<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 58-17I-7 - Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review.</title><meta name="Generator" content="PowerTools for Open XML"><style>span { white-space: pre-wrap; } p.s65bc13df33ff443f93b101ab4d010341Normal { 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.s65bc13df33ff443f93b101ab4d010341SENU { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s65bc13df33ff443f93b101ab4d010341CL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } p.s65bc13df33ff443f93b101ab4d010341Normal-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.s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s65bc13df33ff443f93b101ab4d010341Normal-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.s65bc13df33ff443f93b101ab4d010341000002 { font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s65bc13df33ff443f93b101ab4d010341SCL { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s65bc13df33ff443f93b101ab4d010341SCL-000003 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont-000004 { font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } body { text-decoration-skip-ink: none; } </style><meta name="viewport" content="width=device-width, initial-scale=1"><meta name="twitter:card" content="summary"><meta property="og:title" content="SD 58-17I-7 - Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review."><meta property="og:description" content="SDLRC Codified Law 58-17I-7 - Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review."><meta property="og:type" content="website"><meta property="og:url" content="https://sdlegislature.gov/Statutes/58-17I-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="s65bc13df33ff443f93b101ab4d010341Normal"><a href="https://sdlegislature.gov/Statutes?Statute=58-17I-7" rel="noopener"><span class="s65bc13df33ff443f93b101ab4d010341SENU">58-17I-7</span></a><span xml:space="preserve" class="s65bc13df33ff443f93b101ab4d010341SENU">. </span><span class="s65bc13df33ff443f93b101ab4d010341CL">Review of adverse determination--Time for filing--Designation and notice of reviewers--Scope of review.</span></p><p dir="ltr" class="s65bc13df33ff443f93b101ab4d010341Normal-000000"><span xml:space="preserve" class="s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont">Within one hundred eighty days after the date of receipt of a notice of an adverse determination sent pursuant to chapter </span><a href="https://sdlegislature.gov/Statutes?Statute=58-17H" rel="noopener"><span class="s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont">58-17H</span></a><span class="s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont">, any covered person or the covered person's authorized representative may file a grievance with the health carrier requesting a first level review of the adverse determination. The health carrier shall provide the covered person with the name, address, and telephone number of a person or organizational unit designated to coordinate the first level review on behalf of the health carrier. In providing for a first level review under this section, the health carrier shall ensure that the review conducted in a manner under this section to ensure the independence and impartiality of the individuals involved in making the first level review decision. In ensuring the independence and impartiality of individuals involved in making the first level review decision, no health carrier may make decisions related to such individuals 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="s65bc13df33ff443f93b101ab4d010341Normal-000001"><span class="s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont">The health carrier shall designate one or more health care providers who have appropriate training and experience in the field of medicine involved in the medical judgment to evaluate the adverse determination. No health care provider may have been involved in the initial adverse determination. In conducting the review, a reviewer shall take into consideration all comments, documents, records, and other information regarding the request for services submitted by the covered person or the covered person's authorized representative, without regard to whether the information was submitted or considered in making the initial adverse determination.</span></p><p dir="ltr" class="s65bc13df33ff443f93b101ab4d010341Normal"><span xml:space="preserve" class="s65bc13df33ff443f93b101ab4d010341000002"> </span></p><p dir="ltr" class="s65bc13df33ff443f93b101ab4d010341Normal"><span class="s65bc13df33ff443f93b101ab4d010341SCL">Source:</span><span xml:space="preserve" class="s65bc13df33ff443f93b101ab4d010341SCL-000003"> SL 2011, ch 219, § 79.</span></p><p dir="ltr" class="s65bc13df33ff443f93b101ab4d010341Normal"><span xml:space="preserve" class="s65bc13df33ff443f93b101ab4d010341000002"> </span></p><p dir="ltr" class="s65bc13df33ff443f93b101ab4d010341Normal"><span xml:space="preserve" class="s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont-000004">Commission Note: </span><span class="s65bc13df33ff443f93b101ab4d010341DefaultParagraphFont">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>