<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-48 - Notification of adverse determination--Requirements.</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s013bf928844c4daaab932eb6464e5890Normal { 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.s013bf928844c4daaab932eb6464e5890SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s013bf928844c4daaab932eb6464e5890CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s013bf928844c4daaab932eb6464e5890Normal-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.s013bf928844c4daaab932eb6464e5890DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s013bf928844c4daaab932eb6464e5890Normal-000001 { margin-left: 0.70in; text-indent: -0.45in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } p.s013bf928844c4daaab932eb6464e5890Normal-000002 { margin-left: 1.14in; text-indent: -0.44in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } p.s013bf928844c4daaab932eb6464e5890Normal-000003 { 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.s013bf928844c4daaab932eb6464e5890000004 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s013bf928844c4daaab932eb6464e5890SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s013bf928844c4daaab932eb6464e5890SCL-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s013bf928844c4daaab932eb6464e5890DefaultParagraphFont-000006 { 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-48 - Notification of adverse determination--Requirements."><meta property="og:description" content="SDLRC Codified Law 58-17H-48 - Notification of adverse determination--Requirements."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-48"><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="s013bf928844c4daaab932eb6464e5890Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s013bf928844c4daaab932eb6464e5890SENU">58-17H-48</span></a><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890SENU">. </span><span class="s013bf928844c4daaab932eb6464e5890CL">Notification of adverse determination--Requirements.</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000000"><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">If a health carrier's determination with respect to §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">58-17H-40</span></a><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-47" rel="noopener"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">58-17H-47</span></a><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">, inclusive, is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with this section. A notification of an adverse determination under this section shall, in a manner calculated to be understood by the covered person, set forth:</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(1)    Information sufficient to identify the benefit request or claim involved, including the date of service, if applicable, the health care provider, the claim amount, if applicable, the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(2)    The specific reason or reasons for the adverse determination, including the denial code and its corresponding meaning, as well as a description of the health carrier's standard, if any, that was used in denying the benefit request or claim;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(3)    A reference to the specific plan provisions on which the determination is based;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(4)    A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(5)    A description of the health carrier's internal review procedures established pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">58-17I</span></a><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">, including any time limits applicable to those procedures;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(6)    A description of the health carrier's expedited review procedures established pursuant to §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I-12" rel="noopener"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">58-17I-12</span></a><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I-16" rel="noopener"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">58-17I-16</span></a><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">, inclusive;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(7)    If the health carrier relied upon an internal rule, guideline, protocol, or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that a specific rule, guideline, protocol, or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the covered person upon request;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(8)    If the adverse determination is based on a medical necessity or experimental or investigation treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances, or a statement that an explanation will be provided to the covered person free of charge upon request;</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(9)    If applicable, instructions for requesting:</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000002"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(a)    A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination in accordance with subdivision (7) of this section; or</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000002"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(b)    The written statement of the scientific or clinical rationale for the adverse determination in accordance with subdivision (8) of this section; and</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000001"><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">(10)    A statement explaining the availability of and the right of the covered person, as appropriate, to contact the Division of Insurance at any time for assistance or, upon completion of the health carrier's grievance procedure process as provided under chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">58-17I</span></a><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">, to file a civil suit in a court of competent jurisdiction.</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal-000003"><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">A health carrier may provide the notice required under this section orally, in writing or electronically. If notice of the adverse determination is provided orally, the health carrier shall provide written or electronic notice of the adverse determination within three days following the oral notification.</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal"><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890000004"> </span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal"><span class="s013bf928844c4daaab932eb6464e5890SCL">Source:</span><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890SCL-000005"> SL 2011, ch 219, § 73.</span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal"><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890000004"> </span></p><p dir="ltr" class="s013bf928844c4daaab932eb6464e5890Normal"><span xml:space="preserve" class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont-000006">Commission Note: </span><span class="s013bf928844c4daaab932eb6464e5890DefaultParagraphFont">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>