<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal { text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-left: 0; margin-right: 0; margin-bottom: .001pt; } span.sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000000 { color: #0000FF; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002 { color: #0000FF; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd2f4a322-2366-4a2f-96cb-eca359d8109c000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:99"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000000">20:06:21:99</span></a><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000001">.  Review decision requirements.</span><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont"> The independent review organization shall provide the insured and the insured's authorized representative, if applicable, the insurer, and the director written notice of its decision, within 30 calendar days from receipt of the referral to the independent review organization by the insurer pursuant to § </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:92"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">20:06:21:92</span></a><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">. If the independent review organization overturns the insurer's decision, the independent review organization shall:</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109c000003"> </span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    (1)  Establish the precise date within the specific period of time under review that the benefit trigger was deemed to have been met;</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109c000003"> </span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    (2)  Specify the specific period of time under review for which the insurer declined eligibility, but during which the independent review organization deemed the benefit trigger to have been met; and</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109c000003"> </span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    (3)  For tax-qualified long-term care insurance contracts, provide a certification made by a licensed health care practitioner as defined by subdivision </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:01"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">20:06:21:01</span></a><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">(21) that the insured is a chronically ill individual.</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109c000003"> </span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    The independent review organization's determination shall be used solely to establish liability for benefit trigger decisions, and is intended to be admissible in any proceeding only to the extent it establishes the eligibility of benefits payable. Nothing in §§ </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:87"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">20:06:21:87</span></a><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:104"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">20:06:21:104</span></a><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">, inclusive, restricts the insured's right to submit a new request for benefit trigger determination after the independent review decision, if the independent review organization upholds the insurer's decision.</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109c000003"> </span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    The decision of the independent review organization with respect to whether the insured met the benefit trigger will be final and binding on the insurer, except to the extent the insurer has other remedies available under applicable state or federal law. However, if the decision of the independent review organization is that a benefit trigger has been met and the insurer has sought other applicable state or federal remedies in lieu of accepting the decision of the independent review organization, then the insurer shall provide notice to the director within 30 days of that decision. Nothing in this section prevents the director upon receipt of notice from initiating administrative proceedings pursuant to § </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:108"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">20:06:21:108</span></a><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">, SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=58-6-46"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">58-6-46</span></a><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">, </span><a href="https://sdlegislature.gov/Statutes?Statute=58-6-47"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">58-6-47</span></a><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">, or </span><a href="https://sdlegislature.gov/Statutes?Statute=58-33-67"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">58-33-67</span></a><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">.</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109c000003"> </span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    </span><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000001">Source:</span><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont"> 36 SDR 209, effective July 1, 2010.</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    </span><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000001">General Authority:</span><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17B-4"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">58-17B-4</span></a><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">.</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">    </span><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000001">Law Implemented:</span><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17B-4"><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont-000002">58-17B-4</span></a><span class="sd2f4a322-2366-4a2f-96cb-eca359d8109cDefaultParagraphFont">.</span></p><p dir="ltr" class="sd2f4a322-2366-4a2f-96cb-eca359d8109cNormal"><span xml:space="preserve" class="sd2f4a322-2366-4a2f-96cb-eca359d8109c000003"> </span></p></div></body></html>