20:06:47:02. Establishment of
claims procedures. Any plan providing disability benefits shall establish
and maintain reasonable claim procedures. The procedures shall include the
description of all claim procedures including, but not limited to, any
procedures for obtaining prior authorization as a prerequisite for obtaining a
benefit and adverse determination review procedures;
processes and safeguards to ensure consistent benefit determinations for
regard to voluntary appeal:
plan waives any right to assert that a covered person has failed to exhaust
administrative remedies because the claimant did not elect to submit a benefit
dispute to any such voluntary level of appeal provided by the plan;
plan agrees that any statute of limitations or other defense based on
timeliness is tolled during the time that any such voluntary appeal is pending;
plan provides that a covered person may elect to submit a benefit dispute to
such voluntary level of appeal only after the exhaustion of the appeals; and
plan provides to any covered person, upon request, sufficient information
relating to the voluntary level of appeal to enable the covered person to make
an informed judgment about whether to submit a benefit dispute to the voluntary
level of appeal, including a statement that the decision of a covered person as
to whether or not to submit a benefit dispute to the voluntary level of appeal
will have no effect on the covered person's right to representation, the
process for selecting the decision maker, and the circumstances, if any, that
may affect the impartiality of the decision maker, such as any financial or
personal interests in the result or any past or present relationship with any
party to the review process.
Source: 30 SDR 39, effective September
28, 2003; 37 SDR 241, effective July 1, 2011.
General Authority: SDCL 58-17H-49.
Law Implemented: SDCL 58-17H-49.