<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.s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal { 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.s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000000 { color: #0000FF; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000003 { color: #0000FF; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:101"><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000000">20:06:21:101</span></a><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000001">.  Certification of long-term care insurance independent review organizations.</span><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont"> The director shall consider a long-term care insurance independent review organization to be qualified in this state, if the independent review organization demonstrates that it is unbiased and has either been certified by another state with substantially similar qualifications as contained in Appendix M or meets the following qualifications:</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (1)  Have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured's functional or cognitive impairment (e.g. physical therapy, occupational therapy, neurology, physical medicine, and rehabilitation) to conduct the review;</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (2)  Neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with an entity that previously provided medical care to the insured;</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (3)  Utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured;</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (4)  Neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review;</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (5)  Be state-approved or certified to conduct such reviews if the state requires such approvals or certifications;</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (6)  Provide a description of the fees to be charged by it for independent reviews of a long-term care insurance benefit trigger decision. Such fees shall be reasonable and customary for the type of long-term care insurance benefit trigger decision under review;</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (7)  Provide the name of the medical director or health care professional responsible for the supervision and oversight of the independent review procedure; and</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    (8)  Have on staff or contract with a licensed health care practitioner as defined in subdivision </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:21:01"><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000003">20:06:21:01</span></a><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">(21), who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract.</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    </span><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000001">Source:</span><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont"> 36 SDR 209, effective July 1, 2010.</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    </span><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000001">General Authority:</span><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17B-4"><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000003">58-17B-4</span></a><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">.</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">    </span><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000001">Law Implemented:</span><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17B-4"><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont-000003">58-17B-4</span></a><span class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0DefaultParagraphFont">.</span></p><p dir="ltr" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0Normal"><span xml:space="preserve" class="s483e7b2d-74e5-4ed0-9de8-8193bfcb39a0000002"> </span></p></div></body></html>