<html> <head> <title>Rule 20:06:53:0A Model Notice of Appeal Rights.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:53:0A"> <META NAME="Description" Content="Administrative Rules 20:06:53:0A Model Notice of Appeal Rights."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; punctuation-wrap:simple; text-autospace:none; font-size:12.0pt; font-family:"Times New Roman","serif";} p.MsoFootnoteText, li.MsoFootnoteText, div.MsoFootnoteText {mso-style-link:"Footnote Text Char"; margin:0in; margin-bottom:.0001pt; punctuation-wrap:simple; text-autospace:none; font-size:10.0pt; font-family:"Times New Roman","serif";} span.MsoFootnoteReference {vertical-align:super;} span.FootnoteTextChar {mso-style-name:"Footnote Text Char"; 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punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>DEPARTMENT OF REVENUE AND REGULATION</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>DIVISION OF INSURANCE</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>MODEL NOTICE OF APPEAL RIGHTS</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>Chapter 20:06:53</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>APPENDIX A</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>SEE: &#167;&nbsp;20:06:53:03</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;punctuation-wrap: hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Source: 37 SDR 48, effective September 22, 2010; 42 SDR 52, effective October 13, 2015.</p> <span style='font-size:12.0pt;font-family:"Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>Appendix A -- Model Notice of Appeal Rights</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal align=center style='margin-left:-.7pt;text-align:center; line-height:12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'><b>NOTICE OF APPEAL RIGHTS</b></p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'><b>&nbsp;</b></p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'><b>You have a right to appeal any decision we make that denies payment on your claim or your request for coverage of a health care service or treatment.</b></p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'><b>&nbsp;</b></p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'><b>You may request more explanation when your claim or request for coverage of a health care service or treatment is denied or the health care service or treatment you received was not fully covered.</b> Contact<sup>1</sup> us when you:</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Do not understand the reason for the denial;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Do not understand why the health care service or treatment was not fully covered;</p> <p class=MsoNormal style='margin-left:28.1pt;text-align:justify;text-indent: -.4in;line-height:12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Do not understand why a request for coverage of a health care service or treatment was denied;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Cannot find the applicable provision in your Benefit Plan Document;</p> <p class=MsoNormal style='margin-left:28.1pt;text-align:justify;text-indent: -.4in;line-height:12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Want a copy (free of charge) of the guidelines, criteria, or clinical rationale that we used to make our decision; or</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&#9679;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Disagree with the denial or the amount not covered and you want to appeal.</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>If your claim was denied due to missing or incomplete information, you or your health care provider may resubmit the claim to us with the necessary information to complete the claim.<a href="#_ftn1" name="_ftnref1" title=""><sup><sup><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>[1]</span></sup></sup></a></p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'><b>Appeals:&nbsp;&nbsp;</b>All appeals for claim denials (or any decision that does not cover expenses you believe should have been covered) must be sent to [insert address of where appeals should be sent to the health carrier] within <b>180 days</b> of the date you receive our denial.<a href="#_ftn2" name="_ftnref2" title=""><sup><sup><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>[2]</span></sup></sup></a> We will provide a full and fair review of your claim by individuals associated with us, but who were not involved in making the initial denial of your claim. You may provide us with additional information that relates to your claim and you may request copies of information that we have that pertains to your claims. We will notify you of our decision in writing within <b>60 days</b> of receiving your appeal.<a href="#_ftn3" name="_ftnref3" title=""><sup><sup><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>[3]</span></sup></sup></a> If you do not receive our decision within <b>60 days</b> of receiving your appeal<sup>3</sup>, you may be entitled to file a request for external review.<a href="#_ftn4" name="_ftnref4" title=""><sup><sup><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>[4]</span></sup></sup></a></p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'><b>External Review<sup>4</sup>:&nbsp;&nbsp;</b>If we have denied your request for the provision of or payment for a health care service or course of treatment, you may have a right to have our decision reviewed by independent health care professionals who have no association with us. If our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested, you may submit a request for external review within four months after receipt of this notice to the Division of Insurance, 124 South Euclid Avenue, 2<sup>nd</sup> Floor, Pierre, South Dakota 57501. For standard external review, a decision will be made within 45 days of receiving your request. If you have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed, you may be entitled to request an expedited external review of our denial. If our denial to provide or pay for health care service or course of treatment is based on a determination that the service or treatment is experimental or investigation, you also may be entitled to file a request for external review of our denial. For details, please review your Benefit Plan Document, contact us, or contact your state insurance department.<sup>1</sup></p> <p class=MsoNormal style='margin-left:-.7pt;text-align:justify;line-height: 12.0pt;punctuation-wrap:hanging;text-autospace:ideograph-numeric ideograph-other'>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> </div> <div><br clear=all> <hr align=left size=1 width="33%"> <div id=ftn1> <p class=MsoFootnoteText><a href="#_ftnref1" name="_ftn1" title=""><span class=MsoFootnoteReference><span class=MsoFootnoteReference><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>[1]</span></span></span></a> See address and telephone number on the enclosed Explanation of Benefits if you have questions about this notice.</p> </div> <div id=ftn2> <p class=MsoFootnoteText><a href="#_ftnref2" name="_ftn2" title=""><span class=MsoFootnoteReference><span class=MsoFootnoteReference><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>[2]</span></span></span></a> Unless your plan or any applicable state law allows you additional time.</p> </div> <div id=ftn3> <p class=MsoFootnoteText><a href="#_ftnref3" name="_ftn3" title=""><span class=MsoFootnoteReference><span class=MsoFootnoteReference><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>[3]</span></span></span></a> Some states and plans allow you more (or less) time to file an appeal and less (or more) time for our decision. See your Benefit Plan Document for your state's appeal process.</p> </div> <div id=ftn4> <p class=MsoFootnoteText><a href="#_ftnref4" name="_ftn4" title=""><span class=MsoFootnoteReference><span class=MsoFootnoteReference><span style='font-size:10.0pt;font-family:"Times New Roman","serif"'>[4]</span></span></span></a> See your Benefit Plan Document for your state's appeal process and to determine if you're eligible to request an external review in your state (e.g. some state appeal processes require you to complete your insurer's appeal process before filing an external review request unless waived by your insurer; while some states do not have such a requirement).</p> </div> </div> </body> </html>