<html xmlns="http://www.w3.org/1999/xhtml" lang="en-US"><head><meta charset="UTF-8"><meta http-equiv='content-language' content='en-us'/><title>SDLRC - Codified Law 58-17H-19 - Determinations to be issued in timely manner--Process to ensure consistency.</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s7f36eabd3feb46b6b3d9df92e50ab499Normal { 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.s7f36eabd3feb46b6b3d9df92e50ab499SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s7f36eabd3feb46b6b3d9df92e50ab499CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s7f36eabd3feb46b6b3d9df92e50ab499Normal-000000 { text-indent: 0.50in; 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.s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s7f36eabd3feb46b6b3d9df92e50ab499Normal-000001 { text-indent: 0.25in; 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.s7f36eabd3feb46b6b3d9df92e50ab499000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7f36eabd3feb46b6b3d9df92e50ab499SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s7f36eabd3feb46b6b3d9df92e50ab499SCL-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } body { text-decoration-skip-ink: none; } </style><meta name="viewport" content="width=device-width, initial-scale=1"><meta name="twitter:card" content="summary"><meta property="og:title" content="SD 58-17H-19 - Determinations to be issued in timely manner--Process to ensure consistency."><meta property="og:description" content="SDLRC Codified Law 58-17H-19 - Determinations to be issued in timely manner--Process to ensure consistency."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-19"><meta property="og:image" content="https://lawmakerdocuments.blob.core.usgovcloudapi.net/photos/logoshape.webp"><meta property="og:site_name" content="South Dakota Legislature"></head><body><div><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-19" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499SENU">58-17H-19</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499SENU">. </span><span class="s7f36eabd3feb46b6b3d9df92e50ab499CL">Determinations to be issued in timely manner--Process to ensure consistency.</span></p><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal-000000"><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">A health carrier shall issue utilization review and benefit determinations in a timely manner pursuant to the requirements of §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-27" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-27</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-32</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">, inclusive, and §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-40</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-48</span></a><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">, inclusive. A health carrier shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.</span></p><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal-000001"><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">If a health carrier fails to strictly adhere to the requirements of §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-27" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-27</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-32</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">, inclusive, and §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-40</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-48</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">, inclusive, with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the provisions of chapters </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17G" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17G</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont"> and </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">, and may take action regardless of whether the health carrier asserts that the carrier substantially complied with the requirements of §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-27" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-27</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-32</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">, inclusive, and §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-40</span></a><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">58-17H-48</span></a><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">, inclusive, as applicable, or that any error it committed was de minimus.</span></p><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal-000001"><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">Any covered person may file a request for external review in accordance with rules promulgated by the director. In addition to the external review rights a covered person is entitled to pursue any available remedies under state or federal law on the basis that the health carrier failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim.</span></p><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal"><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499000002"> </span></p><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal"><span class="s7f36eabd3feb46b6b3d9df92e50ab499SCL">Source:</span><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499SCL-000003"> SL 2011, ch 219, § 44.</span></p><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal"><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499000002"> </span></p><p dir="ltr" class="s7f36eabd3feb46b6b3d9df92e50ab499Normal"><span xml:space="preserve" class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont-000004">Commission Note: </span><span class="s7f36eabd3feb46b6b3d9df92e50ab499DefaultParagraphFont">SL 2012, ch 239, § 1 provides: "The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed."</span></p></div></body></html>