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Rule 20:06:47:08 Relevant claim information.

          20:06:47:08.  Relevant claim information. A document, record, or other information shall be considered relevant to a claim if such document, record, or other information:

 

          (1)  Was relied upon in making the benefit determination;

 

          (2)  Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;

 

          (3)  Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination; and

 

          (4)  Constitutes statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the covered person's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit 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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