<html> <head> <title>Rule 20:06:53:0B Model External Review Request Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:53:0B"> <META NAME="Description" Content="Administrative Rules 20:06:53:0B Model External Review Request Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 15 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:"Cambria Math"; panose-1:2 4 5 3 5 4 6 3 2 4;} @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-top:0in; margin-right:0in; margin-bottom:0in; margin-left:-.7pt; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman",serif;} a:link, span.MsoHyperlink {color:blue; text-decoration:underline;} a:visited, span.MsoHyperlinkFollowed {color:purple; text-decoration:underline;} .MsoChpDefault {font-size:10.0pt; font-family:"Calibri",sans-serif;} /* Page Definitions */ @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 63.35pt 49.7pt 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US link=blue vlink=purple> <div class=WordSection1> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>DEPARTMENT OF LABOR AND REGULATION</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>DIVISION OF INSURANCE</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>MODEL EXTERNAL REVIEW REQUEST FORM</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>Chapter 20:06:53</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>APPENDIX B</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal align=center style='text-align:center'>SEE: &#167;&nbsp;20:06:53:06</p> <p class=MsoNormal align=center style='text-align:center'>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&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> <p class=MsoNormal>&nbsp;</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><span style='font-size:11.5pt'>Appendix B - Model External Review Request Form</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>This <b>EXTERNAL REVIEW REQUEST FORM</b> must be filed with the Division of Insurance within <b>FOUR MONTHS</b> after receipt from your insurer of a denial of payment on a claim or request for coverage of a health care service or treatment.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>EXTERNAL REVIEW REQUEST FORM</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><u><span style='font-size:11.5pt'>APPLICANT NAME</span></u></b><span style='font-size:11.5pt'>&nbsp; _______________________________&nbsp;&nbsp; </span><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'> Covered person/Patient&nbsp;&nbsp; &#9633; Provider </span><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'> Authorized Representative</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>COVERED PERSON/PATIENT INFORMATION</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Covered Person Name: ________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Patient Name: _______________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Address: ________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Covered Person Phone #: Home (_____)_________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Work: (_____)_____________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>INSURANCE INFORMATION</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Insurer/HMO Name</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Covered Person Insurance</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>ID#:____________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Insurance Claim/Reference</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>#:______________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Insurer/HMO Mailing Address:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Insurer Telephone #:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>(_____)_________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>EMPLOYER INFORMATION</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Employer's Name:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Employer's Phone #:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>(_____)_________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Is the health coverage you have through your employer a self-funded plan? ______. If you are not certain please check with your employer. Most self-funded plans are not eligible for external review. However, some self-funded plans may voluntarily provide external review, but may have different procedures. You should check with your employer.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>HEALTH CARE PROVIDER INFORMATION</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Treating Physician/Health Care Provider:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Address:___________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Contact Person: _______________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Phone: (&nbsp;&nbsp;&nbsp;&nbsp; )&nbsp; _________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Medical Record #: _____________________________</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>REASON FOR HEALTH CARRIER DENIAL</span></b><span style='font-size:11.5pt'> (Please check one)</span></p> <p class=MsoNormal><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;&nbsp;The health care service or treatment is not medically necessary.</span></p> <p class=MsoNormal><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;&nbsp;The health care service or treatment is experimental or investigational.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>SUMMARY OF EXTERNAL REVIEW REQUEST</span></b><span style='font-size:11.5pt'> (Enter a brief description of the claim, the request for health care service or treatment that was denied, and/or attach a copy of the denial from your health carrier)*</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>________________________________________________________________________________________________________________________________________________________________________________________________________</span></p> <p class=MsoNormal><u><span style='font-size:11.5pt'>*You</span></u><span style='font-size:11.5pt'> may also describe in your own words the health care service or treatment in dispute and why you are appealing this denial using the attached pages below.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>EXPEDITED REVIEW</span></b></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>If you need a fast decision</span></b><span style='font-size:11.5pt'>, you may request that your external appeal be handled on an expedited basis. To complete this request, your treating health care provider must fill out the attached form stating that a delay would seriously jeopardize the life or health of the patient or would jeopardize the patient's ability to regain maximum function.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Is this a request for an expedited appeal?&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Yes ______&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;No _______</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>SIGNATURE AND RELEASE OF MEDICAL RECORDS</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>To appeal your health carrier's denial, you must sign and date this external review request form and consent to the release of medical records.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>I, _______________________, hereby request an external appeal. I attest that the information provided in this application is true and accurate to the best of my knowledge. I authorize my insurance company and my health care providers to release all relevant medical or treatment records to the independent review organization and the South Dakota Division of Insurance. I understand that the independent review organization and the South Dakota Division of Insurance will use this information to make a determination on my external appeal and that the information will be kept confidential and not be released to anyone else. This release is valid for one year.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ____________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Signature of Covered Person (or legal representative)*&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>*(Parent, Guardian, Conservator or Other - Please Specify)</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><u><span style='font-size:11.5pt'>APPOINTMENT OF AUTHORIZED REPRESENTATIVE&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span></u></b></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>(Fill out this section only if someone else will be representing you in this appeal.)</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>You can represent yourself, or you may ask another person, including your treating health care provider, to act as your authorized representative. You may revoke this authorization at any time.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>I hereby authorize ____________________________________ to pursue my appeal on my behalf.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>________________________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ______________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Signature of Covered Person (or legal representative)*&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>*(Parent, Guardian, Conservator or Other - Please Specify)</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Address of Authorized Representative:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Phone #.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Daytime&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (_____)___________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Evening&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (_____)___________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_______________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>HEALTH CARE SERVICE OR TREATMENT DECISION IN DISPUTE</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>DESCRIBE IN YOUR OWN WORDS THE DISAGREEMENT WITH YOUR HEALTH CARRIER. INDICATE CLEARLY THE SERVICE(S) BEING DENIED AND THE SPECIFIC DATE(S) BEING DENIED. EXPLAIN WHY YOU DISAGREE. ATTACH ADDITIONAL PAGES IF NECESSARY AND INCLUDE AVAILABLE PERTINENT MEDICAL RECORDS, ANY INFORMATION YOU RECEIVED FROM YOUR HEALTH CARRIER CONCERNING THE DENIAL, ANY PERTINENT PEER LITERATURE OR CLINICAL STUDIES, AND ANY ADDITIONAL INFORMATION FROM YOUR PHYSICIAN/HEALTH CARE PROVIDER THAT YOU WANT THE INDEPENDENT REVIEW ORGANIZATION REVIEWER TO CONSIDER.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>WHAT TO SEND AND WHERE TO SEND IT</span></b></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>&nbsp;</span></b></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>PLEASE CHECK BELOW (NOTE: YOUR REQUEST WILL NOT BE ACCEPTED FOR FULL REVIEW UNLESS ALL FOUR ITEMS BELOW ARE INCLUDED*)</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>1.&nbsp;&nbsp;&nbsp;</span><span style='font-size:14.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;<b>YES</b>, I have included this completed application form signed and dated;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>2.&nbsp;&nbsp;&nbsp;</span><span style='font-size:14.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;<b>YES</b>, I have included a photocopy of my insurance identification card or other evidence showing that I am insured by the health insurance company named in this application;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>3.&nbsp;&nbsp;&nbsp;</span><span style='font-size:14.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;<b>YES</b>**, I have enclosed the letter from my health carrier or utilization review company that states:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (a)&nbsp;&nbsp;Their decision is final and that I have exhausted all internal review procedures; or</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (b)&nbsp;&nbsp;They have waived the requirement to exhaust all of the health carrier's internal review procedures.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>**You may make a request for external review without exhausting all internal review procedures under certain circumstances. You should contact the Division of Insurance, 124 South Euclid Avenue, 2<sup>nd</sup> Floor, Pierre, SD 57501.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>4.&nbsp;&nbsp;&nbsp;</span><span style='font-size:14.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;<b>YES</b>, I have included a copy of my certificate of coverage or my insurance policy benefit booklet, which lists the benefits under my health benefit plan.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>*Call the Division of Insurance at 605.773.3563 if you need help in completing this application or if you do not have one or more of the above items and would like information on alternative ways to complete your request for external review.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>If you are requesting a standard external review, send all paperwork to:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>South Dakota Division of Insurance</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>124 South Euclid Avenue, 2<sup>nd</sup> Floor</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Pierre, SD 57501</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>If you are requesting an expedited external review, call the Division of Insurance before sending your paperwork, and you will receive instructions on the quickest way to submit the application and supporting information.</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>CERTIFICATON OF TREATING HEALTH CARE PROVIDER</span></b></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>FOR EXPEDITED CONSIDERATION OF A PATIENT'S EXTERNAL REVIEW</span></b></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>APPEAL</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>NOTE TO THE TREATING HEALTH CARE PROVIDER</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Patients can request an external review when a health center has denied a health care service or course of treatment on the basis of a utilization review determination that the requested health care service or course of treatment does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of the health care service or treatment you requested. The South Dakota Division of Insurance oversees external appeals. The standard external review process can take up to 45 days from the date the patient's request for external review is received by our division. Expedited external review is available only if the patient's treating health care provider certifies that adherence to the timeframe for the standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function. An expedited external review must be completed within 72 hours. This form is for the purpose of providing the certification necessary to trigger expedited review.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>GENERAL INFORMATION</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Name of Treating Health Care Provider:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Mailing Address:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Phone Number: (_____)_______________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Fax Number:&nbsp;&nbsp;&nbsp;&nbsp; (_____)_______________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Licensure and Area of Clinical Specialty:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Name of Patient:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Patient's Insurer Member ID#:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>CERTIFICATION</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>I hereby certify that: I am a treating health care provider for</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>_________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>(hereafter referred to as &quot;the patient&quot;); that adherence to the timeframe of conducting a standard external review of the patient's appeal would, in my professional judgment, seriously jeopardize the life or health of the patient or would jeopardize the patient's ability to regain maximum function; and that, for this reason, the patient's appeal of the denial by the patient's health carrier of the requested health care service or course of treatment should be processed on an expedited basis.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>___________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Treating Health Care Provider's Name (Please Print)</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>___________________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Signature&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>PHYSICIAN CERTIFICATION</span></b></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>EXPERIMENTAL/INVESTIGATIONAL DENIALS</span></b></p> <p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:11.5pt'>(To Be Completed by Treating Physician)</span></b></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>I hereby certify that I am the treating physician for ______________________ (insured's name) and that I have requested the authorization for a drug, device, procedure, or therapy denied for coverage due to the insurance company's determination that the proposed therapy is experimental and/or investigational. I understand that in order for the covered person to obtain the right to an external review of this denial, as treating physician I must certify that the insured's medical condition meets certain requirements:</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>In my medical opinion as the Insured's treating physician, I hereby certify to the following:</span></b></p> <p class=MsoNormal><b><span style='font-size:11.5pt'>(Please check all that apply) (NOTE:</span></b><span style='font-size:11.5pt'> Requirements #1 - #3 below must all apply for the covered person to qualify for an external review).</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal style='margin-left:.5in;text-indent:-.5in'><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;1)</span>&nbsp;&nbsp;&nbsp;T<span style='font-size:11.5pt'>he covered person has a terminal medical condition, life threatening condition, or a seriously debilitating condition.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;2)&nbsp;&nbsp;&nbsp;The covered person has a condition that qualifies under one or more of the following:</span></p> <p class=MsoNormal style='margin-left:40.5pt;text-indent:-40.5pt'><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; [please indicate which description(s) apply]:</span></p> <p class=MsoNormal style='margin-left:40.5pt;text-indent:-40.5pt'><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal style='margin-left:.5in;text-indent:-.5in'><span style='font-size:16.0pt'>&#9633;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style='font-size:11.5pt'>Standard health care services or treatments have not been effective in improving the covered person's condition;</span></p> <p class=MsoNormal style='margin-left:.5in;text-indent:-.5in'><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal style='margin-left:.5in;text-indent:-.5in'><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Standard health care services or treatments are not medically appropriate for the covered person; or</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal style='margin-left:36.7pt;text-indent:-36.7pt'><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; There is no available standard health care service or treatment covered by the health carrier that is more beneficial than the requested or recommended health care service or treatment.</span></p> <p class=MsoNormal style='margin-left:31.0pt;text-indent:-31.7pt'><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal style='margin-left:31.5pt;text-indent:-31.5pt'><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;3)</span>&nbsp;&nbsp;<span style='font-size:11.5pt'>The health care service or treatment I have recommended and which has been denied, in my medical opinion, is likely to be more beneficial to the covered person than any available standard health care services or treatments.</span></p> <p class=MsoNormal style='margin-left:31.5pt;text-indent:-31.5pt'><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal style='margin-left:31.5pt;text-indent:-31.5pt'><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;4)</span>&nbsp;&nbsp;<span style='font-size:11.5pt'>The health care service or treatment recommended would be significantly less effective if not promptly initiated.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal style='margin-left:31.7pt;text-indent:-31.7pt'><span style='font-size:16.0pt'>&#9633;</span><span style='font-size:11.5pt'>&nbsp;&nbsp;5)</span>&nbsp;&nbsp;<span style='font-size:11.5pt'>It is my medical opinion based on scientifically valid studies using accepted protocols that the health care service or treatment requested by the covered person and which has been denied is likely to be more beneficial to the covered person than any available standard health care services or treatments.</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Explain: </span></p> <p class=MsoNormal><span style='font-size:11.5pt'>____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Please provide a description of the recommended or requested health care service or treatment that is the subject of the denial. (Attach additional sheets as necessary)</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>____________________________________________________________________________________________________________________________________________________________________</span></p> <p class=MsoNormal><u><span style='font-size:11.5pt'>________________________________________________________________________________</span></u></p> <p class=MsoNormal><u><span style='font-size:11.5pt'><span style='text-decoration: none'>&nbsp;</span></span></u></p> <p class=MsoNormal><span style='font-size:11.5pt'>__________________________________________________________________________________</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>Physician's Signature&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal><span style='font-size:11.5pt'>&nbsp;</span></p> <p class=MsoNormal>&nbsp;</p> </div> </body> </html>