<html> <head> <title>Rule 67:16:06:03.01 Contractor to provide certain services.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:06:03.01"> <META NAME="Description" Content="Administrative Rules 67:16:06:03.01 Contractor to provide certain services."> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Originator content="Microsoft Word 10"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:06:03.01.&nbsp;&nbsp;Contractor to provide certain services.</b> A contractor must provide the following services:</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;At a minimum, the dental services contained in this chapter;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;An automated claims processing and payment system capable of providing data on the claims encountered;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;A provider support unit which, at a minimum, provides eligibility information, responds to claim inquiries, and responds to questions about covered benefits;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;A toll-free telephone service for recipients to register complaints, identify problems, and inquire about benefits;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;A system of provider recruitment and retention;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;A quality assurance program which provides for pre- and post-treatment reviews; and</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;A grievance process for providers and recipients. The provider or recipient must exhaust this process before requesting a fair hearing from the department.</font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 23 SDR 197, effective May 26, 1997.</font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A></font></p> <p><font size=3 face="Times New Roman">&nbsp;</font></p> </div> </body> </html>