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Rule 20:06:47:07 Full and fair review.

          20:06:47:07.  Full and fair review. The plan shall provide full and fair review of an adverse benefit determination. Evidence of a full and fair review consists of the following:

 

          (1)  A reasonable opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;

 

          (2)  Reasonable access to copies of any documents, records, and other information relevant to the claim for benefits upon request and free of charge;

 

          (3)  Consideration of all comments, documents, records, and other information submitted by the covered person relating to the claim for benefits without regard to whether such information was considered or available in the initial determination;

 

          (4)  A minimum of 180 days following notification of an adverse determination in which to appeal;

 

          (5)  No deference to the initial determination and a review that is conducted by neither the individual who made the adverse determination or a subordinate of that individual;

 

          (6)  Consultation by the individual reviewing the appeal with a health care professional of appropriate training and experience in the field of medicine involved when the determination is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate. However, the professional may not be the individual consulted in the initial determination or a subordinate of that individual; and

 

          (7)  The identification of medical or vocational experts whose advice was obtained in regard to the determination, regardless if the advice was relied upon in making the determination.

 

          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.

 


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