<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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s587fc72b32de42939e572c0f93babf63Normal { text-align: center; 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.s587fc72b32de42939e572c0f93babf63HG4 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s587fc72b32de42939e572c0f93babf63DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s587fc72b32de42939e572c0f93babf63HG4C { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s587fc72b32de42939e572c0f93babf63Normal-000000 { 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.s587fc72b32de42939e572c0f93babf63000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s587fc72b32de42939e572c0f93babf63B { margin-left: 1.38in; text-indent: -1.38in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } </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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS"><meta property="og:description" content="SDLRC Codified Law 58-17H - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS"><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H"><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="s587fc72b32de42939e572c0f93babf63Normal"><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63HG4">CHAPTER </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H</span></a></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63Normal"><span class="s587fc72b32de42939e572c0f93babf63HG4C">UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63Normal-000000"><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63000001"> </span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-1" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-1</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Definitions.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-2" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-2</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Health benefit plan defined.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-3" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-3</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Urgent care request defined.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-4" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-4</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Applicability of chapter.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-5" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-5</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-6" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-6</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    In-network emergency services.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-7" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-7</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Cost-sharing requirements for out-of-network emergency services.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-8" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-8</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Cost-sharing requirements for covered persons--Payments to out-of-network providers.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-9" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-9</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Exceptions for payments by capitated and other plans without negotiated fees.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-10" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-10</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Negotiated amounts for in-network providers for a particular emergency service.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-11" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-11</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    General cost-sharing requirements allowed.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-12" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-12</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Access to representative for post-evaluation or post-stabilization services.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-13" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-13</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-14" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-14</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Health carrier responsibility for utilization review activities.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-15" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-15</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Director to hold health carrier responsible for utilization review performance of contractor.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-16" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-16</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Written utilization review program required--Contents of program document.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-17" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-17</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-18" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-18</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Program to be administered by qualified licensed health care professionals.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-19" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-19</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Determinations to be issued in timely manner--Process to ensure consistency.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-20" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-20</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Effectiveness and efficiency of program to be routinely reviewed.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-21" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-21</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Data systems to support program activities and generate management reports.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-22" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-22</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Health carrier oversight of delegated activities--Requirements.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-23" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-23</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Utilization review to be coordinated with other medical management activity of health carrier.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-24" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-24</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Health carrier to provide free access to review staff.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-25" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-25</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Only information necessary for review or determination to be collected.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-26" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-26</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Independence and impartiality required for utilization review.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-27" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-27</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Written procedures required for making determinations--Notification.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-28" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-28</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Prospective review determinations--Timing--Notification of requirements--Extension of time.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-29" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-29</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Concurrent review determinations--Timing--Notification requirements.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-30</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Retrospective review determinations--Timing--Notification requirements.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30.1" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-30.1</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Retroactive denial of paid claim--Restriction--Requirement--Exclusions--Enforcement.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30.2" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-30.2</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Retroactive denial of paid claim--Payment amount.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-31" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-31</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Calculation of time period for determination for prospective and retrospective reviews.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-32</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Notification of adverse determination--Contents.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-33" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-33</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Information required to be provided to covered persons and prospective covered persons.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-34" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-34</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-35" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-35</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Registration of utilization review organizations--Required information.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-36" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-36</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Filing changes in registration information.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-37" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-37</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Requests for information from utilization review organizations.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-38" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-38</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Activities of nonregistered utilization review organizations prohibited.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-39" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-39</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Registration fee for utilization review organizations.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-40</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Urgent care requests--Written procedures required for receipt and determination of requests.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-41" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-41</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Insufficient information for determination--Notice and statement of necessary information.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-42" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-42</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Insufficient information for determination of prospective urgent care requests.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-43" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-43</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Urgent care requests--Timely notification of determination.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-44" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-44</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Time within which to submit necessary information.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-45" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-45</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-46" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-46</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Concurrent review urgent care requests--Extended care requests--Time for determination and notice.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-47" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-47</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Calculation of time periods for determination.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-48</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Notification of adverse determination--Requirements.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-49" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-49</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Promulgation of rules.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-50" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-50</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Coverage for cancer treatment medication.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-51" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-51</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Reclassification of benefits with respect to cancer treatment medications.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-52" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-52</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Medical management practices complying with chapter.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-53" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-53</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Step therapy protocols.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-54" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-54</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Step therapy protocols--Process--Transparency.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-55" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-55</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Step therapy override exceptions.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-56" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-56</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Limitations.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-57" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-57</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Utilization review organization or health carrier--Annual review--Report--Contents--Publication.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-58" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-58</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Utilization review organization or health carrier--Health care service review--Prior authorization requirement elimination.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-59" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-59</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Utilization review organization or health carrier--Health care service review--Annual report--Contents--Publication.</span></p><p dir="ltr" class="s587fc72b32de42939e572c0f93babf63B"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-60" rel="noopener"><span class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">58-17H-60</span></a><span xml:space="preserve" class="s587fc72b32de42939e572c0f93babf63DefaultParagraphFont">    Utilization review organization or health carrier--Health care service--Excluded services.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s01de9d71744c47b08fb8eb268fe07ec8Normal { 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.s01de9d71744c47b08fb8eb268fe07ec8SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s01de9d71744c47b08fb8eb268fe07ec8CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 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span.s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s01de9d71744c47b08fb8eb268fe07ec8SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-1 - Definitions."><meta property="og:description" content="SDLRC Codified Law 58-17H-1 - Definitions."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-1"><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="s01de9d71744c47b08fb8eb268fe07ec8Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-1" rel="noopener"><span class="s01de9d71744c47b08fb8eb268fe07ec8SENU">58-17H-1</span></a><span xml:space="preserve" class="s01de9d71744c47b08fb8eb268fe07ec8SENU">. </span><span class="s01de9d71744c47b08fb8eb268fe07ec8CL">Definitions.</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8Normal"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">Terms used in this chapter mean:</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(1)    "Adverse determination," any of the following:</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(a)    A determination by a health carrier or the carrier's designee utilization review organization that, based upon the information provided, a request by a covered person for a benefit under the health carrier's health benefit plan upon application of any utilization review technique does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part, for the benefit;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(b)    The denial, reduction, termination, or failure to provide or make payment in whole or in part, for a benefit based on a determination by a health carrier or the carrier's designee utilization review organization of a covered person's eligibility to participate in the health carrier's health benefit plan;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(c)    Any prospective review or retrospective review determination that denies, reduces, terminates, or fails to provide or make payment, in whole or in part, for a benefit; or</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(d)    A rescission of coverage determination;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(2)    "Ambulatory review," utilization review of health care services performed or provided in an outpatient setting;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(3)    "Authorized representative," a person to whom a covered person has given express written consent to represent the covered person for purposes of this chapter, a person authorized by law to provide substituted consent for a covered person, a family member of the covered person or the covered person's treating health care professional if the covered person is unable to provide consent, or a health care professional if the covered person's health benefit plan requires that a request for a benefit under the plan be initiated by the health care professional. For any urgent care request, the term includes a health care professional with knowledge of the covered person's medical condition;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(4)    "Case management," a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or other health conditions;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(5)    "Certification," a determination by a health carrier or the carrier's designee utilization review organization that a request for a benefit under the health carrier's health benefit plan has been reviewed and, based on the information provided, satisfies the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(6)    "Clinical practice guidelines," a systematically developed statement to assist decision making by health care professionals and patient decisions about appropriate health care for specific clinical circumstances and conditions;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(7)    "Clinical peer," a physician or other health care professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(8)    "Clinical review criteria," the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of health care services;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(9)    "Concurrent review," utilization review conducted during a patient's hospital stay or course of treatment in a facility or other inpatient or outpatient health care setting;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(10)    "Covered benefits" or "benefits," those health care services to which a covered person is entitled under the terms of a health benefit plan;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(11)    "Covered person," a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(12)    "Director," the director of the Division of Insurance;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(13)    "Discharge planning," the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(14)    "Emergency medical condition," a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate medical attention, would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(15)    "Emergency services," with respect to an emergency medical condition:</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(a)    A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency condition; and</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(b)    Such further medical examination and treatment, to the extent they are within the capability of the staff and facilities at a hospital to stabilize a patient;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(16)    "Facility," an institution providing health care services or a health care setting, including hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory, and imaging centers, and rehabilitation, and other therapeutic health settings;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(17)    "Health care professional," a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(18)    "Health care provider" or "provider," a health care professional or a facility;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(19)    "Health care services," services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(20)    "Health carrier," an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the director, that contracts or offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health services;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(21)    "Managed care contractor," a person who establishes, operates, or maintains a network of participating providers; or contracts with an insurance company, a hospital or medical service plan, an employer, an employee organization, or any other entity providing coverage for health care services to operate a managed care plan or health carrier;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(22)    "Managed care entity," a licensed insurance company, hospital or medical service plan, health maintenance organization, or an employer or employee organization, that operates a managed care plan or a managed care contractor. The term does not include a licensed insurance company unless it contracts with other entities to provide a network of participating providers;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(23)    "Managed care plan," a plan operated by a managed care entity that provides for the financing or delivery of health care services, or both, to persons enrolled in the plan through any of the following:</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(a)    Arrangements with selected providers to furnish health care services;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(b)    Explicit standards for the selection of participating providers; or</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(c)    Financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the plan;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(24)    "Network," the group of participating providers providing services to a health carrier;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(25)    "Participating provider," a provider who, under a contract with the health carrier or with its contractor or subcontractor, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly, from the health carrier;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(26)    "Pharmaceutical sample," a unit of a prescription drug that is not intended to be sold and is intended to promote the sale of the drug;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(27)    "Prospective review," utilization review conducted prior to an admission or the provision of a health care service or a course of treatment in accordance with a health carrier's requirement that the health care service or course of treatment, in whole or in part, be approved prior to its provision;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(28)    "Rescission," a cancellation or discontinuance of coverage under a health benefit plan that has a retroactive effect. The term does not include a cancellation or discontinuance of coverage under a health benefit plan if:</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(a)    The cancellation or discontinuance of coverage has only a prospective effect; or</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber2"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(b)    The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(29)    "Retrospective review," any review of a request for a benefit that is not a prospective review request, which does not include the review of a claim that is limited to veracity of documentation, or accuracy of coding, or adjudication for payment;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(30)    "Second opinion," an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health care service to assess the medical necessity and appropriateness of the initial proposed health care service;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(31)    "Secretary," the secretary of the Department of Health;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(32)    "Stabilized," with respect to an emergency medical condition, that no material deterioration of the condition is likely, with reasonable medical probability, to result from or occur during the transfer of the individual from a facility or, with respect to a pregnant woman, the woman has delivered, including the placenta;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(33)    "Utilization review," a set of formal techniques used by a managed care plan or utilization review organization to monitor and evaluate the medical necessity, appropriateness, and efficiency of health care services and procedures including techniques such as ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, and retrospective review;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1-000000"><span xml:space="preserve" class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(34)    "Step therapy override exception," a step therapy protocol should be overridden in favor of coverage of the prescription drug selected by a health care professional within the applicable time frames in § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-55" rel="noopener"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">58-17H-55</span></a><span xml:space="preserve" class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont"> and in compliance with chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H" rel="noopener"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">58-17H</span></a><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">. This determination is based on a review of the covered person's or health care professional's request for an override, along with supporting rationale and documentation;</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(35)    "Step therapy protocol," a protocol or program that establishes a specific sequence in which prescription drugs are covered under a pharmacy or medical benefit by a health carrier, a health benefit plan, or a utilization review organization for a specified medical condition and medically appropriate for a health carrier, a health benefit plan, or utilization review organization, including self-administered drugs and drugs administered by a health care professional; and</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8StatuteNumber1"><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">(36)    "Utilization review organization," an entity that conducts utilization review other than a health carrier performing utilization review for its own health benefit plans.</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8Normal"><span xml:space="preserve" class="s01de9d71744c47b08fb8eb268fe07ec8000001"> </span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8Normal"><span xml:space="preserve" class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont-000002">Source: </span><span class="s01de9d71744c47b08fb8eb268fe07ec8SCL">SL 2011, ch 219, § 28; SL 2020, ch 209, § 1.</span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8Normal"><span xml:space="preserve" class="s01de9d71744c47b08fb8eb268fe07ec8000001"> </span></p><p dir="ltr" class="s01de9d71744c47b08fb8eb268fe07ec8Normal"><span xml:space="preserve" class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont-000002">Commission Note: </span><span class="s01de9d71744c47b08fb8eb268fe07ec8DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s42aaade962dd4903acfb1a580ebf0aa6Normal { 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.s42aaade962dd4903acfb1a580ebf0aa6SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s42aaade962dd4903acfb1a580ebf0aa6CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s42aaade962dd4903acfb1a580ebf0aa6Statute { 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.s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s42aaade962dd4903acfb1a580ebf0aa6Statute-000000 { 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.s42aaade962dd4903acfb1a580ebf0aa6000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s42aaade962dd4903acfb1a580ebf0aa6NoIndent { text-indent: 0.00in; 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.s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s42aaade962dd4903acfb1a580ebf0aa6SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-2 - Health benefit plan defined."><meta property="og:description" content="SDLRC Codified Law 58-17H-2 - Health benefit plan defined."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-2"><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="s42aaade962dd4903acfb1a580ebf0aa6Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-2" rel="noopener"><span class="s42aaade962dd4903acfb1a580ebf0aa6SENU">58-17H-2</span></a><span xml:space="preserve" class="s42aaade962dd4903acfb1a580ebf0aa6SENU">. </span><span class="s42aaade962dd4903acfb1a580ebf0aa6CL">Health benefit plan defined.</span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6Statute"><span class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont">For the purposes of this chapter, the term, health benefit plan, means a policy, contract, certificate, or agreement entered into, offered, or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. The term includes short-term and catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as otherwise specifically exempted in this definition.</span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6Statute-000000"><span class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont">The term does not include coverage only for accident, or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, specified in federal regulations issued pursuant to Public Law No. 104-191, as amended to January 1, 2011, under which benefits for medical care are secondary or incidental to other insurance benefits.</span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6Statute-000000"><span class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont">The term does not include the following benefits if they are provided under a separate policy, certificate, or contract of insurance or are otherwise not an integral part of the plan: limited scope dental or vision benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof; or other similar, limited benefits specified in federal regulations issued pursuant to Public Law No. 104-191, as amended to January 1, 2011.</span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6Statute-000000"><span class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont">The term does not include the following benefits if the benefits are provided under a separate policy, certificate, or contract of insurance, there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor, and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor: coverage only for a specified disease or illness; or hospital indemnity or other fixed indemnity insurance.</span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6Statute-000000"><span class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont">The term does not include the following if offered as a separate policy, certificate, or contract of insurance: medicare supplemental health insurance as defined under Section 1882(g)(1) of the Social Security Act, as amended to January 1, 2011; coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code (Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)), as amended to January 1, 2011; or similar supplemental coverage provided to coverage under a group health plan.</span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6Normal"><span xml:space="preserve" class="s42aaade962dd4903acfb1a580ebf0aa6000001"> </span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6NoIndent"><span xml:space="preserve" class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont-000002">Source: </span><span class="s42aaade962dd4903acfb1a580ebf0aa6SCL">SL 2011, ch 219, § 91; SL 2021, ch 210, § 14.</span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6NoIndent"><span xml:space="preserve" class="s42aaade962dd4903acfb1a580ebf0aa6000001"> </span></p><p dir="ltr" class="s42aaade962dd4903acfb1a580ebf0aa6NoIndent"><span xml:space="preserve" class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont-000002">Commission Note: </span><span class="s42aaade962dd4903acfb1a580ebf0aa6DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.se25c83745353441399f0995a866f7861Normal { 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.se25c83745353441399f0995a866f7861SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.se25c83745353441399f0995a866f7861CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.se25c83745353441399f0995a866f7861Normal-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.se25c83745353441399f0995a866f7861DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.se25c83745353441399f0995a866f7861Normal-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.se25c83745353441399f0995a866f7861Normal-000002 { 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.se25c83745353441399f0995a866f7861000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se25c83745353441399f0995a866f7861SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.se25c83745353441399f0995a866f7861SCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se25c83745353441399f0995a866f7861DefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-3 - Urgent care request defined."><meta property="og:description" content="SDLRC Codified Law 58-17H-3 - Urgent care request defined."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-3"><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="se25c83745353441399f0995a866f7861Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-3" rel="noopener"><span class="se25c83745353441399f0995a866f7861SENU">58-17H-3</span></a><span xml:space="preserve" class="se25c83745353441399f0995a866f7861SENU">. </span><span class="se25c83745353441399f0995a866f7861CL">Urgent care request defined.</span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal-000000"><span class="se25c83745353441399f0995a866f7861DefaultParagraphFont">For the purposes of this chapter, the term, urgent care request means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination:</span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal-000001"><span class="se25c83745353441399f0995a866f7861DefaultParagraphFont">(1)    Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or</span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal-000001"><span class="se25c83745353441399f0995a866f7861DefaultParagraphFont">(2)    In the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request.</span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal-000002"><span class="se25c83745353441399f0995a866f7861DefaultParagraphFont">Except as provided in subdivision (1) of this section, in determining whether a request is to be treated as an urgent care request, an individual acting on behalf of the health carrier shall apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. Any request that a physician with knowledge of the covered person's medical condition determines is an urgent care request within the meaning of subdivisions (1) and (2) of this section shall be treated as an urgent care request.</span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal"><span xml:space="preserve" class="se25c83745353441399f0995a866f7861000003"> </span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal"><span class="se25c83745353441399f0995a866f7861SCL">Source:</span><span xml:space="preserve" class="se25c83745353441399f0995a866f7861SCL-000004"> SL 2011, ch 219, § 92.</span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal"><span xml:space="preserve" class="se25c83745353441399f0995a866f7861000003"> </span></p><p dir="ltr" class="se25c83745353441399f0995a866f7861Normal"><span xml:space="preserve" class="se25c83745353441399f0995a866f7861DefaultParagraphFont-000005">Commission Note: </span><span class="se25c83745353441399f0995a866f7861DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sb23a324fdc644c3d804e1be19b9e52c3Normal { 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.sb23a324fdc644c3d804e1be19b9e52c3SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb23a324fdc644c3d804e1be19b9e52c3CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sb23a324fdc644c3d804e1be19b9e52c3Normal-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.sb23a324fdc644c3d804e1be19b9e52c3DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb23a324fdc644c3d804e1be19b9e52c3000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb23a324fdc644c3d804e1be19b9e52c3SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb23a324fdc644c3d804e1be19b9e52c3SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb23a324fdc644c3d804e1be19b9e52c3DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-4 - Applicability of chapter."><meta property="og:description" content="SDLRC Codified Law 58-17H-4 - Applicability of chapter."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-4"><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="sb23a324fdc644c3d804e1be19b9e52c3Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-4" rel="noopener"><span class="sb23a324fdc644c3d804e1be19b9e52c3SENU">58-17H-4</span></a><span xml:space="preserve" class="sb23a324fdc644c3d804e1be19b9e52c3SENU">. </span><span class="sb23a324fdc644c3d804e1be19b9e52c3CL">Applicability of chapter.</span></p><p dir="ltr" class="sb23a324fdc644c3d804e1be19b9e52c3Normal-000000"><span class="sb23a324fdc644c3d804e1be19b9e52c3DefaultParagraphFont">The provisions of this chapter apply to any health carrier that provides or performs utilization review services. The requirements of this chapter also apply to any designee of the health carrier or utilization review organization that performs utilization review functions on the carrier's behalf.</span></p><p dir="ltr" class="sb23a324fdc644c3d804e1be19b9e52c3Normal"><span xml:space="preserve" class="sb23a324fdc644c3d804e1be19b9e52c3000001"> </span></p><p dir="ltr" class="sb23a324fdc644c3d804e1be19b9e52c3Normal"><span class="sb23a324fdc644c3d804e1be19b9e52c3SCL">Source:</span><span xml:space="preserve" class="sb23a324fdc644c3d804e1be19b9e52c3SCL-000002"> SL 2011, ch 219, § 29.</span></p><p dir="ltr" class="sb23a324fdc644c3d804e1be19b9e52c3Normal"><span xml:space="preserve" class="sb23a324fdc644c3d804e1be19b9e52c3000001"> </span></p><p dir="ltr" class="sb23a324fdc644c3d804e1be19b9e52c3Normal"><span xml:space="preserve" class="sb23a324fdc644c3d804e1be19b9e52c3DefaultParagraphFont-000003">Commission Note: </span><span class="sb23a324fdc644c3d804e1be19b9e52c3DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sff7bbf45b7fc4a2e95f87db814405e33Normal { 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.sff7bbf45b7fc4a2e95f87db814405e33SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sff7bbf45b7fc4a2e95f87db814405e33CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sff7bbf45b7fc4a2e95f87db814405e33Normal-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.sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sff7bbf45b7fc4a2e95f87db814405e33000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sff7bbf45b7fc4a2e95f87db814405e33SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sff7bbf45b7fc4a2e95f87db814405e33SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-5 - Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services."><meta property="og:description" content="SDLRC Codified Law 58-17H-5 - Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-5"><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="sff7bbf45b7fc4a2e95f87db814405e33Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-5" rel="noopener"><span class="sff7bbf45b7fc4a2e95f87db814405e33SENU">58-17H-5</span></a><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33SENU">. </span><span class="sff7bbf45b7fc4a2e95f87db814405e33CL">Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.</span></p><p dir="ltr" class="sff7bbf45b7fc4a2e95f87db814405e33Normal-000000"><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">If conducting utilization review or making a benefit determination for emergency services, a health carrier that provides benefits for services in an emergency department of a hospital shall comply with the provisions of §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-5" rel="noopener"><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">58-17H-5</span></a><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-13" rel="noopener"><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">58-17H-13</span></a><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">, inclusive. A health carrier shall cover emergency services necessary to screen and stabilize a covered person and may not require prior authorization of such services if a prudent layperson would have reasonably believed that an emergency medical condition existed even if the emergency services are provided on an out of-network basis. A health carrier shall cover emergency services whether the health care provider furnishing the services is a participating provider with respect to such services. If the emergency services are provided out-of-network, the services shall be covered without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers. Emergency services are provided out-of-network by complying with the cost sharing requirements set forth in §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-7" rel="noopener"><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">58-17H-7</span></a><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-10" rel="noopener"><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">58-17H-10</span></a><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">, inclusive, and without regard to any other term or condition of coverage other than the exclusion of or coordination of benefits, an affiliation or waiting periods as permitted under section 2704 of the Public Health Service Act, as amended to January 1, 2011, or cost sharing requirements as set forth in §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-6" rel="noopener"><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">58-17H-6</span></a><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-10" rel="noopener"><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">58-17H-10</span></a><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">, inclusive.</span></p><p dir="ltr" class="sff7bbf45b7fc4a2e95f87db814405e33Normal"><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33000001"> </span></p><p dir="ltr" class="sff7bbf45b7fc4a2e95f87db814405e33Normal"><span class="sff7bbf45b7fc4a2e95f87db814405e33SCL">Source:</span><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33SCL-000002"> SL 2011, ch 219, § 30.</span></p><p dir="ltr" class="sff7bbf45b7fc4a2e95f87db814405e33Normal"><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33000001"> </span></p><p dir="ltr" class="sff7bbf45b7fc4a2e95f87db814405e33Normal"><span xml:space="preserve" class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont-000003">Commission Note: </span><span class="sff7bbf45b7fc4a2e95f87db814405e33DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s62aba92487464547b447900b93cde015Normal { 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.s62aba92487464547b447900b93cde015SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s62aba92487464547b447900b93cde015CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s62aba92487464547b447900b93cde015Normal-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.s62aba92487464547b447900b93cde015DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s62aba92487464547b447900b93cde015000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s62aba92487464547b447900b93cde015SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s62aba92487464547b447900b93cde015SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s62aba92487464547b447900b93cde015DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-6 - In-network emergency services."><meta property="og:description" content="SDLRC Codified Law 58-17H-6 - In-network emergency services."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-6"><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="s62aba92487464547b447900b93cde015Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-6" rel="noopener"><span class="s62aba92487464547b447900b93cde015SENU">58-17H-6</span></a><span xml:space="preserve" class="s62aba92487464547b447900b93cde015SENU">. </span><span class="s62aba92487464547b447900b93cde015CL">In-network emergency services.</span></p><p dir="ltr" class="s62aba92487464547b447900b93cde015Normal-000000"><span class="s62aba92487464547b447900b93cde015DefaultParagraphFont">Coverage of in-network emergency services are subject to applicable copayments, coinsurance, and deductibles.</span></p><p dir="ltr" class="s62aba92487464547b447900b93cde015Normal"><span xml:space="preserve" class="s62aba92487464547b447900b93cde015000001"> </span></p><p dir="ltr" class="s62aba92487464547b447900b93cde015Normal"><span class="s62aba92487464547b447900b93cde015SCL">Source:</span><span xml:space="preserve" class="s62aba92487464547b447900b93cde015SCL-000002"> SL 2011, ch 219, § 31.</span></p><p dir="ltr" class="s62aba92487464547b447900b93cde015Normal"><span xml:space="preserve" class="s62aba92487464547b447900b93cde015000001"> </span></p><p dir="ltr" class="s62aba92487464547b447900b93cde015Normal"><span xml:space="preserve" class="s62aba92487464547b447900b93cde015DefaultParagraphFont-000003">Commission Note: </span><span class="s62aba92487464547b447900b93cde015DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s875a64fe86654434848c841b20b7a35fNormal { 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.s875a64fe86654434848c841b20b7a35fSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s875a64fe86654434848c841b20b7a35fCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s875a64fe86654434848c841b20b7a35fNormal-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.s875a64fe86654434848c841b20b7a35fDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s875a64fe86654434848c841b20b7a35f000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s875a64fe86654434848c841b20b7a35fSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s875a64fe86654434848c841b20b7a35fSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s875a64fe86654434848c841b20b7a35fDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-7 - Cost-sharing requirements for out-of-network emergency services."><meta property="og:description" content="SDLRC Codified Law 58-17H-7 - Cost-sharing requirements for out-of-network emergency services."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-7"><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="s875a64fe86654434848c841b20b7a35fNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-7" rel="noopener"><span class="s875a64fe86654434848c841b20b7a35fSENU">58-17H-7</span></a><span xml:space="preserve" class="s875a64fe86654434848c841b20b7a35fSENU">. </span><span class="s875a64fe86654434848c841b20b7a35fCL">Cost-sharing requirements for out-of-network emergency services.</span></p><p dir="ltr" class="s875a64fe86654434848c841b20b7a35fNormal-000000"><span class="s875a64fe86654434848c841b20b7a35fDefaultParagraphFont">Cost-sharing requirements for out-of-network emergency services expressed as a copayment amount or coinsurance rate imposed with respect to a covered person cannot exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-network.</span></p><p dir="ltr" class="s875a64fe86654434848c841b20b7a35fNormal"><span xml:space="preserve" class="s875a64fe86654434848c841b20b7a35f000001"> </span></p><p dir="ltr" class="s875a64fe86654434848c841b20b7a35fNormal"><span class="s875a64fe86654434848c841b20b7a35fSCL">Source:</span><span xml:space="preserve" class="s875a64fe86654434848c841b20b7a35fSCL-000002"> SL 2011, ch 219, § 32.</span></p><p dir="ltr" class="s875a64fe86654434848c841b20b7a35fNormal"><span xml:space="preserve" class="s875a64fe86654434848c841b20b7a35f000001"> </span></p><p dir="ltr" class="s875a64fe86654434848c841b20b7a35fNormal"><span xml:space="preserve" class="s875a64fe86654434848c841b20b7a35fDefaultParagraphFont-000003">Commission Note: </span><span class="s875a64fe86654434848c841b20b7a35fDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s460d70a48f9a43e5b25a389c2a99d39aNormal { 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.s460d70a48f9a43e5b25a389c2a99d39aSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s460d70a48f9a43e5b25a389c2a99d39aCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s460d70a48f9a43e5b25a389c2a99d39aNormal-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.s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s460d70a48f9a43e5b25a389c2a99d39aNormal-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; } p.s460d70a48f9a43e5b25a389c2a99d39aNormal-000002 { 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; } span.s460d70a48f9a43e5b25a389c2a99d39a000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s460d70a48f9a43e5b25a389c2a99d39aSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s460d70a48f9a43e5b25a389c2a99d39aSCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-8 - Cost-sharing requirements for covered persons--Payments to out-of-network providers."><meta property="og:description" content="SDLRC Codified Law 58-17H-8 - Cost-sharing requirements for covered persons--Payments to out-of-network providers."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-8"><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="s460d70a48f9a43e5b25a389c2a99d39aNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-8" rel="noopener"><span class="s460d70a48f9a43e5b25a389c2a99d39aSENU">58-17H-8</span></a><span xml:space="preserve" class="s460d70a48f9a43e5b25a389c2a99d39aSENU">. </span><span class="s460d70a48f9a43e5b25a389c2a99d39aCL">Cost-sharing requirements for covered persons--Payments to out-of-network providers.</span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal-000000"><span xml:space="preserve" class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">Notwithstanding § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-7" rel="noopener"><span class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">58-17H-7</span></a><span class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">, a covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount the health carrier is required to pay pursuant to this section.</span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal-000001"><span class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">A health carrier complies with the requirements of this section if it provides payment of emergency services provided by an out-of-network provider in an amount not less than the greatest of the following:</span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal-000002"><span class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">(1)    The amount negotiated with in-network providers for emergency services, excluding any in-network copayment or coinsurance imposed with respect to the covered person;</span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal-000002"><span class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">(2)    The amount of the emergency service calculated using the same method the plan uses to determine payments for out-of-network services, but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or</span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal-000002"><span class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">(3)    The amount that would be paid under Medicare for the emergency services, excluding any in-network copayment or coinsurance requirements.</span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal"><span xml:space="preserve" class="s460d70a48f9a43e5b25a389c2a99d39a000003"> </span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal"><span class="s460d70a48f9a43e5b25a389c2a99d39aSCL">Source:</span><span xml:space="preserve" class="s460d70a48f9a43e5b25a389c2a99d39aSCL-000004"> SL 2011, ch 219, § 33.</span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal"><span xml:space="preserve" class="s460d70a48f9a43e5b25a389c2a99d39a000003"> </span></p><p dir="ltr" class="s460d70a48f9a43e5b25a389c2a99d39aNormal"><span xml:space="preserve" class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont-000005">Commission Note: </span><span class="s460d70a48f9a43e5b25a389c2a99d39aDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s6defa3193fa946379ec7e9ae131b64b2Normal { 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.s6defa3193fa946379ec7e9ae131b64b2SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s6defa3193fa946379ec7e9ae131b64b2CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s6defa3193fa946379ec7e9ae131b64b2Normal-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.s6defa3193fa946379ec7e9ae131b64b2DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s6defa3193fa946379ec7e9ae131b64b2000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s6defa3193fa946379ec7e9ae131b64b2SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s6defa3193fa946379ec7e9ae131b64b2SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s6defa3193fa946379ec7e9ae131b64b2DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-9 - Exceptions for payments by capitated and other plans without negotiated fees."><meta property="og:description" content="SDLRC Codified Law 58-17H-9 - Exceptions for payments by capitated and other plans without negotiated fees."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-9"><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="s6defa3193fa946379ec7e9ae131b64b2Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-9" rel="noopener"><span class="s6defa3193fa946379ec7e9ae131b64b2SENU">58-17H-9</span></a><span xml:space="preserve" class="s6defa3193fa946379ec7e9ae131b64b2SENU">. </span><span class="s6defa3193fa946379ec7e9ae131b64b2CL">Exceptions for payments by capitated and other plans without negotiated fees.</span></p><p dir="ltr" class="s6defa3193fa946379ec7e9ae131b64b2Normal-000000"><span xml:space="preserve" class="s6defa3193fa946379ec7e9ae131b64b2DefaultParagraphFont">For capitated or other health benefit plans that do not have a negotiated per-service amount for in-network providers, subdivision </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-8" rel="noopener"><span class="s6defa3193fa946379ec7e9ae131b64b2DefaultParagraphFont">58-17H-8</span></a><span class="s6defa3193fa946379ec7e9ae131b64b2DefaultParagraphFont">(1) does not apply.</span></p><p dir="ltr" class="s6defa3193fa946379ec7e9ae131b64b2Normal"><span xml:space="preserve" class="s6defa3193fa946379ec7e9ae131b64b2000001"> </span></p><p dir="ltr" class="s6defa3193fa946379ec7e9ae131b64b2Normal"><span class="s6defa3193fa946379ec7e9ae131b64b2SCL">Source:</span><span xml:space="preserve" class="s6defa3193fa946379ec7e9ae131b64b2SCL-000002"> SL 2011, ch 219, § 34.</span></p><p dir="ltr" class="s6defa3193fa946379ec7e9ae131b64b2Normal"><span xml:space="preserve" class="s6defa3193fa946379ec7e9ae131b64b2000001"> </span></p><p dir="ltr" class="s6defa3193fa946379ec7e9ae131b64b2Normal"><span xml:space="preserve" class="s6defa3193fa946379ec7e9ae131b64b2DefaultParagraphFont-000003">Commission Note: </span><span class="s6defa3193fa946379ec7e9ae131b64b2DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s11cb0b1c85a94ec98d8245d46091288dNormal { 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.s11cb0b1c85a94ec98d8245d46091288dSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s11cb0b1c85a94ec98d8245d46091288dCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s11cb0b1c85a94ec98d8245d46091288dNormal-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.s11cb0b1c85a94ec98d8245d46091288dDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s11cb0b1c85a94ec98d8245d46091288d000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s11cb0b1c85a94ec98d8245d46091288dSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s11cb0b1c85a94ec98d8245d46091288dSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s11cb0b1c85a94ec98d8245d46091288dDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-10 - Negotiated amounts for in-network providers for a particular emergency service."><meta property="og:description" content="SDLRC Codified Law 58-17H-10 - Negotiated amounts for in-network providers for a particular emergency service."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-10"><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="s11cb0b1c85a94ec98d8245d46091288dNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-10" rel="noopener"><span class="s11cb0b1c85a94ec98d8245d46091288dSENU">58-17H-10</span></a><span xml:space="preserve" class="s11cb0b1c85a94ec98d8245d46091288dSENU">. </span><span class="s11cb0b1c85a94ec98d8245d46091288dCL">Negotiated amounts for in-network providers for a particular emergency service.</span></p><p dir="ltr" class="s11cb0b1c85a94ec98d8245d46091288dNormal-000000"><span xml:space="preserve" class="s11cb0b1c85a94ec98d8245d46091288dDefaultParagraphFont">If a health benefit plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subdivision </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-8" rel="noopener"><span class="s11cb0b1c85a94ec98d8245d46091288dDefaultParagraphFont">58-17H-8</span></a><span class="s11cb0b1c85a94ec98d8245d46091288dDefaultParagraphFont">(1) is the median of these negotiated amounts.</span></p><p dir="ltr" class="s11cb0b1c85a94ec98d8245d46091288dNormal"><span xml:space="preserve" class="s11cb0b1c85a94ec98d8245d46091288d000001"> </span></p><p dir="ltr" class="s11cb0b1c85a94ec98d8245d46091288dNormal"><span class="s11cb0b1c85a94ec98d8245d46091288dSCL">Source:</span><span xml:space="preserve" class="s11cb0b1c85a94ec98d8245d46091288dSCL-000002"> SL 2011, ch 219, § 35.</span></p><p dir="ltr" class="s11cb0b1c85a94ec98d8245d46091288dNormal"><span xml:space="preserve" class="s11cb0b1c85a94ec98d8245d46091288d000001"> </span></p><p dir="ltr" class="s11cb0b1c85a94ec98d8245d46091288dNormal"><span xml:space="preserve" class="s11cb0b1c85a94ec98d8245d46091288dDefaultParagraphFont-000003">Commission Note: </span><span class="s11cb0b1c85a94ec98d8245d46091288dDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s80db0071aa52470c84b67538a6b5bd22Normal { 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.s80db0071aa52470c84b67538a6b5bd22SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s80db0071aa52470c84b67538a6b5bd22CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s80db0071aa52470c84b67538a6b5bd22Normal-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.s80db0071aa52470c84b67538a6b5bd22DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s80db0071aa52470c84b67538a6b5bd22000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s80db0071aa52470c84b67538a6b5bd22SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s80db0071aa52470c84b67538a6b5bd22SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s80db0071aa52470c84b67538a6b5bd22DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-11 - General cost-sharing requirements allowed."><meta property="og:description" content="SDLRC Codified Law 58-17H-11 - General cost-sharing requirements allowed."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-11"><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="s80db0071aa52470c84b67538a6b5bd22Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-11" rel="noopener"><span class="s80db0071aa52470c84b67538a6b5bd22SENU">58-17H-11</span></a><span xml:space="preserve" class="s80db0071aa52470c84b67538a6b5bd22SENU">. </span><span class="s80db0071aa52470c84b67538a6b5bd22CL">General cost-sharing requirements allowed.</span></p><p dir="ltr" class="s80db0071aa52470c84b67538a6b5bd22Normal-000000"><span class="s80db0071aa52470c84b67538a6b5bd22DefaultParagraphFont">Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible or out-of-pocket maximum, may be imposed with respect to emergency services provided out-of-network if the cost-sharing requirement generally applies to out-of-network benefits. A deductible may be imposed with respect to out-of-network emergency services only as part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum generally applies to out-of-network benefits, that out-of-network maximum applies to out-of-network emergency services.</span></p><p dir="ltr" class="s80db0071aa52470c84b67538a6b5bd22Normal"><span xml:space="preserve" class="s80db0071aa52470c84b67538a6b5bd22000001"> </span></p><p dir="ltr" class="s80db0071aa52470c84b67538a6b5bd22Normal"><span class="s80db0071aa52470c84b67538a6b5bd22SCL">Source:</span><span xml:space="preserve" class="s80db0071aa52470c84b67538a6b5bd22SCL-000002"> SL 2011, ch 219, § 36.</span></p><p dir="ltr" class="s80db0071aa52470c84b67538a6b5bd22Normal"><span xml:space="preserve" class="s80db0071aa52470c84b67538a6b5bd22000001"> </span></p><p dir="ltr" class="s80db0071aa52470c84b67538a6b5bd22Normal"><span xml:space="preserve" class="s80db0071aa52470c84b67538a6b5bd22DefaultParagraphFont-000003">Commission Note: </span><span class="s80db0071aa52470c84b67538a6b5bd22DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s7b90cccfb6c6403bb2596b15c3c51600Normal { 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.s7b90cccfb6c6403bb2596b15c3c51600SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s7b90cccfb6c6403bb2596b15c3c51600CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s7b90cccfb6c6403bb2596b15c3c51600Normal-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.s7b90cccfb6c6403bb2596b15c3c51600DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7b90cccfb6c6403bb2596b15c3c51600000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7b90cccfb6c6403bb2596b15c3c51600SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s7b90cccfb6c6403bb2596b15c3c51600SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7b90cccfb6c6403bb2596b15c3c51600DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-12 - Access to representative for post-evaluation or post-stabilization services."><meta property="og:description" content="SDLRC Codified Law 58-17H-12 - Access to representative for post-evaluation or post-stabilization services."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-12"><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="s7b90cccfb6c6403bb2596b15c3c51600Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-12" rel="noopener"><span class="s7b90cccfb6c6403bb2596b15c3c51600SENU">58-17H-12</span></a><span xml:space="preserve" class="s7b90cccfb6c6403bb2596b15c3c51600SENU">. </span><span class="s7b90cccfb6c6403bb2596b15c3c51600CL">Access to representative for post-evaluation or post-stabilization services.</span></p><p dir="ltr" class="s7b90cccfb6c6403bb2596b15c3c51600Normal-000000"><span class="s7b90cccfb6c6403bb2596b15c3c51600DefaultParagraphFont">For immediately required post-evaluation or post-stabilization services, a health carrier shall provide access to a designated representative twenty-four hours a day, seven days a week, to facilitate review, or otherwise provide coverage with no financial penalty to the covered person.</span></p><p dir="ltr" class="s7b90cccfb6c6403bb2596b15c3c51600Normal"><span xml:space="preserve" class="s7b90cccfb6c6403bb2596b15c3c51600000001"> </span></p><p dir="ltr" class="s7b90cccfb6c6403bb2596b15c3c51600Normal"><span class="s7b90cccfb6c6403bb2596b15c3c51600SCL">Source:</span><span xml:space="preserve" class="s7b90cccfb6c6403bb2596b15c3c51600SCL-000002"> SL 2011, ch 219, § 37.</span></p><p dir="ltr" class="s7b90cccfb6c6403bb2596b15c3c51600Normal"><span xml:space="preserve" class="s7b90cccfb6c6403bb2596b15c3c51600000001"> </span></p><p dir="ltr" class="s7b90cccfb6c6403bb2596b15c3c51600Normal"><span xml:space="preserve" class="s7b90cccfb6c6403bb2596b15c3c51600DefaultParagraphFont-000003">Commission Note: </span><span class="s7b90cccfb6c6403bb2596b15c3c51600DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sb409ff2a25e34e1b9c2294c6ec68bbccNormal { 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.sb409ff2a25e34e1b9c2294c6ec68bbccSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb409ff2a25e34e1b9c2294c6ec68bbccCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sb409ff2a25e34e1b9c2294c6ec68bbccNormal-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.sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb409ff2a25e34e1b9c2294c6ec68bbcc000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb409ff2a25e34e1b9c2294c6ec68bbccSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb409ff2a25e34e1b9c2294c6ec68bbccSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-13 - Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body."><meta property="og:description" content="SDLRC Codified Law 58-17H-13 - Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-13"><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="sb409ff2a25e34e1b9c2294c6ec68bbccNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-13" rel="noopener"><span class="sb409ff2a25e34e1b9c2294c6ec68bbccSENU">58-17H-13</span></a><span xml:space="preserve" class="sb409ff2a25e34e1b9c2294c6ec68bbccSENU">. </span><span class="sb409ff2a25e34e1b9c2294c6ec68bbccCL">Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.</span></p><p dir="ltr" class="sb409ff2a25e34e1b9c2294c6ec68bbccNormal-000000"><span xml:space="preserve" class="sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont">If the director and the secretary find that the requirements of any private accrediting body meet the requirements of coverage of emergency medical services as set forth in §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-4" rel="noopener"><span class="sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont">58-17H-4</span></a><span xml:space="preserve" class="sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-12" rel="noopener"><span class="sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont">58-17H-12</span></a><span class="sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont">, inclusive, the health carrier may, at the discretion of the director and secretary, be deemed to have met the applicable requirements.</span></p><p dir="ltr" class="sb409ff2a25e34e1b9c2294c6ec68bbccNormal"><span xml:space="preserve" class="sb409ff2a25e34e1b9c2294c6ec68bbcc000001"> </span></p><p dir="ltr" class="sb409ff2a25e34e1b9c2294c6ec68bbccNormal"><span class="sb409ff2a25e34e1b9c2294c6ec68bbccSCL">Source:</span><span xml:space="preserve" class="sb409ff2a25e34e1b9c2294c6ec68bbccSCL-000002"> SL 2011, ch 219, § 38.</span></p><p dir="ltr" class="sb409ff2a25e34e1b9c2294c6ec68bbccNormal"><span xml:space="preserve" class="sb409ff2a25e34e1b9c2294c6ec68bbcc000001"> </span></p><p dir="ltr" class="sb409ff2a25e34e1b9c2294c6ec68bbccNormal"><span xml:space="preserve" class="sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont-000003">Commission Note: </span><span class="sb409ff2a25e34e1b9c2294c6ec68bbccDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s5acc23567e1f4b89b1847dc5226f26feNormal { 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.s5acc23567e1f4b89b1847dc5226f26feSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5acc23567e1f4b89b1847dc5226f26feCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s5acc23567e1f4b89b1847dc5226f26feNormal-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.s5acc23567e1f4b89b1847dc5226f26feDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5acc23567e1f4b89b1847dc5226f26fe000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5acc23567e1f4b89b1847dc5226f26feSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5acc23567e1f4b89b1847dc5226f26feSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5acc23567e1f4b89b1847dc5226f26feDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-14 - Health carrier responsibility for utilization review activities."><meta property="og:description" content="SDLRC Codified Law 58-17H-14 - Health carrier responsibility for utilization review activities."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-14"><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="s5acc23567e1f4b89b1847dc5226f26feNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-14" rel="noopener"><span class="s5acc23567e1f4b89b1847dc5226f26feSENU">58-17H-14</span></a><span xml:space="preserve" class="s5acc23567e1f4b89b1847dc5226f26feSENU">. </span><span class="s5acc23567e1f4b89b1847dc5226f26feCL">Health carrier responsibility for utilization review activities.</span></p><p dir="ltr" class="s5acc23567e1f4b89b1847dc5226f26feNormal-000000"><span class="s5acc23567e1f4b89b1847dc5226f26feDefaultParagraphFont">A health carrier is responsible for monitoring all utilization review activities carried out by, or on behalf of, the health carrier and for ensuring that all requirements of this chapter and applicable rules are met. The health carrier shall also ensure that appropriate personnel have operational responsibility for the conduct of the health carrier's utilization review program.</span></p><p dir="ltr" class="s5acc23567e1f4b89b1847dc5226f26feNormal"><span xml:space="preserve" class="s5acc23567e1f4b89b1847dc5226f26fe000001"> </span></p><p dir="ltr" class="s5acc23567e1f4b89b1847dc5226f26feNormal"><span class="s5acc23567e1f4b89b1847dc5226f26feSCL">Source:</span><span xml:space="preserve" class="s5acc23567e1f4b89b1847dc5226f26feSCL-000002"> SL 2011, ch 219, § 39.</span></p><p dir="ltr" class="s5acc23567e1f4b89b1847dc5226f26feNormal"><span xml:space="preserve" class="s5acc23567e1f4b89b1847dc5226f26fe000001"> </span></p><p dir="ltr" class="s5acc23567e1f4b89b1847dc5226f26feNormal"><span xml:space="preserve" class="s5acc23567e1f4b89b1847dc5226f26feDefaultParagraphFont-000003">Commission Note: </span><span class="s5acc23567e1f4b89b1847dc5226f26feDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s1e3ba1ce315045e1b5cd025176187d07Normal { 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.s1e3ba1ce315045e1b5cd025176187d07SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s1e3ba1ce315045e1b5cd025176187d07CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s1e3ba1ce315045e1b5cd025176187d07Normal-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.s1e3ba1ce315045e1b5cd025176187d07DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s1e3ba1ce315045e1b5cd025176187d07000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s1e3ba1ce315045e1b5cd025176187d07SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s1e3ba1ce315045e1b5cd025176187d07SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s1e3ba1ce315045e1b5cd025176187d07DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-15 - Director to hold health carrier responsible for utilization review performance of contractor."><meta property="og:description" content="SDLRC Codified Law 58-17H-15 - Director to hold health carrier responsible for utilization review performance of contractor."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-15"><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="s1e3ba1ce315045e1b5cd025176187d07Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-15" rel="noopener"><span class="s1e3ba1ce315045e1b5cd025176187d07SENU">58-17H-15</span></a><span xml:space="preserve" class="s1e3ba1ce315045e1b5cd025176187d07SENU">. </span><span class="s1e3ba1ce315045e1b5cd025176187d07CL">Director to hold health carrier responsible for utilization review performance of contractor.</span></p><p dir="ltr" class="s1e3ba1ce315045e1b5cd025176187d07Normal-000000"><span class="s1e3ba1ce315045e1b5cd025176187d07DefaultParagraphFont">If a health carrier contracts to have a utilization review organization or other entity perform the utilization review functions required by this chapter, or applicable rules, the director shall hold the health carrier responsible for monitoring the activities of the utilization review organization or entity with which the health carrier contracts and for ensuring that the requirements of this chapter, and applicable rules, are met.</span></p><p dir="ltr" class="s1e3ba1ce315045e1b5cd025176187d07Normal"><span xml:space="preserve" class="s1e3ba1ce315045e1b5cd025176187d07000001"> </span></p><p dir="ltr" class="s1e3ba1ce315045e1b5cd025176187d07Normal"><span class="s1e3ba1ce315045e1b5cd025176187d07SCL">Source:</span><span xml:space="preserve" class="s1e3ba1ce315045e1b5cd025176187d07SCL-000002"> SL 2011, ch 219, § 40.</span></p><p dir="ltr" class="s1e3ba1ce315045e1b5cd025176187d07Normal"><span xml:space="preserve" class="s1e3ba1ce315045e1b5cd025176187d07000001"> </span></p><p dir="ltr" class="s1e3ba1ce315045e1b5cd025176187d07Normal"><span xml:space="preserve" class="s1e3ba1ce315045e1b5cd025176187d07DefaultParagraphFont-000003">Commission Note: </span><span class="s1e3ba1ce315045e1b5cd025176187d07DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s5574bbab659e4fc393af79f2b5d0510dNormal { 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.s5574bbab659e4fc393af79f2b5d0510dSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5574bbab659e4fc393af79f2b5d0510dCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s5574bbab659e4fc393af79f2b5d0510dNormal-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.s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s5574bbab659e4fc393af79f2b5d0510dNormal-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; } p.s5574bbab659e4fc393af79f2b5d0510dNormal-000002 { 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; } span.s5574bbab659e4fc393af79f2b5d0510d000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5574bbab659e4fc393af79f2b5d0510dSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5574bbab659e4fc393af79f2b5d0510dSCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-16 - Written utilization review program required--Contents of program document."><meta property="og:description" content="SDLRC Codified Law 58-17H-16 - Written utilization review program required--Contents of program document."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-16"><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="s5574bbab659e4fc393af79f2b5d0510dNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-16" rel="noopener"><span class="s5574bbab659e4fc393af79f2b5d0510dSENU">58-17H-16</span></a><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dSENU">. </span><span class="s5574bbab659e4fc393af79f2b5d0510dCL">Written utilization review program required--Contents of program document.</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000000"><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">A health carrier that requires a request for benefits under the covered person's health plan to be subjected to utilization review shall implement a written utilization review program that describes all review activities, both delegated and nondelegated for the filing of benefit requests, the notification of utilization review and benefit determinations, and the review of adverse determinations in accordance with chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">58-17I</span></a><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">.</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000001"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">The program document shall describe the following:</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000002"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">(1)    Procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000002"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">(2)    Data sources and clinical review criteria used in decision-making;</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000002"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">(3)    Mechanisms to ensure consistent application of review criteria and compatible decisions;</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000002"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">(4)    Data collection processes and analytical methods used in assessing utilization of health care services;</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000002"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">(5)    Provisions for assuring confidentiality of clinical and proprietary information;</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000002"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">(6)    The organizational structure that periodically assesses utilization review activities and reports to the health carrier's governing body; and</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000002"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">(7)    The staff position functionally responsible for day-to-day program management.</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal-000001"><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">A health carrier shall prepare an annual summary report in the format specified of its utilization review program activities and file the report, if requested, with the director and the secretary. A health carrier shall maintain records for a minimum of six years of all benefit requests and claims and notices associated with utilization review and benefit determinations made in accordance with §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-27" rel="noopener"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">58-17H-27</span></a><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">58-17H-32</span></a><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">, inclusive, and §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">58-17H-40</span></a><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">58-17H-48</span></a><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">, inclusive. The health carrier shall make the records available for examination by covered persons and the director upon request.</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal"><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510d000003"> </span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal"><span class="s5574bbab659e4fc393af79f2b5d0510dSCL">Source:</span><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dSCL-000004"> SL 2011, ch 219, § 41.</span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal"><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510d000003"> </span></p><p dir="ltr" class="s5574bbab659e4fc393af79f2b5d0510dNormal"><span xml:space="preserve" class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont-000005">Commission Note: </span><span class="s5574bbab659e4fc393af79f2b5d0510dDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s4c7e5b01095143d4bb4c2538c02bc061Normal { 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.s4c7e5b01095143d4bb4c2538c02bc061SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s4c7e5b01095143d4bb4c2538c02bc061CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s4c7e5b01095143d4bb4c2538c02bc061Normal-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.s4c7e5b01095143d4bb4c2538c02bc061DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s4c7e5b01095143d4bb4c2538c02bc061000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s4c7e5b01095143d4bb4c2538c02bc061SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s4c7e5b01095143d4bb4c2538c02bc061SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s4c7e5b01095143d4bb4c2538c02bc061DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-17 - Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request."><meta property="og:description" content="SDLRC Codified Law 58-17H-17 - Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-17"><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="s4c7e5b01095143d4bb4c2538c02bc061Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-17" rel="noopener"><span class="s4c7e5b01095143d4bb4c2538c02bc061SENU">58-17H-17</span></a><span xml:space="preserve" class="s4c7e5b01095143d4bb4c2538c02bc061SENU">. </span><span class="s4c7e5b01095143d4bb4c2538c02bc061CL">Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.</span></p><p dir="ltr" class="s4c7e5b01095143d4bb4c2538c02bc061Normal-000000"><span class="s4c7e5b01095143d4bb4c2538c02bc061DefaultParagraphFont">A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. A health carrier may develop its own clinical review criteria, or it may purchase or license clinical review criteria from qualified vendors. A health carrier shall make available its clinical review criteria upon request to authorized government agencies including the Division of Insurance and the Department of Health.</span></p><p dir="ltr" class="s4c7e5b01095143d4bb4c2538c02bc061Normal"><span xml:space="preserve" class="s4c7e5b01095143d4bb4c2538c02bc061000001"> </span></p><p dir="ltr" class="s4c7e5b01095143d4bb4c2538c02bc061Normal"><span class="s4c7e5b01095143d4bb4c2538c02bc061SCL">Source:</span><span xml:space="preserve" class="s4c7e5b01095143d4bb4c2538c02bc061SCL-000002"> SL 2011, ch 219, § 42.</span></p><p dir="ltr" class="s4c7e5b01095143d4bb4c2538c02bc061Normal"><span xml:space="preserve" class="s4c7e5b01095143d4bb4c2538c02bc061000001"> </span></p><p dir="ltr" class="s4c7e5b01095143d4bb4c2538c02bc061Normal"><span xml:space="preserve" class="s4c7e5b01095143d4bb4c2538c02bc061DefaultParagraphFont-000003">Commission Note: </span><span class="s4c7e5b01095143d4bb4c2538c02bc061DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s2b5fcd33c46346c5b7e72861a5872c79Normal { 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.s2b5fcd33c46346c5b7e72861a5872c79SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2b5fcd33c46346c5b7e72861a5872c79CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s2b5fcd33c46346c5b7e72861a5872c79Normal-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.s2b5fcd33c46346c5b7e72861a5872c79DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2b5fcd33c46346c5b7e72861a5872c79000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2b5fcd33c46346c5b7e72861a5872c79SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2b5fcd33c46346c5b7e72861a5872c79SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2b5fcd33c46346c5b7e72861a5872c79DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-18 - Program to be administered by qualified licensed health care professionals."><meta property="og:description" content="SDLRC Codified Law 58-17H-18 - Program to be administered by qualified licensed health care professionals."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-18"><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="s2b5fcd33c46346c5b7e72861a5872c79Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-18" rel="noopener"><span class="s2b5fcd33c46346c5b7e72861a5872c79SENU">58-17H-18</span></a><span xml:space="preserve" class="s2b5fcd33c46346c5b7e72861a5872c79SENU">. </span><span class="s2b5fcd33c46346c5b7e72861a5872c79CL">Program to be administered by qualified licensed health care professionals.</span></p><p dir="ltr" class="s2b5fcd33c46346c5b7e72861a5872c79Normal-000000"><span class="s2b5fcd33c46346c5b7e72861a5872c79DefaultParagraphFont">Qualified licensed health care professionals shall administer the utilization review program and oversee review decisions. Any adverse determination shall be evaluated by an appropriately licensed and clinically qualified health care provider.</span></p><p dir="ltr" class="s2b5fcd33c46346c5b7e72861a5872c79Normal"><span xml:space="preserve" class="s2b5fcd33c46346c5b7e72861a5872c79000001"> </span></p><p dir="ltr" class="s2b5fcd33c46346c5b7e72861a5872c79Normal"><span class="s2b5fcd33c46346c5b7e72861a5872c79SCL">Source:</span><span xml:space="preserve" class="s2b5fcd33c46346c5b7e72861a5872c79SCL-000002"> SL 2011, ch 219, § 43.</span></p><p dir="ltr" class="s2b5fcd33c46346c5b7e72861a5872c79Normal"><span xml:space="preserve" class="s2b5fcd33c46346c5b7e72861a5872c79000001"> </span></p><p dir="ltr" class="s2b5fcd33c46346c5b7e72861a5872c79Normal"><span xml:space="preserve" class="s2b5fcd33c46346c5b7e72861a5872c79DefaultParagraphFont-000003">Commission Note: </span><span class="s2b5fcd33c46346c5b7e72861a5872c79DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</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; } </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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s20de190bc258468dbd4e4198cf0d1917Normal { 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.s20de190bc258468dbd4e4198cf0d1917SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s20de190bc258468dbd4e4198cf0d1917CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s20de190bc258468dbd4e4198cf0d1917Normal-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.s20de190bc258468dbd4e4198cf0d1917DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s20de190bc258468dbd4e4198cf0d1917000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s20de190bc258468dbd4e4198cf0d1917SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s20de190bc258468dbd4e4198cf0d1917SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s20de190bc258468dbd4e4198cf0d1917DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-20 - Effectiveness and efficiency of program to be routinely reviewed."><meta property="og:description" content="SDLRC Codified Law 58-17H-20 - Effectiveness and efficiency of program to be routinely reviewed."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-20"><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="s20de190bc258468dbd4e4198cf0d1917Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-20" rel="noopener"><span class="s20de190bc258468dbd4e4198cf0d1917SENU">58-17H-20</span></a><span xml:space="preserve" class="s20de190bc258468dbd4e4198cf0d1917SENU">. </span><span class="s20de190bc258468dbd4e4198cf0d1917CL">Effectiveness and efficiency of program to be routinely reviewed.</span></p><p dir="ltr" class="s20de190bc258468dbd4e4198cf0d1917Normal-000000"><span class="s20de190bc258468dbd4e4198cf0d1917DefaultParagraphFont">Any health carrier shall routinely assess the effectiveness and efficiency of its utilization review program.</span></p><p dir="ltr" class="s20de190bc258468dbd4e4198cf0d1917Normal"><span xml:space="preserve" class="s20de190bc258468dbd4e4198cf0d1917000001"> </span></p><p dir="ltr" class="s20de190bc258468dbd4e4198cf0d1917Normal"><span class="s20de190bc258468dbd4e4198cf0d1917SCL">Source:</span><span xml:space="preserve" class="s20de190bc258468dbd4e4198cf0d1917SCL-000002"> SL 2011, ch 219, § 45.</span></p><p dir="ltr" class="s20de190bc258468dbd4e4198cf0d1917Normal"><span xml:space="preserve" class="s20de190bc258468dbd4e4198cf0d1917000001"> </span></p><p dir="ltr" class="s20de190bc258468dbd4e4198cf0d1917Normal"><span xml:space="preserve" class="s20de190bc258468dbd4e4198cf0d1917DefaultParagraphFont-000003">Commission Note: </span><span class="s20de190bc258468dbd4e4198cf0d1917DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s698b819d61e946f5acfd7dfca57e9dc5Normal { 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.s698b819d61e946f5acfd7dfca57e9dc5SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s698b819d61e946f5acfd7dfca57e9dc5CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s698b819d61e946f5acfd7dfca57e9dc5Normal-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.s698b819d61e946f5acfd7dfca57e9dc5DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s698b819d61e946f5acfd7dfca57e9dc5000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s698b819d61e946f5acfd7dfca57e9dc5SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s698b819d61e946f5acfd7dfca57e9dc5SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s698b819d61e946f5acfd7dfca57e9dc5DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-21 - Data systems to support program activities and generate management reports."><meta property="og:description" content="SDLRC Codified Law 58-17H-21 - Data systems to support program activities and generate management reports."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-21"><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="s698b819d61e946f5acfd7dfca57e9dc5Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-21" rel="noopener"><span class="s698b819d61e946f5acfd7dfca57e9dc5SENU">58-17H-21</span></a><span xml:space="preserve" class="s698b819d61e946f5acfd7dfca57e9dc5SENU">. </span><span class="s698b819d61e946f5acfd7dfca57e9dc5CL">Data systems to support program activities and generate management reports.</span></p><p dir="ltr" class="s698b819d61e946f5acfd7dfca57e9dc5Normal-000000"><span class="s698b819d61e946f5acfd7dfca57e9dc5DefaultParagraphFont">Any health carrier's data system shall be sufficient to support utilization review program activities and to generate management reports to enable the health carrier to monitor and manage health care services effectively.</span></p><p dir="ltr" class="s698b819d61e946f5acfd7dfca57e9dc5Normal"><span xml:space="preserve" class="s698b819d61e946f5acfd7dfca57e9dc5000001"> </span></p><p dir="ltr" class="s698b819d61e946f5acfd7dfca57e9dc5Normal"><span class="s698b819d61e946f5acfd7dfca57e9dc5SCL">Source:</span><span xml:space="preserve" class="s698b819d61e946f5acfd7dfca57e9dc5SCL-000002"> SL 2011, ch 219, § 46.</span></p><p dir="ltr" class="s698b819d61e946f5acfd7dfca57e9dc5Normal"><span xml:space="preserve" class="s698b819d61e946f5acfd7dfca57e9dc5000001"> </span></p><p dir="ltr" class="s698b819d61e946f5acfd7dfca57e9dc5Normal"><span xml:space="preserve" class="s698b819d61e946f5acfd7dfca57e9dc5DefaultParagraphFont-000003">Commission Note: </span><span class="s698b819d61e946f5acfd7dfca57e9dc5DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s355b901b3d6140fe998ac23ed176b057Normal { 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.s355b901b3d6140fe998ac23ed176b057SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s355b901b3d6140fe998ac23ed176b057CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s355b901b3d6140fe998ac23ed176b057Normal-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.s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s355b901b3d6140fe998ac23ed176b057Normal-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; } span.s355b901b3d6140fe998ac23ed176b057000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s355b901b3d6140fe998ac23ed176b057SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s355b901b3d6140fe998ac23ed176b057SCL-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-22 - Health carrier oversight of delegated activities--Requirements."><meta property="og:description" content="SDLRC Codified Law 58-17H-22 - Health carrier oversight of delegated activities--Requirements."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-22"><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="s355b901b3d6140fe998ac23ed176b057Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-22" rel="noopener"><span class="s355b901b3d6140fe998ac23ed176b057SENU">58-17H-22</span></a><span xml:space="preserve" class="s355b901b3d6140fe998ac23ed176b057SENU">. </span><span class="s355b901b3d6140fe998ac23ed176b057CL">Health carrier oversight of delegated activities--Requirements.</span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal-000000"><span class="s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont">If a health carrier delegates any utilization review activities to a utilization review organization, the health carrier shall maintain adequate oversight, which shall include:</span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal-000001"><span class="s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont">(1)    A written description of the utilization review organization's activities and responsibilities, including reporting requirements;</span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal-000001"><span class="s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont">(2)    Evidence of formal approval of the utilization review organization program by the health carrier; and</span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal-000001"><span class="s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont">(3)    A process by which the health carrier evaluates the performance of the utilization review organization.</span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal"><span xml:space="preserve" class="s355b901b3d6140fe998ac23ed176b057000002"> </span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal"><span class="s355b901b3d6140fe998ac23ed176b057SCL">Source:</span><span xml:space="preserve" class="s355b901b3d6140fe998ac23ed176b057SCL-000003"> SL 2011, ch 219, § 47.</span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal"><span xml:space="preserve" class="s355b901b3d6140fe998ac23ed176b057000002"> </span></p><p dir="ltr" class="s355b901b3d6140fe998ac23ed176b057Normal"><span xml:space="preserve" class="s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont-000004">Commission Note: </span><span class="s355b901b3d6140fe998ac23ed176b057DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.seeb1b3bf55ba4ebdaf09251dfca9b4baNormal { 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.seeb1b3bf55ba4ebdaf09251dfca9b4baSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.seeb1b3bf55ba4ebdaf09251dfca9b4baCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.seeb1b3bf55ba4ebdaf09251dfca9b4baNormal-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.seeb1b3bf55ba4ebdaf09251dfca9b4baDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.seeb1b3bf55ba4ebdaf09251dfca9b4ba000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.seeb1b3bf55ba4ebdaf09251dfca9b4baSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.seeb1b3bf55ba4ebdaf09251dfca9b4baSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.seeb1b3bf55ba4ebdaf09251dfca9b4baDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-23 - Utilization review to be coordinated with other medical management activity of health carrier."><meta property="og:description" content="SDLRC Codified Law 58-17H-23 - Utilization review to be coordinated with other medical management activity of health carrier."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-23"><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="seeb1b3bf55ba4ebdaf09251dfca9b4baNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-23" rel="noopener"><span class="seeb1b3bf55ba4ebdaf09251dfca9b4baSENU">58-17H-23</span></a><span xml:space="preserve" class="seeb1b3bf55ba4ebdaf09251dfca9b4baSENU">. </span><span class="seeb1b3bf55ba4ebdaf09251dfca9b4baCL">Utilization review to be coordinated with other medical management activity of health carrier.</span></p><p dir="ltr" class="seeb1b3bf55ba4ebdaf09251dfca9b4baNormal-000000"><span class="seeb1b3bf55ba4ebdaf09251dfca9b4baDefaultParagraphFont">Each health carrier shall coordinate the utilization review program with other medical management activity conducted by the carrier, such as quality assurance, credentialing, provider contracting data reporting, grievance procedures, processes for assessing member satisfaction, and risk management.</span></p><p dir="ltr" class="seeb1b3bf55ba4ebdaf09251dfca9b4baNormal"><span xml:space="preserve" class="seeb1b3bf55ba4ebdaf09251dfca9b4ba000001"> </span></p><p dir="ltr" class="seeb1b3bf55ba4ebdaf09251dfca9b4baNormal"><span class="seeb1b3bf55ba4ebdaf09251dfca9b4baSCL">Source:</span><span xml:space="preserve" class="seeb1b3bf55ba4ebdaf09251dfca9b4baSCL-000002"> SL 2011, ch 219, § 48.</span></p><p dir="ltr" class="seeb1b3bf55ba4ebdaf09251dfca9b4baNormal"><span xml:space="preserve" class="seeb1b3bf55ba4ebdaf09251dfca9b4ba000001"> </span></p><p dir="ltr" class="seeb1b3bf55ba4ebdaf09251dfca9b4baNormal"><span xml:space="preserve" class="seeb1b3bf55ba4ebdaf09251dfca9b4baDefaultParagraphFont-000003">Commission Note: </span><span class="seeb1b3bf55ba4ebdaf09251dfca9b4baDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.seaa62f8d42e448cfaa9bc1f45366e3a0Normal { 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.seaa62f8d42e448cfaa9bc1f45366e3a0SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.seaa62f8d42e448cfaa9bc1f45366e3a0CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.seaa62f8d42e448cfaa9bc1f45366e3a0Normal-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.seaa62f8d42e448cfaa9bc1f45366e3a0DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.seaa62f8d42e448cfaa9bc1f45366e3a0000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.seaa62f8d42e448cfaa9bc1f45366e3a0SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.seaa62f8d42e448cfaa9bc1f45366e3a0SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.seaa62f8d42e448cfaa9bc1f45366e3a0DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-24 - Health carrier to provide free access to review staff."><meta property="og:description" content="SDLRC Codified Law 58-17H-24 - Health carrier to provide free access to review staff."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-24"><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="seaa62f8d42e448cfaa9bc1f45366e3a0Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-24" rel="noopener"><span class="seaa62f8d42e448cfaa9bc1f45366e3a0SENU">58-17H-24</span></a><span xml:space="preserve" class="seaa62f8d42e448cfaa9bc1f45366e3a0SENU">. </span><span class="seaa62f8d42e448cfaa9bc1f45366e3a0CL">Health carrier to provide free access to review staff.</span></p><p dir="ltr" class="seaa62f8d42e448cfaa9bc1f45366e3a0Normal-000000"><span class="seaa62f8d42e448cfaa9bc1f45366e3a0DefaultParagraphFont">Each health carrier shall provide covered persons and participating providers with access to its review staff by a toll-free number or collect call telephone line.</span></p><p dir="ltr" class="seaa62f8d42e448cfaa9bc1f45366e3a0Normal"><span xml:space="preserve" class="seaa62f8d42e448cfaa9bc1f45366e3a0000001"> </span></p><p dir="ltr" class="seaa62f8d42e448cfaa9bc1f45366e3a0Normal"><span class="seaa62f8d42e448cfaa9bc1f45366e3a0SCL">Source:</span><span xml:space="preserve" class="seaa62f8d42e448cfaa9bc1f45366e3a0SCL-000002"> SL 2011, ch 219, § 49.</span></p><p dir="ltr" class="seaa62f8d42e448cfaa9bc1f45366e3a0Normal"><span xml:space="preserve" class="seaa62f8d42e448cfaa9bc1f45366e3a0000001"> </span></p><p dir="ltr" class="seaa62f8d42e448cfaa9bc1f45366e3a0Normal"><span xml:space="preserve" class="seaa62f8d42e448cfaa9bc1f45366e3a0DefaultParagraphFont-000003">Commission Note: </span><span class="seaa62f8d42e448cfaa9bc1f45366e3a0DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sec6df0ce36894d338ca34ae170d2ddc5Normal { 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.sec6df0ce36894d338ca34ae170d2ddc5SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sec6df0ce36894d338ca34ae170d2ddc5CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sec6df0ce36894d338ca34ae170d2ddc5Normal-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.sec6df0ce36894d338ca34ae170d2ddc5DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sec6df0ce36894d338ca34ae170d2ddc5000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sec6df0ce36894d338ca34ae170d2ddc5SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sec6df0ce36894d338ca34ae170d2ddc5SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sec6df0ce36894d338ca34ae170d2ddc5DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-25 - Only information necessary for review or determination to be collected."><meta property="og:description" content="SDLRC Codified Law 58-17H-25 - Only information necessary for review or determination to be collected."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-25"><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="sec6df0ce36894d338ca34ae170d2ddc5Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-25" rel="noopener"><span class="sec6df0ce36894d338ca34ae170d2ddc5SENU">58-17H-25</span></a><span xml:space="preserve" class="sec6df0ce36894d338ca34ae170d2ddc5SENU">. </span><span class="sec6df0ce36894d338ca34ae170d2ddc5CL">Only information necessary for review or determination to be collected.</span></p><p dir="ltr" class="sec6df0ce36894d338ca34ae170d2ddc5Normal-000000"><span class="sec6df0ce36894d338ca34ae170d2ddc5DefaultParagraphFont">If conducting a utilization review, the health carrier shall collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination.</span></p><p dir="ltr" class="sec6df0ce36894d338ca34ae170d2ddc5Normal"><span xml:space="preserve" class="sec6df0ce36894d338ca34ae170d2ddc5000001"> </span></p><p dir="ltr" class="sec6df0ce36894d338ca34ae170d2ddc5Normal"><span class="sec6df0ce36894d338ca34ae170d2ddc5SCL">Source:</span><span xml:space="preserve" class="sec6df0ce36894d338ca34ae170d2ddc5SCL-000002"> SL 2011, ch 219, § 50.</span></p><p dir="ltr" class="sec6df0ce36894d338ca34ae170d2ddc5Normal"><span xml:space="preserve" class="sec6df0ce36894d338ca34ae170d2ddc5000001"> </span></p><p dir="ltr" class="sec6df0ce36894d338ca34ae170d2ddc5Normal"><span xml:space="preserve" class="sec6df0ce36894d338ca34ae170d2ddc5DefaultParagraphFont-000003">Commission Note: </span><span class="sec6df0ce36894d338ca34ae170d2ddc5DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sad4a11e63292424a9df295a6da4833d3Normal { 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.sad4a11e63292424a9df295a6da4833d3SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sad4a11e63292424a9df295a6da4833d3CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sad4a11e63292424a9df295a6da4833d3Normal-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.sad4a11e63292424a9df295a6da4833d3DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sad4a11e63292424a9df295a6da4833d3Normal-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.sad4a11e63292424a9df295a6da4833d3000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sad4a11e63292424a9df295a6da4833d3SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sad4a11e63292424a9df295a6da4833d3SCL-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sad4a11e63292424a9df295a6da4833d3DefaultParagraphFont-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-26 - Independence and impartiality required for utilization review."><meta property="og:description" content="SDLRC Codified Law 58-17H-26 - Independence and impartiality required for utilization review."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-26"><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="sad4a11e63292424a9df295a6da4833d3Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-26" rel="noopener"><span class="sad4a11e63292424a9df295a6da4833d3SENU">58-17H-26</span></a><span xml:space="preserve" class="sad4a11e63292424a9df295a6da4833d3SENU">. </span><span class="sad4a11e63292424a9df295a6da4833d3CL">Independence and impartiality required for utilization review.</span></p><p dir="ltr" class="sad4a11e63292424a9df295a6da4833d3Normal-000000"><span class="sad4a11e63292424a9df295a6da4833d3DefaultParagraphFont">In conducting utilization review, the health carrier shall ensure that the review is conducted in a manner to ensure the independence and impartiality of the individuals involved in making the utilization review or benefit determination.</span></p><p dir="ltr" class="sad4a11e63292424a9df295a6da4833d3Normal-000001"><span class="sad4a11e63292424a9df295a6da4833d3DefaultParagraphFont">In ensuring the independence and impartially of individuals involved in making the utilization review or benefit determination, no health carrier may make decisions regarding hiring, compensation, termination, promotion, or other similar matters based upon the likelihood that the individual will support the denial of benefits.</span></p><p dir="ltr" class="sad4a11e63292424a9df295a6da4833d3Normal"><span xml:space="preserve" class="sad4a11e63292424a9df295a6da4833d3000002"> </span></p><p dir="ltr" class="sad4a11e63292424a9df295a6da4833d3Normal"><span class="sad4a11e63292424a9df295a6da4833d3SCL">Source:</span><span xml:space="preserve" class="sad4a11e63292424a9df295a6da4833d3SCL-000003"> SL 2011, ch 219, § 51.</span></p><p dir="ltr" class="sad4a11e63292424a9df295a6da4833d3Normal"><span xml:space="preserve" class="sad4a11e63292424a9df295a6da4833d3000002"> </span></p><p dir="ltr" class="sad4a11e63292424a9df295a6da4833d3Normal"><span xml:space="preserve" class="sad4a11e63292424a9df295a6da4833d3DefaultParagraphFont-000004">Commission Note: </span><span class="sad4a11e63292424a9df295a6da4833d3DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s5be732bd25154312a5e86961c706f6e9Normal { 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.s5be732bd25154312a5e86961c706f6e9SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5be732bd25154312a5e86961c706f6e9CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s5be732bd25154312a5e86961c706f6e9Normal-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.s5be732bd25154312a5e86961c706f6e9DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5be732bd25154312a5e86961c706f6e9000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5be732bd25154312a5e86961c706f6e9SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5be732bd25154312a5e86961c706f6e9SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5be732bd25154312a5e86961c706f6e9DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-27 - Written procedures required for making determinations--Notification."><meta property="og:description" content="SDLRC Codified Law 58-17H-27 - Written procedures required for making determinations--Notification."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-27"><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="s5be732bd25154312a5e86961c706f6e9Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-27" rel="noopener"><span class="s5be732bd25154312a5e86961c706f6e9SENU">58-17H-27</span></a><span xml:space="preserve" class="s5be732bd25154312a5e86961c706f6e9SENU">. </span><span class="s5be732bd25154312a5e86961c706f6e9CL">Written procedures required for making determinations--Notification.</span></p><p dir="ltr" class="s5be732bd25154312a5e86961c706f6e9Normal-000000"><span class="s5be732bd25154312a5e86961c706f6e9DefaultParagraphFont">A health carrier shall maintain written procedures pursuant to this chapter, for making standard utilization review and benefit determinations on requests submitted to the health carrier by covered persons or their authorized representatives for benefits and for notifying covered persons and their authorized representatives of its determinations with respect to these requests within the specified time frames required under this chapter. If a period of time is extended as permitted by this chapter due to a claimant's failure to submit information necessary to decide a prospective, retrospective, or disability claim, the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.</span></p><p dir="ltr" class="s5be732bd25154312a5e86961c706f6e9Normal"><span xml:space="preserve" class="s5be732bd25154312a5e86961c706f6e9000001"> </span></p><p dir="ltr" class="s5be732bd25154312a5e86961c706f6e9Normal"><span class="s5be732bd25154312a5e86961c706f6e9SCL">Source:</span><span xml:space="preserve" class="s5be732bd25154312a5e86961c706f6e9SCL-000002"> SL 2011, ch 219, § 52.</span></p><p dir="ltr" class="s5be732bd25154312a5e86961c706f6e9Normal"><span xml:space="preserve" class="s5be732bd25154312a5e86961c706f6e9000001"> </span></p><p dir="ltr" class="s5be732bd25154312a5e86961c706f6e9Normal"><span xml:space="preserve" class="s5be732bd25154312a5e86961c706f6e9DefaultParagraphFont-000003">Commission Note: </span><span class="s5be732bd25154312a5e86961c706f6e9DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s5c0755671a314368b3ed9a493123ea0cNormal { 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.s5c0755671a314368b3ed9a493123ea0cSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5c0755671a314368b3ed9a493123ea0cCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s5c0755671a314368b3ed9a493123ea0cNormal-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.s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s5c0755671a314368b3ed9a493123ea0cNormal-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; } p.s5c0755671a314368b3ed9a493123ea0cNormal-000002 { 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; } span.s5c0755671a314368b3ed9a493123ea0c000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5c0755671a314368b3ed9a493123ea0cSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s5c0755671a314368b3ed9a493123ea0cSCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-28 - Prospective review determinations--Timing--Notification of requirements--Extension of time."><meta property="og:description" content="SDLRC Codified Law 58-17H-28 - Prospective review determinations--Timing--Notification of requirements--Extension of time."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-28"><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="s5c0755671a314368b3ed9a493123ea0cNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-28" rel="noopener"><span class="s5c0755671a314368b3ed9a493123ea0cSENU">58-17H-28</span></a><span xml:space="preserve" class="s5c0755671a314368b3ed9a493123ea0cSENU">. </span><span class="s5c0755671a314368b3ed9a493123ea0cCL">Prospective review determinations--Timing--Notification of requirements--Extension of time.</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal-000000"><span xml:space="preserve" class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">For any prospective review determination, other than allowed by this section, a health carrier shall make the determination and notify the covered person or, if applicable, the covered person's authorized representative of the determination, whether the carrier certifies the provision of the benefit or not, within a reasonable period of time appropriate to the covered person's medical condition, but in no event later than fifteen days after the date the health carrier receives the request. If the determination is an adverse determination, the health carrier shall make the notification of the adverse determination in accordance with § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">58-17H-32</span></a><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">.</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal-000001"><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">The time period for making a determination and notifying the covered person or, if applicable, the covered person's authorized representative, of the determination pursuant to this section may be extended once by the health carrier for up to fifteen days, if the health carrier:</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal-000002"><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">(1)    Determines that an extension is necessary due to matters beyond the health carrier's control; and</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal-000002"><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">(2)    Notifies the covered person or, if applicable, the covered person's authorized representative, prior to the expiration of the initial fifteen-day time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal-000001"><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">If the extension is necessary due to the failure of the covered person or the covered person's authorized representative to submit information necessary to reach a determination on the request, the notice of extension shall specifically describe the required information necessary to complete the request and give the covered person or, if applicable, the covered person's authorized representative at least forty-five days from the date of receipt of the notice to provide the specified information.</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal-000001"><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">If the health carrier receives a prospective review request from a covered person or the covered person's authorized representative that fails to meet the health carrier's filing procedures, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative of this failure and provide in the notice information on the proper procedures to be followed for filing a request. This notice shall be provided as soon as possible, but in no event later than five days following the date of the failure. The health carrier may provide the notice orally or, if requested by the covered person or the covered person's authorized representative, in writing. The provisions only apply in a case of failure that is a communication by a covered person or the covered person's authorized representative that is received by a person or organizational unit of the health carrier responsible for handling benefit matters and is a communication that refers to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment, or provider for which certification is being requested.</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal"><span xml:space="preserve" class="s5c0755671a314368b3ed9a493123ea0c000003"> </span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal"><span class="s5c0755671a314368b3ed9a493123ea0cSCL">Source:</span><span xml:space="preserve" class="s5c0755671a314368b3ed9a493123ea0cSCL-000004"> SL 2011, ch 219, § 53.</span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal"><span xml:space="preserve" class="s5c0755671a314368b3ed9a493123ea0c000003"> </span></p><p dir="ltr" class="s5c0755671a314368b3ed9a493123ea0cNormal"><span xml:space="preserve" class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont-000005">Commission Note: </span><span class="s5c0755671a314368b3ed9a493123ea0cDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sec07478f122745b881fadf2bf9b6e1fdNormal { 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.sec07478f122745b881fadf2bf9b6e1fdSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sec07478f122745b881fadf2bf9b6e1fdCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sec07478f122745b881fadf2bf9b6e1fdNormal-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.sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sec07478f122745b881fadf2bf9b6e1fdNormal-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.sec07478f122745b881fadf2bf9b6e1fdNormal-000002 { 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.sec07478f122745b881fadf2bf9b6e1fd000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sec07478f122745b881fadf2bf9b6e1fdSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sec07478f122745b881fadf2bf9b6e1fdSCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-29 - Concurrent review determinations--Timing--Notification requirements."><meta property="og:description" content="SDLRC Codified Law 58-17H-29 - Concurrent review determinations--Timing--Notification requirements."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-29"><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="sec07478f122745b881fadf2bf9b6e1fdNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-29" rel="noopener"><span class="sec07478f122745b881fadf2bf9b6e1fdSENU">58-17H-29</span></a><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fdSENU">. </span><span class="sec07478f122745b881fadf2bf9b6e1fdCL">Concurrent review determinations--Timing--Notification requirements.</span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal-000000"><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">For concurrent review determinations, if a health carrier has certified an ongoing course of treatment to be provided over a period of time or number of treatments:</span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal-000001"><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">(1)    Any reduction or termination by the health carrier during the course of treatment before the end of the period or number treatments, other than by health benefit plan amendment or termination of the health benefit plan, shall constitute an adverse determination; and</span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal-000001"><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">(2)    The health carrier shall notify the covered person of the adverse determination in accordance with § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">58-17H-32</span></a><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont"> at a time sufficiently in advance of the reduction or termination to allow the covered person or, if applicable, the covered person's authorized representative, to file a grievance to request a review of the adverse determination pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">58-17I</span></a><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">, and obtain a determination with respect to that review of the adverse determination before the benefit is reduced or terminated.</span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal-000002"><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">The health care service or treatment that is the subject of the adverse determination shall be continued without liability to the covered person until the covered person has been notified of the determination by the health carrier with respect to the internal review request made pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">58-17I</span></a><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">.</span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal"><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fd000003"> </span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal"><span class="sec07478f122745b881fadf2bf9b6e1fdSCL">Source:</span><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fdSCL-000004"> SL 2011, ch 219, § 54.</span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal"><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fd000003"> </span></p><p dir="ltr" class="sec07478f122745b881fadf2bf9b6e1fdNormal"><span xml:space="preserve" class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont-000005">Commission Note: </span><span class="sec07478f122745b881fadf2bf9b6e1fdDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sd0d6af04c5b440a9987a9e131d42818eNormal { 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.sd0d6af04c5b440a9987a9e131d42818eSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd0d6af04c5b440a9987a9e131d42818eCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sd0d6af04c5b440a9987a9e131d42818eNormal-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.sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sd0d6af04c5b440a9987a9e131d42818eNormal-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; } p.sd0d6af04c5b440a9987a9e131d42818eNormal-000002 { 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; } span.sd0d6af04c5b440a9987a9e131d42818e000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd0d6af04c5b440a9987a9e131d42818eSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd0d6af04c5b440a9987a9e131d42818eSCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-30 - Retrospective review determinations--Timing--Notification requirements."><meta property="og:description" content="SDLRC Codified Law 58-17H-30 - Retrospective review determinations--Timing--Notification requirements."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-30"><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="sd0d6af04c5b440a9987a9e131d42818eNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30" rel="noopener"><span class="sd0d6af04c5b440a9987a9e131d42818eSENU">58-17H-30</span></a><span xml:space="preserve" class="sd0d6af04c5b440a9987a9e131d42818eSENU">. </span><span class="sd0d6af04c5b440a9987a9e131d42818eCL">Retrospective review determinations--Timing--Notification requirements.</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal-000000"><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">For retrospective review determinations, the health carrier shall make the determination within a reasonable period of time, but in no event later than thirty days after the date of receiving the benefit request.</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal-000001"><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">In the case of a certification, the health carrier may notify in writing the covered person and the provider rendering the service.</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal-000001"><span xml:space="preserve" class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">If the determination is an adverse determination, the health carrier shall provide notice of the adverse determination to the covered person or, if applicable, the covered person's authorized representative, in accordance with § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">58-17H-32</span></a><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">. The time period for making a determination and notifying the covered person or, if applicable, the covered person's authorized representative, of the determination pursuant to this section may be extended once by the health carrier for up to fifteen days, if the health carrier:</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal-000002"><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">(1)    Determines that an extension is necessary due to matters beyond the health carrier's control; and</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal-000002"><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">(2)    Notifies the covered person or, if applicable, the covered person's authorized representative, prior to the expiration of the initial thirty-day time period, of the circumstances requiring the extension of time and the date by which the health carrier expects to make a determination.</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal-000001"><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">If the extension under this section is necessary due to the failure of the covered person or, if applicable, the covered person's authorized representative to submit information necessary to reach a determination on the request, the notice of extension shall specifically describe the required information necessary to complete the request and give the covered person or, if applicable, the covered person's authorized representative at least forty-five days from the date of receipt of the notice to provide the specified information.</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal"><span xml:space="preserve" class="sd0d6af04c5b440a9987a9e131d42818e000003"> </span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal"><span class="sd0d6af04c5b440a9987a9e131d42818eSCL">Source:</span><span xml:space="preserve" class="sd0d6af04c5b440a9987a9e131d42818eSCL-000004"> SL 2011, ch 219, § 55.</span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal"><span xml:space="preserve" class="sd0d6af04c5b440a9987a9e131d42818e000003"> </span></p><p dir="ltr" class="sd0d6af04c5b440a9987a9e131d42818eNormal"><span xml:space="preserve" class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont-000005">Commission Note: </span><span class="sd0d6af04c5b440a9987a9e131d42818eDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.seb17aa2913184068aaea0e3a6c8d3d0eNormal { 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.seb17aa2913184068aaea0e3a6c8d3d0eSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.seb17aa2913184068aaea0e3a6c8d3d0eCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.seb17aa2913184068aaea0e3a6c8d3d0eStatute { 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.seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } a.seb17aa2913184068aaea0e3a6c8d3d0e000000 { text-decoration: none; } p.seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1 { margin-left: 0.75in; text-indent: -0.50in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } span.seb17aa2913184068aaea0e3a6c8d3d0e000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.seb17aa2913184068aaea0e3a6c8d3d0eNoIndent { text-indent: 0.00in; 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.seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.seb17aa2913184068aaea0e3a6c8d3d0eSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-30.1 - Retroactive denial of paid claim--Restriction--Requirement--Exclusions--Enforcement."><meta property="og:description" content="SDLRC Codified Law 58-17H-30.1 - Retroactive denial of paid claim--Restriction--Requirement--Exclusions--Enforcement."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-30.1"><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="seb17aa2913184068aaea0e3a6c8d3d0eNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30.1" rel="noopener"><span class="seb17aa2913184068aaea0e3a6c8d3d0eSENU">58-17H-30.1</span></a><span xml:space="preserve" class="seb17aa2913184068aaea0e3a6c8d3d0eSENU">. </span><span class="seb17aa2913184068aaea0e3a6c8d3d0eCL">Retroactive denial of paid claim--Restriction--Requirement--Exclusions--Enforcement.</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatute"><span xml:space="preserve" class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">Except as otherwise provided in this section, a previously paid claim may be </span><a id="_Hlk219281078" class="seb17aa2913184068aaea0e3a6c8d3d0e000000" rel="noopener"></a><span xml:space="preserve" class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">recouped, recovered, or retroactively denied </span><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">by the health carrier only within eighteen months from the date the claim payment was made, if the health carrier has provided written notice of the reason to the provider. This limitation does not apply to a previously paid claim that:</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">(1)    Was determined by the health carrier to have been submitted fraudulently or to involve waste or abuse;</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">(2)    Is the subject of an adjustment with a different health carrier, administrator, or payor, and the adjustment is not affected by a contractual relationship, association, or affiliation involving claims payment, processing, or pricing;</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1"><span xml:space="preserve" class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">(3)    Was for medical services covered by casualty insurance, as defined by §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-9-11" rel="noopener"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">58-9-11</span></a><span xml:space="preserve" class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-9-27" rel="noopener"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">58-9-27</span></a><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">, inclusive;</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">(4)    Was for medical services covered by a self-insured health plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001 to 1461, inclusive (July 6, 2012);</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">(5)    Was for medical services covered under medicare, 42 U.S.C. §§ 1395-1395lll, inclusive (March 15, 2025), medicaid, 42 U.S.C. §§ 1396 to 1396w-6, inclusive (July 4, 2025), or any other federal law;</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">(6)    Was for medical services covered by workers' compensation, as provided for in title 62; or</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatuteNumber1"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">(7)    Was incorrect because the provider or the member was already paid for the medical services identified in the claim.</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatute"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">A violation of this section is subject to enforcement by the Division of Insurance under title 58.</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatute"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">For purposes of this section, "medical services," do not include dental services, pharmaceutical services, or the provision of prescription drug products or supplies.</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eStatute"><span class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont">For purposes of this section, "retroactively deny a previously paid claim" means to retroactively collect claim payments made to a provider by requiring repayment of the payments, reducing other payments currently owed to the provider, withholding or setting off against future payments, or reducing or affecting the future claim payments to the provider in any other manner.</span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eNormal"><span xml:space="preserve" class="seb17aa2913184068aaea0e3a6c8d3d0e000001"> </span></p><p dir="ltr" class="seb17aa2913184068aaea0e3a6c8d3d0eNoIndent"><span xml:space="preserve" class="seb17aa2913184068aaea0e3a6c8d3d0eDefaultParagraphFont-000002">Source: </span><span class="seb17aa2913184068aaea0e3a6c8d3d0eSCL">SL 2026, ch 200, § 1.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s1e4772ee851b4e13934357b9a383e248Normal { 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.s1e4772ee851b4e13934357b9a383e248SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s1e4772ee851b4e13934357b9a383e248CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s1e4772ee851b4e13934357b9a383e248Statute { 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.s1e4772ee851b4e13934357b9a383e248DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s1e4772ee851b4e13934357b9a383e248000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s1e4772ee851b4e13934357b9a383e248NoIndent { text-indent: 0.00in; 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.s1e4772ee851b4e13934357b9a383e248DefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s1e4772ee851b4e13934357b9a383e248SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-30.2 - Retroactive denial of paid claim--Payment amount."><meta property="og:description" content="SDLRC Codified Law 58-17H-30.2 - Retroactive denial of paid claim--Payment amount."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-30.2"><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="s1e4772ee851b4e13934357b9a383e248Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30.2" rel="noopener"><span class="s1e4772ee851b4e13934357b9a383e248SENU">58-17H-30.2</span></a><span xml:space="preserve" class="s1e4772ee851b4e13934357b9a383e248SENU">. </span><span class="s1e4772ee851b4e13934357b9a383e248CL">Retroactive denial of paid claim--Payment amount.</span></p><p dir="ltr" class="s1e4772ee851b4e13934357b9a383e248Statute"><span xml:space="preserve" class="s1e4772ee851b4e13934357b9a383e248DefaultParagraphFont">A payment remitted by the provider to the health carrier, as provided for in § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30.1" rel="noopener"><span class="s1e4772ee851b4e13934357b9a383e248DefaultParagraphFont">58-17H-30.1</span></a><span class="s1e4772ee851b4e13934357b9a383e248DefaultParagraphFont">, must be in the amount originally paid by the carrier and may not include any additional fees, penalties, or interest.</span></p><p dir="ltr" class="s1e4772ee851b4e13934357b9a383e248Normal"><span xml:space="preserve" class="s1e4772ee851b4e13934357b9a383e248000000"> </span></p><p dir="ltr" class="s1e4772ee851b4e13934357b9a383e248NoIndent"><span xml:space="preserve" class="s1e4772ee851b4e13934357b9a383e248DefaultParagraphFont-000001">Source: </span><span class="s1e4772ee851b4e13934357b9a383e248SCL">SL 2026, ch 200, § 2.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sd6cbf1b8e1614383a77d71e24c0efc3aNormal { 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.sd6cbf1b8e1614383a77d71e24c0efc3aSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd6cbf1b8e1614383a77d71e24c0efc3aCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sd6cbf1b8e1614383a77d71e24c0efc3aNormal-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.sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd6cbf1b8e1614383a77d71e24c0efc3a000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd6cbf1b8e1614383a77d71e24c0efc3aSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sd6cbf1b8e1614383a77d71e24c0efc3aSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-31 - Calculation of time period for determination for prospective and retrospective reviews."><meta property="og:description" content="SDLRC Codified Law 58-17H-31 - Calculation of time period for determination for prospective and retrospective reviews."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-31"><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="sd6cbf1b8e1614383a77d71e24c0efc3aNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-31" rel="noopener"><span class="sd6cbf1b8e1614383a77d71e24c0efc3aSENU">58-17H-31</span></a><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3aSENU">. </span><span class="sd6cbf1b8e1614383a77d71e24c0efc3aCL">Calculation of time period for determination for prospective and retrospective reviews.</span></p><p dir="ltr" class="sd6cbf1b8e1614383a77d71e24c0efc3aNormal-000000"><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont">For purposes of calculating the time periods within which a determination is required to be made for prospective and retrospective reviews, the time period within which the determination is required to be made begins on the date the request is received by the health carrier in accordance with the health carrier's procedures established pursuant to § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-16" rel="noopener"><span class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont">58-17H-16</span></a><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont">. If the time period for making the determination for a prospective or retrospective review is extended due to the covered person or, if applicable, the covered person's authorized representative's failure to submit the information necessary to make the determination, the time period for making the determination shall be tolled from the date on which the health carrier sends the notification of the extension to the covered person or, if applicable, the covered person's authorized representative, until the earlier of: the date on which the covered person or, if applicable, the covered person's authorized representative, responds to the request for additional information or the date on which the specified information was to have been submitted. If the covered person or the covered person's authorized representative fails to submit the information before the end of the period of the extension, as specified in §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-28" rel="noopener"><span class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont">58-17H-28</span></a><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont"> and </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-30" rel="noopener"><span class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont">58-17H-30</span></a><span class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont">, the health carrier may deny the certification of the requested benefit.</span></p><p dir="ltr" class="sd6cbf1b8e1614383a77d71e24c0efc3aNormal"><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3a000001"> </span></p><p dir="ltr" class="sd6cbf1b8e1614383a77d71e24c0efc3aNormal"><span class="sd6cbf1b8e1614383a77d71e24c0efc3aSCL">Source:</span><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3aSCL-000002"> SL 2011, ch 219, § 56.</span></p><p dir="ltr" class="sd6cbf1b8e1614383a77d71e24c0efc3aNormal"><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3a000001"> </span></p><p dir="ltr" class="sd6cbf1b8e1614383a77d71e24c0efc3aNormal"><span xml:space="preserve" class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont-000003">Commission Note: </span><span class="sd6cbf1b8e1614383a77d71e24c0efc3aDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s202a19d138fe4178806e1a149004be23Normal { 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.s202a19d138fe4178806e1a149004be23SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s202a19d138fe4178806e1a149004be23CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s202a19d138fe4178806e1a149004be23Normal-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.s202a19d138fe4178806e1a149004be23DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s202a19d138fe4178806e1a149004be23Normal-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.s202a19d138fe4178806e1a149004be23Normal-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.s202a19d138fe4178806e1a149004be23Normal-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.s202a19d138fe4178806e1a149004be23000004 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s202a19d138fe4178806e1a149004be23SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s202a19d138fe4178806e1a149004be23SCL-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s202a19d138fe4178806e1a149004be23DefaultParagraphFont-000006 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-32 - Notification of adverse determination--Contents."><meta property="og:description" content="SDLRC Codified Law 58-17H-32 - Notification of adverse determination--Contents."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-32"><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="s202a19d138fe4178806e1a149004be23Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s202a19d138fe4178806e1a149004be23SENU">58-17H-32</span></a><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23SENU">. </span><span class="s202a19d138fe4178806e1a149004be23CL">Notification of adverse determination--Contents.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000000"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">Any notification of an adverse determination under this section shall, in a manner which is designed to be understood by the covered person, set forth:</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000001"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(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="s202a19d138fe4178806e1a149004be23Normal-000001"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(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="s202a19d138fe4178806e1a149004be23Normal-000001"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(3)    A reference to the specific plan provision on which the determination is based;</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000001"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(4)    A description of additional material or information necessary for the covered person to complete the benefit request, including an explanation of why the material or information is necessary to complete the request;</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000001"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(5)    A description of the health carrier's grievance procedures established pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">58-17I</span></a><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">, including time limits applicable to those procedures;</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000001"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(6)    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="s202a19d138fe4178806e1a149004be23Normal-000001"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(7)    If the adverse determination is based on a medical necessity or experimental or investigational 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="s202a19d138fe4178806e1a149004be23Normal-000001"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(8)    If applicable, instructions for requesting:</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000002"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(a)    A copy of the rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination, as provided in subdivision (6) of this section; or</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000002"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(b)    The written statement of the scientific or clinical rationale for the adverse determination, as provided in subdivision (7) of this section; and</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000001"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">(9)    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="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">58-17I</span></a><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">, to file a civil suit in a court of competent jurisdiction.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">If the adverse determination is a rescission, the health carrier shall provide, in addition to any applicable disclosures required under § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">58-17H-32</span></a><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">, clear identification of the alleged fraudulent practice or omission or the intentional misrepresentation of material fact, an explanation as to why the act, practice, or omission was fraudulent or was an intentional misrepresentation of a material fact, and the effective date of the rescission.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">A health carrier may provide the notice required under this section in writing or electronically.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">If the adverse determination is a rescission, the health carrier shall provide advance notice of the rescission determination required by rules promulgated by the director, in addition to any applicable disclosures required under this section.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">The health carrier shall provide clear identification of the alleged fraudulent act, practice, or omission or the intentional misrepresentation of material fact.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">The health carrier shall provide an explanation as to why the act, practice, or omission was fraudulent or was an intentional misrepresentation of a material fact.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">The health carrier shall provide notice that the covered person or the covered person's authorized representative, prior to the date the advance notice of the proposed rescission ends, may immediately file a grievance to request a review of the adverse determination to rescind coverage pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">58-17I</span></a><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">The health carrier shall provide a description of the health carrier's grievance procedures established pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17I" rel="noopener"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">58-17I</span></a><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">, including any time limits applicable to those procedures.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal-000003"><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">The health carrier shall provide the date when the advance notice ends and the date back to which the coverage will be retroactively rescinded.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23000004"> </span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal"><span class="s202a19d138fe4178806e1a149004be23SCL">Source:</span><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23SCL-000005"> SL 2011, ch 219, § 57.</span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23000004"> </span></p><p dir="ltr" class="s202a19d138fe4178806e1a149004be23Normal"><span xml:space="preserve" class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont-000006">Commission Note: </span><span class="s202a19d138fe4178806e1a149004be23DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s760aab714bf3456b91834a42acf59582Normal { 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.s760aab714bf3456b91834a42acf59582SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s760aab714bf3456b91834a42acf59582CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s760aab714bf3456b91834a42acf59582Normal-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.s760aab714bf3456b91834a42acf59582DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s760aab714bf3456b91834a42acf59582000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s760aab714bf3456b91834a42acf59582SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s760aab714bf3456b91834a42acf59582SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s760aab714bf3456b91834a42acf59582DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-33 - Information required to be provided to covered persons and prospective covered persons."><meta property="og:description" content="SDLRC Codified Law 58-17H-33 - Information required to be provided to covered persons and prospective covered persons."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-33"><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="s760aab714bf3456b91834a42acf59582Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-33" rel="noopener"><span class="s760aab714bf3456b91834a42acf59582SENU">58-17H-33</span></a><span xml:space="preserve" class="s760aab714bf3456b91834a42acf59582SENU">. </span><span class="s760aab714bf3456b91834a42acf59582CL">Information required to be provided to covered persons and prospective covered persons.</span></p><p dir="ltr" class="s760aab714bf3456b91834a42acf59582Normal-000000"><span class="s760aab714bf3456b91834a42acf59582DefaultParagraphFont">In the certificate of coverage or member handbook provided to covered persons, a health carrier shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of rights and responsibilities of covered persons with respect to those procedures. A health carrier shall include a summary of its utilization review and benefit determination procedures in materials intended for prospective covered persons. A health carrier shall print on its membership cards a toll-free telephone number to call for utilization review and benefit decisions.</span></p><p dir="ltr" class="s760aab714bf3456b91834a42acf59582Normal"><span xml:space="preserve" class="s760aab714bf3456b91834a42acf59582000001"> </span></p><p dir="ltr" class="s760aab714bf3456b91834a42acf59582Normal"><span class="s760aab714bf3456b91834a42acf59582SCL">Source:</span><span xml:space="preserve" class="s760aab714bf3456b91834a42acf59582SCL-000002"> SL 2011, ch 219, § 58.</span></p><p dir="ltr" class="s760aab714bf3456b91834a42acf59582Normal"><span xml:space="preserve" class="s760aab714bf3456b91834a42acf59582000001"> </span></p><p dir="ltr" class="s760aab714bf3456b91834a42acf59582Normal"><span xml:space="preserve" class="s760aab714bf3456b91834a42acf59582DefaultParagraphFont-000003">Commission Note: </span><span class="s760aab714bf3456b91834a42acf59582DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s131b93be4c2b44e099ab99d2cb2a34f7Normal { 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.s131b93be4c2b44e099ab99d2cb2a34f7SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s131b93be4c2b44e099ab99d2cb2a34f7CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s131b93be4c2b44e099ab99d2cb2a34f7Normal-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.s131b93be4c2b44e099ab99d2cb2a34f7DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s131b93be4c2b44e099ab99d2cb2a34f7000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s131b93be4c2b44e099ab99d2cb2a34f7SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s131b93be4c2b44e099ab99d2cb2a34f7SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s131b93be4c2b44e099ab99d2cb2a34f7DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-34 - Health carrier may be deemed to meet utilization review requirements if met by private accrediting body."><meta property="og:description" content="SDLRC Codified Law 58-17H-34 - Health carrier may be deemed to meet utilization review requirements if met by private accrediting body."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-34"><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="s131b93be4c2b44e099ab99d2cb2a34f7Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-34" rel="noopener"><span class="s131b93be4c2b44e099ab99d2cb2a34f7SENU">58-17H-34</span></a><span xml:space="preserve" class="s131b93be4c2b44e099ab99d2cb2a34f7SENU">. </span><span class="s131b93be4c2b44e099ab99d2cb2a34f7CL">Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.</span></p><p dir="ltr" class="s131b93be4c2b44e099ab99d2cb2a34f7Normal-000000"><span class="s131b93be4c2b44e099ab99d2cb2a34f7DefaultParagraphFont">If the director and the secretary find that the requirements of any private accrediting body meet the requirements of utilization review as set forth in this chapter, the health carrier may, at the discretion of the director and secretary, be deemed to have met the applicable requirements.</span></p><p dir="ltr" class="s131b93be4c2b44e099ab99d2cb2a34f7Normal"><span xml:space="preserve" class="s131b93be4c2b44e099ab99d2cb2a34f7000001"> </span></p><p dir="ltr" class="s131b93be4c2b44e099ab99d2cb2a34f7Normal"><span class="s131b93be4c2b44e099ab99d2cb2a34f7SCL">Source:</span><span xml:space="preserve" class="s131b93be4c2b44e099ab99d2cb2a34f7SCL-000002"> SL 2011, ch 219, § 59.</span></p><p dir="ltr" class="s131b93be4c2b44e099ab99d2cb2a34f7Normal"><span xml:space="preserve" class="s131b93be4c2b44e099ab99d2cb2a34f7000001"> </span></p><p dir="ltr" class="s131b93be4c2b44e099ab99d2cb2a34f7Normal"><span xml:space="preserve" class="s131b93be4c2b44e099ab99d2cb2a34f7DefaultParagraphFont-000003">Commission Note: </span><span class="s131b93be4c2b44e099ab99d2cb2a34f7DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sb2cd804b5d334a40a0e16897d88c4e77Normal { 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.sb2cd804b5d334a40a0e16897d88c4e77SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb2cd804b5d334a40a0e16897d88c4e77CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sb2cd804b5d334a40a0e16897d88c4e77Normal-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.sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sb2cd804b5d334a40a0e16897d88c4e77Normal-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; } span.sb2cd804b5d334a40a0e16897d88c4e77000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb2cd804b5d334a40a0e16897d88c4e77SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb2cd804b5d334a40a0e16897d88c4e77SCL-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-35 - Registration of utilization review organizations--Required information."><meta property="og:description" content="SDLRC Codified Law 58-17H-35 - Registration of utilization review organizations--Required information."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-35"><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="sb2cd804b5d334a40a0e16897d88c4e77Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-35" rel="noopener"><span class="sb2cd804b5d334a40a0e16897d88c4e77SENU">58-17H-35</span></a><span xml:space="preserve" class="sb2cd804b5d334a40a0e16897d88c4e77SENU">. </span><span class="sb2cd804b5d334a40a0e16897d88c4e77CL">Registration of utilization review organizations--Required information.</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal-000000"><span xml:space="preserve" class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">Any utilization review organization which engages in utilization review activities in this state shall register with the Division of Insurance prior to conducting business in this state. The registration shall be in a format prescribed by the director. In prescribing the form or in carrying out other functions required by §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-35" rel="noopener"><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">58-17H-35</span></a><span xml:space="preserve" class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-39" rel="noopener"><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">58-17H-39</span></a><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">, inclusive, the director shall consult with the secretary if applicable. The director or the secretary may require that the following information be submitted:</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal-000001"><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">(1)    Information relating to its actual or anticipated activities in this state;</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal-000001"><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">(2)    The status of any accreditation designation it holds or has sought;</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal-000001"><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">(3)    Information pertaining to its place of business, officers, and directors;</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal-000001"><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">(4)    Qualifications of review staff; and</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal-000001"><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">(5)    Any other information reasonable and necessary to monitor its activities in this state.</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal"><span xml:space="preserve" class="sb2cd804b5d334a40a0e16897d88c4e77000002"> </span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal"><span class="sb2cd804b5d334a40a0e16897d88c4e77SCL">Source:</span><span xml:space="preserve" class="sb2cd804b5d334a40a0e16897d88c4e77SCL-000003"> SL 2011, ch 219, § 60.</span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal"><span xml:space="preserve" class="sb2cd804b5d334a40a0e16897d88c4e77000002"> </span></p><p dir="ltr" class="sb2cd804b5d334a40a0e16897d88c4e77Normal"><span xml:space="preserve" class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont-000004">Commission Note: </span><span class="sb2cd804b5d334a40a0e16897d88c4e77DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s7e40579729b24d75a526e67d9b437f52Normal { 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.s7e40579729b24d75a526e67d9b437f52SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s7e40579729b24d75a526e67d9b437f52CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s7e40579729b24d75a526e67d9b437f52Normal-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.s7e40579729b24d75a526e67d9b437f52DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7e40579729b24d75a526e67d9b437f52000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7e40579729b24d75a526e67d9b437f52SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s7e40579729b24d75a526e67d9b437f52SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s7e40579729b24d75a526e67d9b437f52DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-36 - Filing changes in registration information."><meta property="og:description" content="SDLRC Codified Law 58-17H-36 - Filing changes in registration information."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-36"><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="s7e40579729b24d75a526e67d9b437f52Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-36" rel="noopener"><span class="s7e40579729b24d75a526e67d9b437f52SENU">58-17H-36</span></a><span xml:space="preserve" class="s7e40579729b24d75a526e67d9b437f52SENU">. </span><span class="s7e40579729b24d75a526e67d9b437f52CL">Filing changes in registration information.</span></p><p dir="ltr" class="s7e40579729b24d75a526e67d9b437f52Normal-000000"><span class="s7e40579729b24d75a526e67d9b437f52DefaultParagraphFont">Any utilization review organization which has previously registered in this state shall, on or before July first of each year, file with the Division of Insurance any changes to the initial or subsequent annual registration for the utilization review organization.</span></p><p dir="ltr" class="s7e40579729b24d75a526e67d9b437f52Normal"><span xml:space="preserve" class="s7e40579729b24d75a526e67d9b437f52000001"> </span></p><p dir="ltr" class="s7e40579729b24d75a526e67d9b437f52Normal"><span class="s7e40579729b24d75a526e67d9b437f52SCL">Source:</span><span xml:space="preserve" class="s7e40579729b24d75a526e67d9b437f52SCL-000002"> SL 2011, ch 219, § 61.</span></p><p dir="ltr" class="s7e40579729b24d75a526e67d9b437f52Normal"><span xml:space="preserve" class="s7e40579729b24d75a526e67d9b437f52000001"> </span></p><p dir="ltr" class="s7e40579729b24d75a526e67d9b437f52Normal"><span xml:space="preserve" class="s7e40579729b24d75a526e67d9b437f52DefaultParagraphFont-000003">Commission Note: </span><span class="s7e40579729b24d75a526e67d9b437f52DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.se988dbe9a2c943d8a36a89672f182865Normal { 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.se988dbe9a2c943d8a36a89672f182865SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.se988dbe9a2c943d8a36a89672f182865CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.se988dbe9a2c943d8a36a89672f182865Normal-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.se988dbe9a2c943d8a36a89672f182865DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se988dbe9a2c943d8a36a89672f182865000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se988dbe9a2c943d8a36a89672f182865SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.se988dbe9a2c943d8a36a89672f182865SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se988dbe9a2c943d8a36a89672f182865DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-37 - Requests for information from utilization review organizations."><meta property="og:description" content="SDLRC Codified Law 58-17H-37 - Requests for information from utilization review organizations."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-37"><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="se988dbe9a2c943d8a36a89672f182865Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-37" rel="noopener"><span class="se988dbe9a2c943d8a36a89672f182865SENU">58-17H-37</span></a><span xml:space="preserve" class="se988dbe9a2c943d8a36a89672f182865SENU">. </span><span class="se988dbe9a2c943d8a36a89672f182865CL">Requests for information from utilization review organizations.</span></p><p dir="ltr" class="se988dbe9a2c943d8a36a89672f182865Normal-000000"><span class="se988dbe9a2c943d8a36a89672f182865DefaultParagraphFont">The director or the secretary may request information from any utilization review organization at any time pertaining to its activities in this state. The utilization review organization shall respond to all requests for information within twenty days.</span></p><p dir="ltr" class="se988dbe9a2c943d8a36a89672f182865Normal"><span xml:space="preserve" class="se988dbe9a2c943d8a36a89672f182865000001"> </span></p><p dir="ltr" class="se988dbe9a2c943d8a36a89672f182865Normal"><span class="se988dbe9a2c943d8a36a89672f182865SCL">Source:</span><span xml:space="preserve" class="se988dbe9a2c943d8a36a89672f182865SCL-000002"> SL 2011, ch 219, § 62.</span></p><p dir="ltr" class="se988dbe9a2c943d8a36a89672f182865Normal"><span xml:space="preserve" class="se988dbe9a2c943d8a36a89672f182865000001"> </span></p><p dir="ltr" class="se988dbe9a2c943d8a36a89672f182865Normal"><span xml:space="preserve" class="se988dbe9a2c943d8a36a89672f182865DefaultParagraphFont-000003">Commission Note: </span><span class="se988dbe9a2c943d8a36a89672f182865DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s094ded7129fc4543a1b22fd752f242bfNormal { 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.s094ded7129fc4543a1b22fd752f242bfSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s094ded7129fc4543a1b22fd752f242bfCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s094ded7129fc4543a1b22fd752f242bfNormal-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.s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s094ded7129fc4543a1b22fd752f242bf000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s094ded7129fc4543a1b22fd752f242bfSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s094ded7129fc4543a1b22fd752f242bfSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-38 - Activities of nonregistered utilization review organizations prohibited."><meta property="og:description" content="SDLRC Codified Law 58-17H-38 - Activities of nonregistered utilization review organizations prohibited."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-38"><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="s094ded7129fc4543a1b22fd752f242bfNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-38" rel="noopener"><span class="s094ded7129fc4543a1b22fd752f242bfSENU">58-17H-38</span></a><span xml:space="preserve" class="s094ded7129fc4543a1b22fd752f242bfSENU">. </span><span class="s094ded7129fc4543a1b22fd752f242bfCL">Activities of nonregistered utilization review organizations prohibited.</span></p><p dir="ltr" class="s094ded7129fc4543a1b22fd752f242bfNormal-000000"><span xml:space="preserve" class="s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont">A utilization review organization may not engage in utilization review in this state unless the utilization review organization is properly registered. The director may issue a cease and desist order against any utilization review organization which fails to comply with the requirements of §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-35" rel="noopener"><span class="s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont">58-17H-35</span></a><span xml:space="preserve" class="s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-39" rel="noopener"><span class="s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont">58-17H-39</span></a><span class="s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont">, inclusive, prohibiting the utilization review organization from engaging in utilization review activities in this state.</span></p><p dir="ltr" class="s094ded7129fc4543a1b22fd752f242bfNormal"><span xml:space="preserve" class="s094ded7129fc4543a1b22fd752f242bf000001"> </span></p><p dir="ltr" class="s094ded7129fc4543a1b22fd752f242bfNormal"><span class="s094ded7129fc4543a1b22fd752f242bfSCL">Source:</span><span xml:space="preserve" class="s094ded7129fc4543a1b22fd752f242bfSCL-000002"> SL 2011, ch 219, § 63.</span></p><p dir="ltr" class="s094ded7129fc4543a1b22fd752f242bfNormal"><span xml:space="preserve" class="s094ded7129fc4543a1b22fd752f242bf000001"> </span></p><p dir="ltr" class="s094ded7129fc4543a1b22fd752f242bfNormal"><span xml:space="preserve" class="s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont-000003">Commission Note: </span><span class="s094ded7129fc4543a1b22fd752f242bfDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sda6211111cd84ce7a8895cf401a06d9eNormal { 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.sda6211111cd84ce7a8895cf401a06d9eSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sda6211111cd84ce7a8895cf401a06d9eCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sda6211111cd84ce7a8895cf401a06d9eNormal-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.sda6211111cd84ce7a8895cf401a06d9eDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sda6211111cd84ce7a8895cf401a06d9e000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sda6211111cd84ce7a8895cf401a06d9eSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sda6211111cd84ce7a8895cf401a06d9eSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sda6211111cd84ce7a8895cf401a06d9eDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-39 - Registration fee for utilization review organizations."><meta property="og:description" content="SDLRC Codified Law 58-17H-39 - Registration fee for utilization review organizations."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-39"><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="sda6211111cd84ce7a8895cf401a06d9eNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-39" rel="noopener"><span class="sda6211111cd84ce7a8895cf401a06d9eSENU">58-17H-39</span></a><span xml:space="preserve" class="sda6211111cd84ce7a8895cf401a06d9eSENU">. </span><span class="sda6211111cd84ce7a8895cf401a06d9eCL">Registration fee for utilization review organizations.</span></p><p dir="ltr" class="sda6211111cd84ce7a8895cf401a06d9eNormal-000000"><span xml:space="preserve" class="sda6211111cd84ce7a8895cf401a06d9eDefaultParagraphFont">The director may require the payment of a fee in conjunction with the initial or annual registration of a utilization review organization not to exceed two hundred fifty dollars per registration. The fee shall be established by rules promulgated pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=1-26" rel="noopener"><span class="sda6211111cd84ce7a8895cf401a06d9eDefaultParagraphFont">1-26</span></a><span class="sda6211111cd84ce7a8895cf401a06d9eDefaultParagraphFont">.</span></p><p dir="ltr" class="sda6211111cd84ce7a8895cf401a06d9eNormal"><span xml:space="preserve" class="sda6211111cd84ce7a8895cf401a06d9e000001"> </span></p><p dir="ltr" class="sda6211111cd84ce7a8895cf401a06d9eNormal"><span class="sda6211111cd84ce7a8895cf401a06d9eSCL">Source:</span><span xml:space="preserve" class="sda6211111cd84ce7a8895cf401a06d9eSCL-000002"> SL 2011, ch 219, § 64.</span></p><p dir="ltr" class="sda6211111cd84ce7a8895cf401a06d9eNormal"><span xml:space="preserve" class="sda6211111cd84ce7a8895cf401a06d9e000001"> </span></p><p dir="ltr" class="sda6211111cd84ce7a8895cf401a06d9eNormal"><span xml:space="preserve" class="sda6211111cd84ce7a8895cf401a06d9eDefaultParagraphFont-000003">Commission Note: </span><span class="sda6211111cd84ce7a8895cf401a06d9eDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s96d3af8e67554327b98e11504f8f1f6fNormal { 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.s96d3af8e67554327b98e11504f8f1f6fSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s96d3af8e67554327b98e11504f8f1f6fCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s96d3af8e67554327b98e11504f8f1f6fNormal-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.s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s96d3af8e67554327b98e11504f8f1f6f000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s96d3af8e67554327b98e11504f8f1f6fSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s96d3af8e67554327b98e11504f8f1f6fSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-40 - Urgent care requests--Written procedures required for receipt and determination of requests."><meta property="og:description" content="SDLRC Codified Law 58-17H-40 - Urgent care requests--Written procedures required for receipt and determination of requests."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-40"><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="s96d3af8e67554327b98e11504f8f1f6fNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s96d3af8e67554327b98e11504f8f1f6fSENU">58-17H-40</span></a><span xml:space="preserve" class="s96d3af8e67554327b98e11504f8f1f6fSENU">. </span><span class="s96d3af8e67554327b98e11504f8f1f6fCL">Urgent care requests--Written procedures required for receipt and determination of requests.</span></p><p dir="ltr" class="s96d3af8e67554327b98e11504f8f1f6fNormal-000000"><span xml:space="preserve" class="s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont">Each health carrier shall establish written procedures, in accordance with §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-40" rel="noopener"><span class="s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont">58-17H-40</span></a><span xml:space="preserve" class="s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont">58-17H-48</span></a><span class="s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont">, inclusive, for receiving benefit requests from covered persons or their authorized representatives and for making and notifying covered persons or their authorized representatives of expedited utilization review and benefit determinations with respect to urgent care requests and concurrent review urgent care requests.</span></p><p dir="ltr" class="s96d3af8e67554327b98e11504f8f1f6fNormal"><span xml:space="preserve" class="s96d3af8e67554327b98e11504f8f1f6f000001"> </span></p><p dir="ltr" class="s96d3af8e67554327b98e11504f8f1f6fNormal"><span class="s96d3af8e67554327b98e11504f8f1f6fSCL">Source:</span><span xml:space="preserve" class="s96d3af8e67554327b98e11504f8f1f6fSCL-000002"> SL 2011, ch 219, § 65.</span></p><p dir="ltr" class="s96d3af8e67554327b98e11504f8f1f6fNormal"><span xml:space="preserve" class="s96d3af8e67554327b98e11504f8f1f6f000001"> </span></p><p dir="ltr" class="s96d3af8e67554327b98e11504f8f1f6fNormal"><span xml:space="preserve" class="s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont-000003">Commission Note: </span><span class="s96d3af8e67554327b98e11504f8f1f6fDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s4b15db25f6354c529a52e19466061963Normal { 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.s4b15db25f6354c529a52e19466061963SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s4b15db25f6354c529a52e19466061963CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s4b15db25f6354c529a52e19466061963Normal-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.s4b15db25f6354c529a52e19466061963DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s4b15db25f6354c529a52e19466061963000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s4b15db25f6354c529a52e19466061963SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s4b15db25f6354c529a52e19466061963SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s4b15db25f6354c529a52e19466061963DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-41 - Insufficient information for determination--Notice and statement of necessary information."><meta property="og:description" content="SDLRC Codified Law 58-17H-41 - Insufficient information for determination--Notice and statement of necessary information."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-41"><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="s4b15db25f6354c529a52e19466061963Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-41" rel="noopener"><span class="s4b15db25f6354c529a52e19466061963SENU">58-17H-41</span></a><span xml:space="preserve" class="s4b15db25f6354c529a52e19466061963SENU">. </span><span class="s4b15db25f6354c529a52e19466061963CL">Insufficient information for determination--Notice and statement of necessary information.</span></p><p dir="ltr" class="s4b15db25f6354c529a52e19466061963Normal-000000"><span class="s4b15db25f6354c529a52e19466061963DefaultParagraphFont">If the covered person or, if applicable, the covered person's authorized representative has failed to provide sufficient information for the health carrier to make a determination, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, either orally or, if requested by the covered person or the covered person's authorized representative, in writing of this failure and state what specific information is needed as soon as possible, but in no event later than twenty-four hours after receipt of the request.</span></p><p dir="ltr" class="s4b15db25f6354c529a52e19466061963Normal"><span xml:space="preserve" class="s4b15db25f6354c529a52e19466061963000001"> </span></p><p dir="ltr" class="s4b15db25f6354c529a52e19466061963Normal"><span class="s4b15db25f6354c529a52e19466061963SCL">Source:</span><span xml:space="preserve" class="s4b15db25f6354c529a52e19466061963SCL-000002"> SL 2011, ch 219, § 66.</span></p><p dir="ltr" class="s4b15db25f6354c529a52e19466061963Normal"><span xml:space="preserve" class="s4b15db25f6354c529a52e19466061963000001"> </span></p><p dir="ltr" class="s4b15db25f6354c529a52e19466061963Normal"><span xml:space="preserve" class="s4b15db25f6354c529a52e19466061963DefaultParagraphFont-000003">Commission Note: </span><span class="s4b15db25f6354c529a52e19466061963DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s435dc7f8d942461887b408189e736f09Normal { 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.s435dc7f8d942461887b408189e736f09SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s435dc7f8d942461887b408189e736f09CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s435dc7f8d942461887b408189e736f09Normal-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.s435dc7f8d942461887b408189e736f09DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s435dc7f8d942461887b408189e736f09Normal-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; } span.s435dc7f8d942461887b408189e736f09000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s435dc7f8d942461887b408189e736f09SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s435dc7f8d942461887b408189e736f09SCL-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s435dc7f8d942461887b408189e736f09DefaultParagraphFont-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-42 - Insufficient information for determination of prospective urgent care requests."><meta property="og:description" content="SDLRC Codified Law 58-17H-42 - Insufficient information for determination of prospective urgent care requests."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-42"><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="s435dc7f8d942461887b408189e736f09Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-42" rel="noopener"><span class="s435dc7f8d942461887b408189e736f09SENU">58-17H-42</span></a><span xml:space="preserve" class="s435dc7f8d942461887b408189e736f09SENU">. </span><span class="s435dc7f8d942461887b408189e736f09CL">Insufficient information for determination of prospective urgent care requests.</span></p><p dir="ltr" class="s435dc7f8d942461887b408189e736f09Normal-000000"><span xml:space="preserve" class="s435dc7f8d942461887b408189e736f09DefaultParagraphFont">If the benefit request involves a prospective review urgent care request, the provisions of § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-41" rel="noopener"><span class="s435dc7f8d942461887b408189e736f09DefaultParagraphFont">58-17H-41</span></a><span xml:space="preserve" class="s435dc7f8d942461887b408189e736f09DefaultParagraphFont"> apply only in the case of a failure that:</span></p><p dir="ltr" class="s435dc7f8d942461887b408189e736f09Normal-000001"><span class="s435dc7f8d942461887b408189e736f09DefaultParagraphFont">(1)    Is a communication by a covered person or, if applicable, the covered person's authorized representative, that is received by a person or organizational unit of the health carrier responsible for handling benefit matters; and</span></p><p dir="ltr" class="s435dc7f8d942461887b408189e736f09Normal-000001"><span class="s435dc7f8d942461887b408189e736f09DefaultParagraphFont">(2)    Is a communication that refers to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment, or provider for which approval is being requested.</span></p><p dir="ltr" class="s435dc7f8d942461887b408189e736f09Normal"><span xml:space="preserve" class="s435dc7f8d942461887b408189e736f09000002"> </span></p><p dir="ltr" class="s435dc7f8d942461887b408189e736f09Normal"><span class="s435dc7f8d942461887b408189e736f09SCL">Source:</span><span xml:space="preserve" class="s435dc7f8d942461887b408189e736f09SCL-000003"> SL 2011, ch 219, § 67.</span></p><p dir="ltr" class="s435dc7f8d942461887b408189e736f09Normal"><span xml:space="preserve" class="s435dc7f8d942461887b408189e736f09000002"> </span></p><p dir="ltr" class="s435dc7f8d942461887b408189e736f09Normal"><span xml:space="preserve" class="s435dc7f8d942461887b408189e736f09DefaultParagraphFont-000004">Commission Note: </span><span class="s435dc7f8d942461887b408189e736f09DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s088196ca9e2d4b1893ff967cdb2b97e0Normal { 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.s088196ca9e2d4b1893ff967cdb2b97e0SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s088196ca9e2d4b1893ff967cdb2b97e0CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s088196ca9e2d4b1893ff967cdb2b97e0Normal-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.s088196ca9e2d4b1893ff967cdb2b97e0DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s088196ca9e2d4b1893ff967cdb2b97e0000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s088196ca9e2d4b1893ff967cdb2b97e0SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s088196ca9e2d4b1893ff967cdb2b97e0SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s088196ca9e2d4b1893ff967cdb2b97e0DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-43 - Urgent care requests--Timely notification of determination."><meta property="og:description" content="SDLRC Codified Law 58-17H-43 - Urgent care requests--Timely notification of determination."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-43"><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="s088196ca9e2d4b1893ff967cdb2b97e0Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-43" rel="noopener"><span class="s088196ca9e2d4b1893ff967cdb2b97e0SENU">58-17H-43</span></a><span xml:space="preserve" class="s088196ca9e2d4b1893ff967cdb2b97e0SENU">. </span><span class="s088196ca9e2d4b1893ff967cdb2b97e0CL">Urgent care requests--Timely notification of determination.</span></p><p dir="ltr" class="s088196ca9e2d4b1893ff967cdb2b97e0Normal-000000"><span xml:space="preserve" class="s088196ca9e2d4b1893ff967cdb2b97e0DefaultParagraphFont">For an urgent care request, unless the covered person or the covered person's authorized representative has failed to provide sufficient information for the health carrier to determine whether, or to what extent, the benefits requested are covered benefits or payable under the health carrier's health benefit plan, the health carrier shall notify the covered person or, if applicable, the covered person's authorized representative of the health carrier's determination with respect to the request, whether or not the determination is an adverse determination, as soon as possible, taking into account the medical condition of the covered person, but in no event later than twenty-four hours after the date of the receipt of the request by the health carrier. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s088196ca9e2d4b1893ff967cdb2b97e0DefaultParagraphFont">58-17H-48</span></a><span class="s088196ca9e2d4b1893ff967cdb2b97e0DefaultParagraphFont">.</span></p><p dir="ltr" class="s088196ca9e2d4b1893ff967cdb2b97e0Normal"><span xml:space="preserve" class="s088196ca9e2d4b1893ff967cdb2b97e0000001"> </span></p><p dir="ltr" class="s088196ca9e2d4b1893ff967cdb2b97e0Normal"><span class="s088196ca9e2d4b1893ff967cdb2b97e0SCL">Source:</span><span xml:space="preserve" class="s088196ca9e2d4b1893ff967cdb2b97e0SCL-000002"> SL 2011, ch 219, § 68.</span></p><p dir="ltr" class="s088196ca9e2d4b1893ff967cdb2b97e0Normal"><span xml:space="preserve" class="s088196ca9e2d4b1893ff967cdb2b97e0000001"> </span></p><p dir="ltr" class="s088196ca9e2d4b1893ff967cdb2b97e0Normal"><span xml:space="preserve" class="s088196ca9e2d4b1893ff967cdb2b97e0DefaultParagraphFont-000003">Commission Note: </span><span class="s088196ca9e2d4b1893ff967cdb2b97e0DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.se52c731b515c42a4b182fce1206027cbNormal { 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.se52c731b515c42a4b182fce1206027cbSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.se52c731b515c42a4b182fce1206027cbCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.se52c731b515c42a4b182fce1206027cbNormal-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.se52c731b515c42a4b182fce1206027cbDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se52c731b515c42a4b182fce1206027cb000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se52c731b515c42a4b182fce1206027cbSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.se52c731b515c42a4b182fce1206027cbSCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.se52c731b515c42a4b182fce1206027cbDefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-44 - Time within which to submit necessary information."><meta property="og:description" content="SDLRC Codified Law 58-17H-44 - Time within which to submit necessary information."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-44"><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="se52c731b515c42a4b182fce1206027cbNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-44" rel="noopener"><span class="se52c731b515c42a4b182fce1206027cbSENU">58-17H-44</span></a><span xml:space="preserve" class="se52c731b515c42a4b182fce1206027cbSENU">. </span><span class="se52c731b515c42a4b182fce1206027cbCL">Time within which to submit necessary information.</span></p><p dir="ltr" class="se52c731b515c42a4b182fce1206027cbNormal-000000"><span xml:space="preserve" class="se52c731b515c42a4b182fce1206027cbDefaultParagraphFont">The health carrier shall provide the covered person or, if applicable, the covered person's authorized representative, a reasonable period of time to submit the necessary information, taking into account the circumstances, but in no event less than forty-eight hours after the date of notifying the covered person or the covered person's authorized representative of the failure to submit sufficient information, as provided in §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-41" rel="noopener"><span class="se52c731b515c42a4b182fce1206027cbDefaultParagraphFont">58-17H-41</span></a><span xml:space="preserve" class="se52c731b515c42a4b182fce1206027cbDefaultParagraphFont"> and </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-42" rel="noopener"><span class="se52c731b515c42a4b182fce1206027cbDefaultParagraphFont">58-17H-42</span></a><span class="se52c731b515c42a4b182fce1206027cbDefaultParagraphFont">.</span></p><p dir="ltr" class="se52c731b515c42a4b182fce1206027cbNormal"><span xml:space="preserve" class="se52c731b515c42a4b182fce1206027cb000001"> </span></p><p dir="ltr" class="se52c731b515c42a4b182fce1206027cbNormal"><span class="se52c731b515c42a4b182fce1206027cbSCL">Source:</span><span xml:space="preserve" class="se52c731b515c42a4b182fce1206027cbSCL-000002"> SL 2011, ch 219, § 69.</span></p><p dir="ltr" class="se52c731b515c42a4b182fce1206027cbNormal"><span xml:space="preserve" class="se52c731b515c42a4b182fce1206027cb000001"> </span></p><p dir="ltr" class="se52c731b515c42a4b182fce1206027cbNormal"><span xml:space="preserve" class="se52c731b515c42a4b182fce1206027cbDefaultParagraphFont-000003">Commission Note: </span><span class="se52c731b515c42a4b182fce1206027cbDefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s942b41e6776e40a6b0e175237ccc44a8Normal { 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.s942b41e6776e40a6b0e175237ccc44a8SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s942b41e6776e40a6b0e175237ccc44a8CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s942b41e6776e40a6b0e175237ccc44a8Normal-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.s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s942b41e6776e40a6b0e175237ccc44a8Normal-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.s942b41e6776e40a6b0e175237ccc44a8Normal-000002 { 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.s942b41e6776e40a6b0e175237ccc44a8000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s942b41e6776e40a6b0e175237ccc44a8SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s942b41e6776e40a6b0e175237ccc44a8SCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-45 - Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification."><meta property="og:description" content="SDLRC Codified Law 58-17H-45 - Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-45"><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="s942b41e6776e40a6b0e175237ccc44a8Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-45" rel="noopener"><span class="s942b41e6776e40a6b0e175237ccc44a8SENU">58-17H-45</span></a><span xml:space="preserve" class="s942b41e6776e40a6b0e175237ccc44a8SENU">. </span><span class="s942b41e6776e40a6b0e175237ccc44a8CL">Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.</span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal-000000"><span class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">The health carrier shall notify the covered person or, if applicable, the covered person's authorized representative, of its determination with respect to the urgent care request as soon as possible, but in no event more than forty-eight hours after the earlier of:</span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal-000001"><span class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">(1)    The health carrier's receipt of the requested specified information; or</span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal-000001"><span class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">(2)    The end of the period provided for the covered person or, if applicable, the covered person's authorized representative, to submit the requested specified information.</span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal-000002"><span xml:space="preserve" class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">If the covered person or the covered person's authorized representative fails to submit the information before the end of the period of the extension, as specified in § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-44" rel="noopener"><span class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">58-17H-44</span></a><span xml:space="preserve" class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">, the health carrier may deny the certification of the requested benefit. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-32" rel="noopener"><span class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">58-17H-32</span></a><span class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">.</span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal"><span xml:space="preserve" class="s942b41e6776e40a6b0e175237ccc44a8000003"> </span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal"><span class="s942b41e6776e40a6b0e175237ccc44a8SCL">Source:</span><span xml:space="preserve" class="s942b41e6776e40a6b0e175237ccc44a8SCL-000004"> SL 2011, ch 219, § 70.</span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal"><span xml:space="preserve" class="s942b41e6776e40a6b0e175237ccc44a8000003"> </span></p><p dir="ltr" class="s942b41e6776e40a6b0e175237ccc44a8Normal"><span xml:space="preserve" class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont-000005">Commission Note: </span><span class="s942b41e6776e40a6b0e175237ccc44a8DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s9c6e4d99d92f443bb967a287c4240460Normal { 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.s9c6e4d99d92f443bb967a287c4240460SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s9c6e4d99d92f443bb967a287c4240460CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s9c6e4d99d92f443bb967a287c4240460Normal-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.s9c6e4d99d92f443bb967a287c4240460DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s9c6e4d99d92f443bb967a287c4240460000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s9c6e4d99d92f443bb967a287c4240460SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s9c6e4d99d92f443bb967a287c4240460SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s9c6e4d99d92f443bb967a287c4240460DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-46 - Concurrent review urgent care requests--Extended care requests--Time for determination and notice."><meta property="og:description" content="SDLRC Codified Law 58-17H-46 - Concurrent review urgent care requests--Extended care requests--Time for determination and notice."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-46"><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="s9c6e4d99d92f443bb967a287c4240460Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-46" rel="noopener"><span class="s9c6e4d99d92f443bb967a287c4240460SENU">58-17H-46</span></a><span xml:space="preserve" class="s9c6e4d99d92f443bb967a287c4240460SENU">. </span><span class="s9c6e4d99d92f443bb967a287c4240460CL">Concurrent review urgent care requests--Extended care requests--Time for determination and notice.</span></p><p dir="ltr" class="s9c6e4d99d92f443bb967a287c4240460Normal-000000"><span xml:space="preserve" class="s9c6e4d99d92f443bb967a287c4240460DefaultParagraphFont">For concurrent review urgent care requests involving a request by the covered person or the covered person's authorized representative to extend the course of treatment beyond the initial period of time or the number of treatments, if the request is made at least twenty-four hours prior to the expiration of the prescribed period of time or number of treatments, the health carrier shall make a determination with respect to the request and notify the covered person or, if applicable, the covered person's authorized representative, of the determination, whether it is an adverse determination or not, as soon as possible, taking into account the covered person's medical condition but in no event more than twenty-four hours after the date of the health carrier's receipt of the request. If the health carrier's determination is an adverse determination, the health carrier shall provide notice of the adverse determination in accordance with § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-48" rel="noopener"><span class="s9c6e4d99d92f443bb967a287c4240460DefaultParagraphFont">58-17H-48</span></a><span class="s9c6e4d99d92f443bb967a287c4240460DefaultParagraphFont">.</span></p><p dir="ltr" class="s9c6e4d99d92f443bb967a287c4240460Normal"><span xml:space="preserve" class="s9c6e4d99d92f443bb967a287c4240460000001"> </span></p><p dir="ltr" class="s9c6e4d99d92f443bb967a287c4240460Normal"><span class="s9c6e4d99d92f443bb967a287c4240460SCL">Source:</span><span xml:space="preserve" class="s9c6e4d99d92f443bb967a287c4240460SCL-000002"> SL 2011, ch 219, § 71.</span></p><p dir="ltr" class="s9c6e4d99d92f443bb967a287c4240460Normal"><span xml:space="preserve" class="s9c6e4d99d92f443bb967a287c4240460000001"> </span></p><p dir="ltr" class="s9c6e4d99d92f443bb967a287c4240460Normal"><span xml:space="preserve" class="s9c6e4d99d92f443bb967a287c4240460DefaultParagraphFont-000003">Commission Note: </span><span class="s9c6e4d99d92f443bb967a287c4240460DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sdae06ed87369402688956427b8c93b77Normal { 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.sdae06ed87369402688956427b8c93b77SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sdae06ed87369402688956427b8c93b77CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sdae06ed87369402688956427b8c93b77Normal-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.sdae06ed87369402688956427b8c93b77DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sdae06ed87369402688956427b8c93b77000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sdae06ed87369402688956427b8c93b77SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sdae06ed87369402688956427b8c93b77SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sdae06ed87369402688956427b8c93b77DefaultParagraphFont-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-47 - Calculation of time periods for determination."><meta property="og:description" content="SDLRC Codified Law 58-17H-47 - Calculation of time periods for determination."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-47"><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="sdae06ed87369402688956427b8c93b77Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-47" rel="noopener"><span class="sdae06ed87369402688956427b8c93b77SENU">58-17H-47</span></a><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77SENU">. </span><span class="sdae06ed87369402688956427b8c93b77CL">Calculation of time periods for determination.</span></p><p dir="ltr" class="sdae06ed87369402688956427b8c93b77Normal-000000"><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont">For purposes of calculating the time periods within which a determination is required to be made under §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-43" rel="noopener"><span class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont">58-17H-43</span></a><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-45" rel="noopener"><span class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont">58-17H-45</span></a><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont">, inclusive, the time period within which the determination is required to be made shall begin on the date the request is filed with the health carrier in accordance with the health carrier's procedures established pursuant to § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-16" rel="noopener"><span class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont">58-17H-16</span></a><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont"> for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.</span></p><p dir="ltr" class="sdae06ed87369402688956427b8c93b77Normal"><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77000001"> </span></p><p dir="ltr" class="sdae06ed87369402688956427b8c93b77Normal"><span class="sdae06ed87369402688956427b8c93b77SCL">Source:</span><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77SCL-000002"> SL 2011, ch 219, § 72.</span></p><p dir="ltr" class="sdae06ed87369402688956427b8c93b77Normal"><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77000001"> </span></p><p dir="ltr" class="sdae06ed87369402688956427b8c93b77Normal"><span xml:space="preserve" class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont-000003">Commission Note: </span><span class="sdae06ed87369402688956427b8c93b77DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</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; } </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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s8974b8debec14d59b4c7027c4ce30e05Normal { 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.s8974b8debec14d59b4c7027c4ce30e05SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s8974b8debec14d59b4c7027c4ce30e05CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s8974b8debec14d59b4c7027c4ce30e05Normal-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.s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s8974b8debec14d59b4c7027c4ce30e05Normal-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.s8974b8debec14d59b4c7027c4ce30e05Normal-000002 { 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.s8974b8debec14d59b4c7027c4ce30e05000003 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s8974b8debec14d59b4c7027c4ce30e05SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s8974b8debec14d59b4c7027c4ce30e05SCL-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont-000005 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } </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-49 - Promulgation of rules."><meta property="og:description" content="SDLRC Codified Law 58-17H-49 - Promulgation of rules."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-49"><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="s8974b8debec14d59b4c7027c4ce30e05Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-49" rel="noopener"><span class="s8974b8debec14d59b4c7027c4ce30e05SENU">58-17H-49</span></a><span xml:space="preserve" class="s8974b8debec14d59b4c7027c4ce30e05SENU">. </span><span class="s8974b8debec14d59b4c7027c4ce30e05CL">Promulgation of rules.</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal-000000"><span xml:space="preserve" class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">The director may, after consultation with the secretary, promulgate rules, pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=1-26" rel="noopener"><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">1-26</span></a><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">, to carry out the provisions of this chapter. The rules shall provide for a timely administration of utilization review by the public and assure that utilization review decisions are made in a fair and clinically acceptable manner. The rules may include the following:</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal-000001"><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">(1)    Definition of terms;</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal-000001"><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">(2)    Timing, form, and content of reports;</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal-000001"><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">(3)    Application of clinical criteria as it relates to utilization review;</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal-000001"><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">(4)    Written determinations; and</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal-000001"><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">(5)    Utilization review procedures.</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal-000002"><span xml:space="preserve" class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">The director may promulgate rules, pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=1-26" rel="noopener"><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">1-26</span></a><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">, pertaining to claims for group disability income plans. The rules shall be consistent with applicable federal requirements included in 29 CFR Part 2560 as amended to January 1, 2011.</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal"><span xml:space="preserve" class="s8974b8debec14d59b4c7027c4ce30e05000003"> </span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal"><span class="s8974b8debec14d59b4c7027c4ce30e05SCL">Source:</span><span xml:space="preserve" class="s8974b8debec14d59b4c7027c4ce30e05SCL-000004"> SL 2011, ch 219, § 74.</span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal"><span xml:space="preserve" class="s8974b8debec14d59b4c7027c4ce30e05000003"> </span></p><p dir="ltr" class="s8974b8debec14d59b4c7027c4ce30e05Normal"><span xml:space="preserve" class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont-000005">Commission Note: </span><span class="s8974b8debec14d59b4c7027c4ce30e05DefaultParagraphFont">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><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s2084298Normal { 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.s2084298SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2084298CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s2084298Normal-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.s2084298DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2084298000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2084298SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2084298SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-50 - Coverage for cancer treatment medication."><meta property="og:description" content="SDLRC Codified Law 58-17H-50 - Coverage for cancer treatment medication."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes?Statute=58-17H-50"><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="s2084298Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-50" rel="noopener"><span class="s2084298SENU">58-17H-50</span></a><span xml:space="preserve" class="s2084298SENU">. </span><span class="s2084298CL">Coverage for cancer treatment medication.</span></p><p dir="ltr" class="s2084298Normal-000000"><span xml:space="preserve" class="s2084298DefaultParagraphFont">Any health benefit plan as defined in § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-2" rel="noopener"><span class="s2084298DefaultParagraphFont">58-17H-2</span></a><span xml:space="preserve" class="s2084298DefaultParagraphFont"> that provides benefits for injected or intravenously administered cancer treatment medication used to kill or slow the growth of cancerous cells shall provide no less favorable benefits for prescribed, orally administered anticancer medication covered by the plan, regardless of the formulation or benefit category determination by the health plan.</span></p><p dir="ltr" class="s2084298Normal"><span xml:space="preserve" class="s2084298000001"> </span></p><p dir="ltr" class="s2084298Normal"><span class="s2084298SCL">Source:</span><span xml:space="preserve" class="s2084298SCL-000002"> SL 2015, ch 252, § 1, eff. Jan. 1, 2016.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s2084300Normal { 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.s2084300SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2084300CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s2084300Normal-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.s2084300DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s2084300Normal-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; } span.s2084300000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2084300SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2084300SCL-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-51 - Reclassification of benefits with respect to cancer treatment medications."><meta property="og:description" content="SDLRC Codified Law 58-17H-51 - Reclassification of benefits with respect to cancer treatment medications."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes?Statute=58-17H-51"><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="s2084300Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-51" rel="noopener"><span class="s2084300SENU">58-17H-51</span></a><span xml:space="preserve" class="s2084300SENU">. </span><span class="s2084300CL">Reclassification of benefits with respect to cancer treatment medications.</span></p><p dir="ltr" class="s2084300Normal-000000"><span class="s2084300DefaultParagraphFont">A health carrier may not reclassify benefits with respect to cancer treatment medications or increase a copayment, deductible, or coinsurance amount for covered cancer treatment medications that are injected or intravenously administered unless:</span></p><p dir="ltr" class="s2084300Normal-000001"><span xml:space="preserve" class="s2084300DefaultParagraphFont">(1)    The increase is applied generally to other medical or pharmaceutical benefits covered under the plan and is not done to circumvent § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-50" rel="noopener"><span class="s2084300DefaultParagraphFont">58-17H-50</span></a><span class="s2084300DefaultParagraphFont">;</span></p><p dir="ltr" class="s2084300Normal-000001"><span xml:space="preserve" class="s2084300DefaultParagraphFont">(2)    The reclassification of benefits with respect to cancer treatment medications is done in a manner that is consistent with §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-50" rel="noopener"><span class="s2084300DefaultParagraphFont">58-17H-50</span></a><span xml:space="preserve" class="s2084300DefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-52" rel="noopener"><span class="s2084300DefaultParagraphFont">58-17H-52</span></a><span class="s2084300DefaultParagraphFont">, inclusive; or</span></p><p dir="ltr" class="s2084300Normal-000001"><span class="s2084300DefaultParagraphFont">(3)    A health carrier is applying cost-sharing increases consistent with the annual increases in the cost of health care.</span></p><p dir="ltr" class="s2084300Normal"><span xml:space="preserve" class="s2084300000002"> </span></p><p dir="ltr" class="s2084300Normal"><span class="s2084300SCL">Source:</span><span xml:space="preserve" class="s2084300SCL-000003"> SL 2015, ch 252, § 2, eff. Jan. 1, 2016.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s2084301Normal { 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.s2084301SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2084301CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s2084301Normal-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.s2084301DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2084301000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s2084301SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s2084301SCL-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-52 - Medical management practices complying with chapter."><meta property="og:description" content="SDLRC Codified Law 58-17H-52 - Medical management practices complying with chapter."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes?Statute=58-17H-52"><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="s2084301Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-52" rel="noopener"><span class="s2084301SENU">58-17H-52</span></a><span xml:space="preserve" class="s2084301SENU">. </span><span class="s2084301CL">Medical management practices complying with chapter.</span></p><p dir="ltr" class="s2084301Normal-000000"><span xml:space="preserve" class="s2084301DefaultParagraphFont">Nothing in §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-50" rel="noopener"><span class="s2084301DefaultParagraphFont">58-17H-50</span></a><span xml:space="preserve" class="s2084301DefaultParagraphFont"> and </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-51" rel="noopener"><span class="s2084301DefaultParagraphFont">58-17H-51</span></a><span xml:space="preserve" class="s2084301DefaultParagraphFont"> prohibits a health carrier from performing medical management practices that comply with the provisions of this chapter.</span></p><p dir="ltr" class="s2084301Normal"><span xml:space="preserve" class="s2084301000001"> </span></p><p dir="ltr" class="s2084301Normal"><span class="s2084301SCL">Source:</span><span xml:space="preserve" class="s2084301SCL-000002"> SL 2015, ch 252, § 3, eff. Jan. 1, 2016.</span></p></div></body></html><br /><hr><br /><html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta charset="UTF-8" /> <meta http-equiv='content-language' content='en-us'/><title>SDLRC - Codified Law 58-17H - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title> <meta name="Generator" content="PowerTools for Open XML" /> <style>span { white-space: pre-wrap; } p.pt-Normal { 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.pt-SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.pt-Statute { 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.pt-DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.pt-000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.pt-NoIndent { text-indent: 0.00in; 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.pt-DefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-SCL { 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="pt-Normal"> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17H-53"> <span class="pt-SENU">58-17H-53</span> </a> <span xml:space="preserve" class="pt-SENU">. </span> <span class="pt-CL">Step therapy protocols.</span> </p> <p dir="ltr" class="pt-Statute"> <span class="pt-DefaultParagraphFont">A health carrier, health benefit plan, or utilization review organization shall consider available recognized evidence-based and peer-reviewed clinical practice guidelines when establishing a step therapy protocol. Upon written request of a covered person, a health carrier, health benefit plan, or utilization review organization shall provide any clinical review criteria applicable to a specific prescription drug covered by the health carrier, health benefit plan, or utilization review organization.</span> </p> <p dir="ltr" class="pt-Normal"> <span xml:space="preserve" class="pt-000000"> </span> </p> <p dir="ltr" class="pt-NoIndent"> <span xml:space="preserve" class="pt-DefaultParagraphFont-000001">Source: </span> <span class="pt-SCL">SL 2020, ch 209, § 2.</span> </p> </div> </body> </html><br /><hr><br /><html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta charset="UTF-8" /> <meta http-equiv='content-language' content='en-us'/><title>SDLRC - Codified Law 58-17H - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title> <meta name="Generator" content="PowerTools for Open XML" /> <style>span { white-space: pre-wrap; } p.pt-Normal { 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.pt-SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.pt-Statute { 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.pt-DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.pt-000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.pt-NoIndent { text-indent: 0.00in; 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.pt-DefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-SCL { 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="pt-Normal"> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17H-54"> <span class="pt-SENU">58-17H-54</span> </a> <span xml:space="preserve" class="pt-SENU">. </span> <span class="pt-CL">Step therapy protocols--Process--Transparency.</span> </p> <p dir="ltr" class="pt-Statute"> <span class="pt-DefaultParagraphFont">When coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization through the use of a step therapy protocol, the covered person and the prescribing health care professional shall have access to a clear, readily accessible, and convenient process to request a step therapy override exception. A health carrier, health benefit plan, or utilization review organization may use its existing medical exceptions process to satisfy this requirement. The process used shall be easily accessible on the internet site of the health carrier, health benefit plan, or utilization review organization.</span> </p> <p dir="ltr" class="pt-Normal"> <span xml:space="preserve" class="pt-000000"> </span> </p> <p dir="ltr" class="pt-NoIndent"> <span xml:space="preserve" class="pt-DefaultParagraphFont-000001">Source: </span> <span class="pt-SCL">SL 2020, ch 209, § 3.</span> </p> </div> </body> </html><br /><hr><br /><html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta charset="UTF-8" /> <meta http-equiv='content-language' content='en-us'/><title>SDLRC - Codified Law 58-17H - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title> <meta name="Generator" content="PowerTools for Open XML" /> <style>span { white-space: pre-wrap; } p.pt-Normal { 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.pt-SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.pt-Statute { 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.pt-DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.pt-StatuteNumber1 { margin-left: 0.75in; text-indent: -0.50in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } span.pt-DefaultParagraphFont-000000 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; display: inline-block; text-indent: 0; width: 0.500in; } p.pt-StatuteNumber2 { margin-left: 1.25in; text-indent: -0.50in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } span.pt-000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.pt-NoIndent { text-indent: 0.00in; 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.pt-DefaultParagraphFont-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-SCL { 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="pt-Normal"> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17H-55"> <span class="pt-SENU">58-17H-55</span> </a> <span xml:space="preserve" class="pt-SENU">. </span> <span class="pt-CL">Step therapy override exceptions.</span> </p> <p dir="ltr" class="pt-Statute"> <span class="pt-DefaultParagraphFont">A step therapy override exception shall be approved by a health carrier, health benefit plan, or utilization review organization if any of the following circumstances apply:</span> </p> <p dir="ltr" class="pt-StatuteNumber1"> <span class="pt-DefaultParagraphFont-000000">(1)</span> <span class="pt-DefaultParagraphFont">The prescription drug required under the step therapy protocol is contraindicated pursuant to the drug manufacturer's prescribing information for the drug or, due to a documented adverse event with a previous use or a documented medical condition, including a comorbid condition, is likely to do any of the following:</span> </p> <p dir="ltr" class="pt-StatuteNumber2"> <span class="pt-DefaultParagraphFont-000000">(a)</span> <span class="pt-DefaultParagraphFont">Cause an adverse reaction to a covered person;</span> </p> <p dir="ltr" class="pt-StatuteNumber2"> <span class="pt-DefaultParagraphFont-000000">(b)</span> <span class="pt-DefaultParagraphFont">Decrease the ability of a covered person to achieve or maintain reasonable functional ability in performing daily activities;</span> </p> <p dir="ltr" class="pt-StatuteNumber2"> <span class="pt-DefaultParagraphFont-000000">(c)</span> <span class="pt-DefaultParagraphFont">Cause physical or mental harm to a covered person;</span> </p> <p dir="ltr" class="pt-StatuteNumber1"> <span class="pt-DefaultParagraphFont-000000">(2)</span> <span class="pt-DefaultParagraphFont">The prescription drug required under the step therapy protocol is expected to be ineffective based on the known clinical characteristics of the covered person, such as the covered person's adherence to or compliance with the covered person's individual plan of care, and any of the following:</span> </p> <p dir="ltr" class="pt-StatuteNumber2"> <span class="pt-DefaultParagraphFont-000000">(a)</span> <span class="pt-DefaultParagraphFont">The known characteristics of the prescription drug regimen as described in peer-reviewed literature or in the manufacturer's prescribing information for the drug;</span> </p> <p dir="ltr" class="pt-StatuteNumber2"> <span class="pt-DefaultParagraphFont-000000">(b)</span> <span class="pt-DefaultParagraphFont">The health care professional's medical judgment based on clinical practice guidelines or peer-reviewed journals;</span> </p> <p dir="ltr" class="pt-StatuteNumber2"> <span class="pt-DefaultParagraphFont-000000">(c)</span> <span class="pt-DefaultParagraphFont">The covered person's documented experience with the prescription drug regimen;</span> </p> <p dir="ltr" class="pt-StatuteNumber1"> <span class="pt-DefaultParagraphFont-000000">(3)</span> <span class="pt-DefaultParagraphFont">The covered person has had a trial of a therapeutically equivalent dose of the prescription drug under the step therapy protocol while under the covered person's current or previous health benefit plan for a period of time to allow for a positive treatment outcome, and such prescription drug was discontinued by the covered person's health care professional due to lack of effectiveness;</span> </p> <p dir="ltr" class="pt-StatuteNumber1"> <span class="pt-DefaultParagraphFont-000000">(4)</span> <span class="pt-DefaultParagraphFont">The covered person is currently receiving a positive therapeutic outcome on a prescription drug selected by the covered person's health care professional for the medical condition under consideration while under the covered person's current or previous health benefit plan. This subdivision may not be construed to encourage the use of a pharmaceutical sample for the sole purpose of meeting the requirements for a step therapy override exception.</span> </p> <p dir="ltr" class="pt-Statute"> <span class="pt-DefaultParagraphFont">Upon approval of a step therapy override exception, the health carrier, health benefit plan, or utilization review organization shall authorize coverage for the prescription drug selected by the covered person's prescribing health care professional if the prescription drug is a covered prescription drug under the covered person's health benefit plan.</span> </p> <p dir="ltr" class="pt-Statute"> <span class="pt-DefaultParagraphFont">Except in the case of an urgent care request, a health carrier, health benefit plan, or utilization review organization shall make a determination to approve or deny a request for a step therapy override exception within five calendar days after receipt of complete, clinically relevant written documentation supporting a step therapy override exception under subdivisions (1) through (4) of this section. In the case of an urgent care request, a health carrier, health benefit plan, or utilization review organization shall approve or deny a request for a step therapy override exception within seventy-two hours after receipt of such documentation. If a request for a step therapy override exception is incomplete or additional clinically relevant information is required, the health carrier, health benefit plan, or utilization review organization may request such information within the applicable time period provided in this section. Once the information is submitted, the applicable time period for approval or denial shall begin again. If a health carrier, health plan, or utilization review organization fails to respond to the request for a step override exception within the applicable time, the step therapy override exception shall be deemed granted.</span> </p> <p dir="ltr" class="pt-Statute"> <span xml:space="preserve" class="pt-DefaultParagraphFont">If a nonurgent care request for a step therapy override exception is denied, the denial is an adverse determination and the health carrier, health benefit plan, or utilization review organization shall provide notification of adverse determination pursuant to § </span> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17H-32"> <span class="pt-DefaultParagraphFont">58-17H-32</span> </a> <span xml:space="preserve" class="pt-DefaultParagraphFont">. If an urgent care request is denied, the health carrier, health benefit plan, or utilization review organization shall provide notification of adverse determination pursuant to § </span> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17H-48"> <span class="pt-DefaultParagraphFont">58-17H-48</span> </a> <span xml:space="preserve" class="pt-DefaultParagraphFont">. Any denial of a request for a step therapy override exception is subject to the grievance procedures under chapter </span> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17I"> <span class="pt-DefaultParagraphFont">58-17I</span> </a> <span class="pt-DefaultParagraphFont">.</span> </p> <p dir="ltr" class="pt-Normal"> <span xml:space="preserve" class="pt-000001"> </span> </p> <p dir="ltr" class="pt-NoIndent"> <span xml:space="preserve" class="pt-DefaultParagraphFont-000002">Source: </span> <span class="pt-SCL">SL 2020, ch 209, § 4.</span> </p> </div> </body> </html><br /><hr><br /><html xmlns="http://www.w3.org/1999/xhtml"> <head> <meta charset="UTF-8" /> <meta http-equiv='content-language' content='en-us'/><title>SDLRC - Codified Law 58-17H - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title> <meta name="Generator" content="PowerTools for Open XML" /> <style>span { white-space: pre-wrap; } p.pt-Normal { 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.pt-SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.pt-Statute { 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.pt-DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.pt-StatuteNumber1 { margin-left: 0.75in; text-indent: -0.50in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } span.pt-DefaultParagraphFont-000000 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; display: inline-block; text-indent: 0; width: 0.500in; } span.pt-000001 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.pt-NoIndent { text-indent: 0.00in; 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.pt-DefaultParagraphFont-000002 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.pt-SCL { 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="pt-Normal"> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17H-56"> <span class="pt-SENU">58-17H-56</span> </a> <span xml:space="preserve" class="pt-SENU">. </span> <span class="pt-CL">Limitations.</span> </p> <p dir="ltr" class="pt-Statute"> <span xml:space="preserve" class="pt-DefaultParagraphFont">Nothing in §§ </span> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=58-17H-53"> <span class="pt-DefaultParagraphFont">58-17H-53</span> </a> <span xml:space="preserve" class="pt-DefaultParagraphFont"> to 55-17H-56 shall be construed to prevent:</span> </p> <p dir="ltr" class="pt-StatuteNumber1"> <span class="pt-DefaultParagraphFont-000000">(1)</span> <span xml:space="preserve" class="pt-DefaultParagraphFont">A health carrier, health benefit plan, or utilization review organization from requiring a covered person to try a prescription drug with the same generic name and demonstrated bioavailability or biological product that is an interchangeable biological product pursuant to §§ </span> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=36-11-46.1"> <span class="pt-DefaultParagraphFont">36-11-46.1</span> </a> <span xml:space="preserve" class="pt-DefaultParagraphFont"> and </span> <a href="https://sdlegislature.gov/Statutes/Codified_Laws/DisplayStatute.aspx?Type=Statute&amp;Statute=36-11-46.9"> <span class="pt-DefaultParagraphFont">36-11-46.9</span> </a> <span xml:space="preserve" class="pt-DefaultParagraphFont"> before providing coverage for the equivalent branded prescription drug;</span> </p> <p dir="ltr" class="pt-StatuteNumber1"> <span class="pt-DefaultParagraphFont-000000">(2)</span> <span class="pt-DefaultParagraphFont">A health care professional from prescribing a prescription drug that is determined to be medically appropriate.</span> </p> <p dir="ltr" class="pt-Normal"> <span xml:space="preserve" class="pt-000001"> </span> </p> <p dir="ltr" class="pt-NoIndent"> <span xml:space="preserve" class="pt-DefaultParagraphFont-000002">Source: </span> <span class="pt-SCL">SL 2020, ch 209, § 5.</span> </p> </div> </body> </html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s4a726c6bc6b549d79fc0a8ccf6273b3eNormal { 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.s4a726c6bc6b549d79fc0a8ccf6273b3eSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s4a726c6bc6b549d79fc0a8ccf6273b3eCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s4a726c6bc6b549d79fc0a8ccf6273b3eStatute { 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.s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s4a726c6bc6b549d79fc0a8ccf6273b3eStatuteNumber1 { margin-left: 0.75in; text-indent: -0.50in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } span.s4a726c6bc6b549d79fc0a8ccf6273b3e000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s4a726c6bc6b549d79fc0a8ccf6273b3eNoIndent { text-indent: 0.00in; 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.s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s4a726c6bc6b549d79fc0a8ccf6273b3eSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-57 - Utilization review organization or health carrier--Annual review--Report--Contents--Publication."><meta property="og:description" content="SDLRC Codified Law 58-17H-57 - Utilization review organization or health carrier--Annual review--Report--Contents--Publication."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-57"><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="s4a726c6bc6b549d79fc0a8ccf6273b3eNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-57" rel="noopener"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eSENU">58-17H-57</span></a><span xml:space="preserve" class="s4a726c6bc6b549d79fc0a8ccf6273b3eSENU">. </span><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eCL">Utilization review organization or health carrier--Annual review--Report--Contents--Publication.</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatute"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">A utilization review organization or health carrier shall conduct an annual review and submit the findings in a report to the Division of Insurance, at the time and in the manner directed by the division.</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatute"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">The report must contain the following information for the previous calendar year, aggregated for all health care services or items:</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatuteNumber1"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">(1)    The number and percentage of urgent prior authorization requests that the utilization review organization or health carrier approved;</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatuteNumber1"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">(2)    The number and percentage of urgent prior authorization requests that the utilization review organization or health carrier denied;</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatuteNumber1"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">(3)    The number and percentage of nonurgent prior authorization requests that the utilization review organization or health carrier approved;</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatuteNumber1"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">(4)    The number and percentage of nonurgent prior authorization requests that the utilization review organization or health carrier denied;</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatuteNumber1"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">(5)    The average and median time that elapsed between the submission of a prior authorization request and a determination by the utilization review organization or health carrier; and</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatuteNumber1"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">(6)    The average and median time that elapsed between the submission of an urgent prior authorization request and a determination by the utilization review organization or health carrier.</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eStatute"><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont">The division shall publish the report required by this section, on the division's website, within sixty days after receiving the report.</span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eNormal"><span xml:space="preserve" class="s4a726c6bc6b549d79fc0a8ccf6273b3e000000"> </span></p><p dir="ltr" class="s4a726c6bc6b549d79fc0a8ccf6273b3eNoIndent"><span xml:space="preserve" class="s4a726c6bc6b549d79fc0a8ccf6273b3eDefaultParagraphFont-000001">Source: </span><span class="s4a726c6bc6b549d79fc0a8ccf6273b3eSCL">SL 2026, ch 201, § 1.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sa8679f3d83554735a10c124e5346b9e9Normal { 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.sa8679f3d83554735a10c124e5346b9e9SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sa8679f3d83554735a10c124e5346b9e9CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sa8679f3d83554735a10c124e5346b9e9Statute { 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.sa8679f3d83554735a10c124e5346b9e9DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sa8679f3d83554735a10c124e5346b9e9000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sa8679f3d83554735a10c124e5346b9e9NoIndent { text-indent: 0.00in; 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.sa8679f3d83554735a10c124e5346b9e9DefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sa8679f3d83554735a10c124e5346b9e9SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-58 - Utilization review organization or health carrier--Health care service review--Prior authorization requirement elimination."><meta property="og:description" content="SDLRC Codified Law 58-17H-58 - Utilization review organization or health carrier--Health care service review--Prior authorization requirement elimination."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-58"><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="sa8679f3d83554735a10c124e5346b9e9Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-58" rel="noopener"><span class="sa8679f3d83554735a10c124e5346b9e9SENU">58-17H-58</span></a><span xml:space="preserve" class="sa8679f3d83554735a10c124e5346b9e9SENU">. </span><span class="sa8679f3d83554735a10c124e5346b9e9CL">Utilization review organization or health carrier--Health care service review--Prior authorization requirement elimination.</span></p><p dir="ltr" class="sa8679f3d83554735a10c124e5346b9e9Statute"><span class="sa8679f3d83554735a10c124e5346b9e9DefaultParagraphFont">A utilization review organization or health carrier shall annually review each health care service for which a health benefit plan requires prior authorization and shall eliminate the prior authorization requirement for any health care service if prior authorization requests are routinely approved with such frequency as to demonstrate that the prior authorization requirement does not promote health care quality or reduce health care spending, to a degree that justifies the plan's administrative costs associated with the prior authorization requirement.</span></p><p dir="ltr" class="sa8679f3d83554735a10c124e5346b9e9Normal"><span xml:space="preserve" class="sa8679f3d83554735a10c124e5346b9e9000000"> </span></p><p dir="ltr" class="sa8679f3d83554735a10c124e5346b9e9NoIndent"><span xml:space="preserve" class="sa8679f3d83554735a10c124e5346b9e9DefaultParagraphFont-000001">Source: </span><span class="sa8679f3d83554735a10c124e5346b9e9SCL">SL 2026, ch 201, § 2.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sdd86efb94d434e86b614130a7a32e2a7Normal { 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.sdd86efb94d434e86b614130a7a32e2a7SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sdd86efb94d434e86b614130a7a32e2a7CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sdd86efb94d434e86b614130a7a32e2a7Statute { 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.sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sdd86efb94d434e86b614130a7a32e2a7StatuteNumber1 { margin-left: 0.75in; text-indent: -0.50in; text-align: justify; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; margin-top: 0; margin-right: 0; margin-bottom: .001pt; } span.sdd86efb94d434e86b614130a7a32e2a7000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sdd86efb94d434e86b614130a7a32e2a7NoIndent { text-indent: 0.00in; 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.sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sdd86efb94d434e86b614130a7a32e2a7SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </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-59 - Utilization review organization or health carrier--Health care service review--Annual report--Contents--Publication."><meta property="og:description" content="SDLRC Codified Law 58-17H-59 - Utilization review organization or health carrier--Health care service review--Annual report--Contents--Publication."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-59"><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="sdd86efb94d434e86b614130a7a32e2a7Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-59" rel="noopener"><span class="sdd86efb94d434e86b614130a7a32e2a7SENU">58-17H-59</span></a><span xml:space="preserve" class="sdd86efb94d434e86b614130a7a32e2a7SENU">. </span><span class="sdd86efb94d434e86b614130a7a32e2a7CL">Utilization review organization or health carrier--Health care service review--Annual report--Contents--Publication.</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7Statute"><span xml:space="preserve" class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">A utilization review organization or health carrier shall submit an annual report to the Division of Insurance, at the time and in the manner requested by the division, regarding the review required in accordance with § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-58" rel="noopener"><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">58-17H-58</span></a><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">. The report must set forth:</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7StatuteNumber1"><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">(1)    The number of prior authorizations evaluated in accordance with the review;</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7StatuteNumber1"><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">(2)    The number of prior authorizations eliminated as a result of the review, and the reason for the elimination;</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7StatuteNumber1"><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">(3)    The list of prior authorizations that had at least eighty percent of all requests approved, during the preceding calendar year, for a specific health care service covered by the health benefit plan, but for which the prior authorization requirement was retained due to medical or scientific evidence that justified continuation of the requirement; and</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7StatuteNumber1"><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">(4)    The number of prior authorization requests that were submitted in the preceding calendar year for each eliminated prior authorization and the number of health care providers that had submitted a request for each eliminated prior authorization requirement.</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7Statute"><span xml:space="preserve" class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">With respect to each health care service for which prior authorization was eliminated under § </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-58" rel="noopener"><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">58-17H-58</span></a><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">, the report must provide data regarding any increase or decrease of ten percent or more, in the average number of claims submitted per health care provider, for that service, compared to the calendar year preceding the elimination.</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7Statute"><span class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont">The division shall publish the report required by this section on the division's website within sixty days after receiving the report.</span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7Normal"><span xml:space="preserve" class="sdd86efb94d434e86b614130a7a32e2a7000000"> </span></p><p dir="ltr" class="sdd86efb94d434e86b614130a7a32e2a7NoIndent"><span xml:space="preserve" class="sdd86efb94d434e86b614130a7a32e2a7DefaultParagraphFont-000001">Source: </span><span class="sdd86efb94d434e86b614130a7a32e2a7SCL">SL 2026, ch 201, § 3.</span></p></div></body></html><br /><hr><br /><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 - UTILIZATION REVIEW AND BENEFIT DETERMINATIONS</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.sb68a65fd51144ac29c3cde5eafe3ef5cNormal { 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.sb68a65fd51144ac29c3cde5eafe3ef5cSENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb68a65fd51144ac29c3cde5eafe3ef5cCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.sb68a65fd51144ac29c3cde5eafe3ef5cStatute { 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.sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sb68a65fd51144ac29c3cde5eafe3ef5c000000 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sb68a65fd51144ac29c3cde5eafe3ef5cNoIndent { text-indent: 0.00in; 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.sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont-000001 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sb68a65fd51144ac29c3cde5eafe3ef5cSCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; 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-60 - Utilization review organization or health carrier--Health care service--Excluded services."><meta property="og:description" content="SDLRC Codified Law 58-17H-60 - Utilization review organization or health carrier--Health care service--Excluded services."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17H-60"><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="sb68a65fd51144ac29c3cde5eafe3ef5cNormal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-60" rel="noopener"><span class="sb68a65fd51144ac29c3cde5eafe3ef5cSENU">58-17H-60</span></a><span xml:space="preserve" class="sb68a65fd51144ac29c3cde5eafe3ef5cSENU">. </span><span class="sb68a65fd51144ac29c3cde5eafe3ef5cCL">Utilization review organization or health carrier--Health care service--Excluded services.</span></p><p dir="ltr" class="sb68a65fd51144ac29c3cde5eafe3ef5cStatute"><span xml:space="preserve" class="sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont">For purposes of §§ </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-57" rel="noopener"><span class="sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont">58-17H-57</span></a><span xml:space="preserve" class="sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont"> to </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H-59" rel="noopener"><span class="sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont">58-17H-59</span></a><span class="sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont">, inclusive,  health care services do not include dental services, pharmaceutical services, or the provision of prescription drug products or supplies.</span></p><p dir="ltr" class="sb68a65fd51144ac29c3cde5eafe3ef5cNormal"><span xml:space="preserve" class="sb68a65fd51144ac29c3cde5eafe3ef5c000000"> </span></p><p dir="ltr" class="sb68a65fd51144ac29c3cde5eafe3ef5cNoIndent"><span xml:space="preserve" class="sb68a65fd51144ac29c3cde5eafe3ef5cDefaultParagraphFont-000001">Source: </span><span class="sb68a65fd51144ac29c3cde5eafe3ef5cSCL">SL 2026, ch 201, § 4.</span></p></div></body></html>