<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns="http://www.w3.org/TR/REC-html40"> <head> <title>Rule 67:16:14:24 Appeal process.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:14:24"> <META NAME="Description" Content="Administrative Rules 67:16:14:24 Appeal process."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=ProgId content=Word.Document> <meta name=Generator content="Microsoft Word 10"> <meta name=Originator content="Microsoft Word 10"> <link rel=File-List href="6716140002400d_files/filelist.xml"> <!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>lrpr14296</o:Author> <o:LastAuthor>lrpr14296</o:LastAuthor> <o:Revision>2</o:Revision> <o:TotalTime>3</o:TotalTime> <o:LastPrinted>2006-01-30T19:15:00Z</o:LastPrinted> <o:Created>2006-01-31T15:46:00Z</o:Created> <o:LastSaved>2006-01-31T15:46:00Z</o:LastSaved> <o:Pages>1</o:Pages> <o:Words>112</o:Words> <o:Characters>644</o:Characters> <o:Company>State of South Dakota</o:Company> <o:Lines>5</o:Lines> <o:Paragraphs>1</o:Paragraphs> <o:CharactersWithSpaces>755</o:CharactersWithSpaces> <o:Version>10.4219</o:Version> </o:DocumentProperties> <o:OfficeDocumentSettings> <o:DoNotRelyOnCSS/> </o:OfficeDocumentSettings> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:SpellingState>Clean</w:SpellingState> <w:GrammarState>Clean</w:GrammarState> <w:DisplayHorizontalDrawingGridEvery>0</w:DisplayHorizontalDrawingGridEvery> <w:DisplayVerticalDrawingGridEvery>0</w:DisplayVerticalDrawingGridEvery> <w:UseMarginsForDrawingGridOrigin/> <w:Compatibility> <w:FootnoteLayoutLikeWW8/> <w:ShapeLayoutLikeWW8/> <w:AlignTablesRowByRow/> <w:ForgetLastTabAlignment/> <w:LayoutRawTableWidth/> <w:LayoutTableRowsApart/> <w:UseWord97LineBreakingRules/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--> <style> <!-- /* Font Definitions */ @font-face {font-family:Tahoma; panose-1:2 11 6 4 3 5 4 4 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:1627421319 -2147483648 8 0 66047 0;} @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:536902279 -2147483648 8 0 511 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:Times; mso-fareast-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman";} span.GramE {mso-style-name:""; mso-gram-e:yes;} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style> <!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman";} </style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="1026"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--> </head> <body lang=EN-US style='tab-interval:.5in'> <div class=Section1> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'><span style='font-weight:bold;mso-bidi-font-weight: normal'>67:16:14:24<span class=GramE>&nbsp;&nbsp;Appeal</span> process.</span></b> If the department denies the prior authorization request, the medical professional may appeal the decision. At the time of the denial, the department shall advise the medical professional of the procedures to follow to appeal the denial and that the appeal must be made within 24 hours following the denial<o:p></o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>The medical professional will receive a final decision within 24 hours after the additional information is received.<o:p></o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>If the request is approved, the pharmacist may fill the prescription as written.<o:p></o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>If the original decision to deny the claim is confirmed, the medical professional will be notified.<o:p></o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'><span style='font-weight:bold;mso-bidi-font-weight: normal'>Source:</span></b> 32 SDR 129, effective February 1, 2006.<o:p></o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'><span style='font-weight:bold;mso-bidi-font-weight: normal'>General Authority:</span></b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A><o:p></o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'><span style='font-weight:bold;mso-bidi-font-weight: normal'>Law Implemented:</span></b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1.</A><o:p></o:p></span></font></p> <p class=MsoNormal style='text-align:justify;tab-stops:.4in .6in .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in 3.1in 3.4in 3.6in 3.9in 4.1in'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;mso-bidi-font-size: 10.0pt;font-family:"Times New Roman"'><o:p>&nbsp;</o:p></span></font></p> </div> </body> </html>