nrecommendation:
\r\n\r\n(3) The\r\ndate the independent review organization was assigned by the director to\r\nconduct the external review;
\r\n\r\n(4) The\r\ndate the external review was conducted;
\r\n\r\n(5) The\r\ndate of its decision;
\r\n\r\n(6) The\r\nprincipal reason or reasons for its decision; and
\r\n\r\n(7) The\r\nrationale for its decision.
\r\n\r\n
A\r\ncovered person or the covered person's authorized representative may not file a\r\nsubsequent request for external review involving the same adverse determination\r\nor final adverse determination for which the covered person has already\r\nreceived an external review decision pursuant to this chapter.
\r\n\r\n
Any\r\nindependent review organization wishing to be approved to conduct external\r\nreviews pursuant to this chapter shall submit an application form as prescribed\r\nby the director and include with the form all documentation and information\r\nnecessary for the director to determine if the independent review organization\r\nsatisfies the minimum qualifications established pursuant to\r\n§§ 20:06:53:57 to 20:06:53:62, inclusive.
\r\n\r\nThe\r\ndirector may approve independent review organizations that are not accredited\r\nby a nationally recognized private accrediting entity if there are no\r\nacceptable nationally recognized private accrediting entities providing\r\nindependent review organization accreditation.
\r\n\r\n
Whenever\r\nthe director determines that an independent review organization has lost its\r\naccreditation or no longer satisfies the minimum requirements established\r\npursuant to §§ 20:06:53:57 to 20:06:53:62, inclusive, the director shall\r\nterminate the approval of the independent review organization and remove the\r\nindependent review organization from the list of independent review\r\norganizations approved to conduct external reviews pursuant to this chapter\r\nthat is maintained by the director pursuant to § 20:06:53:62.
\r\n\r\n
(1) A\r\nquality assurance mechanism in place that:
\r\n\r\n(a) Ensures\r\nthat external reviews are conducted within the specified timeframes and\r\nrequired notices are provided in a timely manner;
\r\n\r\n(b) Ensures\r\nthe selection of qualified and impartial clinical reviewers to conduct external\r\nreviews on behalf of the independent review organization and suitable matching\r\nof reviewers to specific cases and that the independent review organization\r\nemploys or contracts with an adequate number of clinical reviewers to meet this\r\nobjective;
\r\n\r\n(c) Ensures\r\nthe confidentiality of medical and treatment records and clinical review\r\ncriteria; and
\r\n\r\n(d) Ensures\r\nthat any person employed by or under contract with the independent review\r\norganization adheres to the requirements of this chapter;
\r\n\r\n(2) A\r\ntoll-free telephone service to receive information on a 24-hour-day,\r\n7-day-a-week basis related to external reviews that is capable of accepting,\r\nrecording, or providing appropriate instruction to incoming telephone callers\r\nduring other than normal business hours; and
\r\n\r\n(3) An\r\nagreement to maintain and provide to the director the information set out in\r\n§§ 20:06:53:64 and 20:06:53:65.
\r\n\r\n
(1) Be\r\nan expert in the treatment of the covered person's medical condition that is\r\nthe subject of the external review;
\r\n\r\n(2) Be\r\nknowledgeable about the recommended health care service or treatment through\r\nrecent or current actual clinical experience treating patients with the same or\r\nsimilar medical condition of the covered person;
\r\n\r\n(3) Hold\r\na non-restricted license in a state of the United States and, for physicians, a\r\ncurrent certification by a recognized American medical specialty board in the\r\narea or areas appropriate to the subject of the external review; and
\r\n\r\n(4) Have\r\nno history of disciplinary actions or sanctions, including loss of staff\r\nprivileges or participation restrictions, that have been taken or are pending\r\nby any hospital, governmental agency or unit, or regulatory body that raise a\r\nsubstantial question as to the clinical reviewer's physical, mental, or\r\nprofessional competence or moral character.
\r\n\r\n
(1) The\r\nhealth carrier that is the subject of the external review;
\r\n\r\n(2) The\r\ncovered person whose treatment is the subject of the external review or the\r\ncovered person's authorized representative;
\r\n\r\n(3) Any\r\nofficer, director, or management employee of the health carrier that is the\r\nsubject of the external review;
\r\n\r\n(4) The\r\nhealth care provider or the health care provider's medical group or independent\r\npractice association recommending the health care service or treatment that is\r\nthe subject of the external review;
\r\n\r\n(5) The\r\nfacility at which the recommended health care service or treatment would be\r\nprovided; or
\r\n\r\n(6) The\r\ndeveloper or manufacturer of the principal drug, device, procedure, or other\r\ntherapy being recommended for the covered person whose treatment is the subject\r\nof the external review.
\r\n\r\nIn\r\ndetermining whether an independent review organization or a clinical reviewer\r\nof the independent review organization has a material professional, familial,\r\nor financial conflict of interest for purposes of this section, the director\r\nshall take into consideration situations where the independent review\r\norganization to be assigned to conduct an external review of a specified case\r\nor a clinical reviewer to be assigned by the independent review organization to\r\nconduct an external review of a specified case may have an apparent\r\nprofessional, familial, or financial relationship or connection with a person\r\ndescribed in this section, but that the characteristics of that relationship or\r\nconnection are such that they are not a material professional, familial, or\r\nfinancial conflict of interest that results in the disapproval of the\r\nindependent review organization or the clinical reviewer from conducting the\r\nexternal review.
\r\n\r\n
The\r\ndirector shall initially review and periodically review the independent review\r\norganization accreditation standards of a nationally recognized private\r\naccrediting entity to determine whether the entity's standards are, and\r\ncontinue to be, equivalent to or exceed the minimum qualifications established\r\nunder this section. The director may accept a review conducted by the NAIC for\r\nthe purpose of the determination under this section.
\r\n\r\nUpon\r\nrequest, a nationally recognized private accrediting entity shall make its\r\ncurrent independent review organization accreditation standards available to\r\nthe director or the NAIC in order for the director to determine if the entity's\r\nstandards are equivalent to or exceed the minimum qualifications established\r\nunder this section. The director may exclude any private accrediting entity\r\nthat is not reviewed by the NAIC.
\r\n\r\n
Each\r\nindependent review organization required to maintain written records on all\r\nrequests for external review pursuant to this section for which it was assigned\r\nto conduct an external review shall submit to the director, upon request, a\r\nreport in the format specified by the director. The report shall include in the\r\naggregate by state, and for each health carrier, the following:
\r\n\r\n(1) The\r\ntotal number of requests for external review;
\r\n\r\n(2) The\r\nnumber of requests for external review resolved and, of those resolved, the number\r\nresolved upholding the adverse determination or final adverse determination and\r\nthe number resolved reversing the adverse determination or final adverse\r\ndetermination;
\r\n\r\n(3) The\r\naverage length of time for resolution;
\r\n\r\n(4) A\r\nsummary of the types of coverages or cases for which an external review was\r\nsought, as provided in the format required by the director; and
\r\n\r\n(5) The\r\nnumber of external reviews pursuant to § 20:06:53:19 that were terminated\r\nas the result of a reconsideration by the health carrier of its adverse\r\ndetermination or final adverse determination after the receipt of additional\r\ninformation from the covered person or the covered person's authorized\r\nrepresentative.
\r\n\r\nThe\r\ndirector may request additional information to be included within the report or\r\nto be provided at an alternate date that relates to the independent review\r\norganization's compliance with this chapter.
\r\n\r\n
Each\r\nhealth carrier shall maintain written records in the aggregate, by state and\r\nfor each type of health benefit plan offered by the health carrier, on all\r\nrequests for external review that the health carrier receives notice of from\r\nthe director pursuant to this chapter. Each health carrier required to maintain\r\nwritten records on all requests for external review pursuant to this section\r\nshall submit to the director, upon request, a report in the format of Appendix\r\nD. The report shall include in the aggregate, by state, and by type of health\r\nbenefit plan the following information:
\r\n\r\n(1) The\r\ntotal number of requests for external review; and
\r\n\r\n(2) From\r\nthe total number of requests for external review reported under subdivision (1)\r\nof this section, the number of requests determined eligible for a full external\r\nreview.
\r\n\r\nThe\r\ndirector may request additional information to be included within the report or\r\nto be provided at an alternate date that relates to the health carrier's\r\ncompliance with this chapter.
\r\n\r\nThe\r\nhealth carrier shall retain the written records required pursuant to this\r\nsection for at least three years.
\r\n\r\n
    20:06:53:66.  Funding of external review. The health carrier against which a request for any review subject to this chapter is filed shall pay the cost of the independent review organization for conducting the external review.
    Source: 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 1, 2011; 38 SDR 102, effective December 7, 2011; 50 SDR 63, effective November 28, 2023.
    General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.
    Law Implemented: SDCL 58-17-87, 58-18-79.
Plans\r\nand issuers must provide notice in accordance with SDCL 58-17H-32 and 58-17H-48. Insurers may comply with the notice requirements required in SDCL 58-17H-32 and 58-17H-48 by providing notification of the right to request and receive diagnoses and treatment codes and their meanings in all notices of adverse benefit determinations and final adverse benefit determinations.
\r\n\r\n
The\r\nclaimant is entitled upon written request to an explanation of the plan's or\r\nissuer's basis for asserting that it meets this standard. If the external\r\nreview or the court rejects the claimant's request for immediate review on the\r\nbasis that the plan met this standard, the claimant has the right to resubmit\r\nand pursue the internal appeal under SDCL 58-17I-7.
\r\n\r\n
For\r\npurposes of calculating the time period for re-filing the benefit request or\r\nclaim under this subparagraph, the time period shall begin to run upon the\r\ncovered person's or, if applicable, the covered person's authorized\r\nrepresentative receipt of the notice of opportunity to resubmit.
\r\n\r\n