Rule 20:06:40:09 Notification of determinations on preexisting waiting periods and appeal and reconsideration procedures.
of determinations on preexisting waiting periods and appeal and reconsideration
procedures (repealed January 1, 2014). Within a reasonable
time following the receipt of the certificate or other evidence of coverage, a
plan or carrier must determine the length of any preexisting condition waiting
period that applies to the individual and notify the individual of its
determination. Whether a determination and notification are made within a
reasonable period of time depends upon the relevant facts and circumstances,
including whether the application of the preexisting condition waiting period
would prevent access to urgent medical services. The plan or carrier is
required to notify the individual, however, only if, after considering the
evidence, it has determined that a preexisting condition waiting period will be
imposed on the individual. The basis of the determination, including the source
and substance of any information on which the plan or carrier relied, must be
included in the notification. The notification must also explain the plan�s
appeal procedures and the opportunity of the individual to present additional
The plan or carrier may reconsider and
modify its initial determination if it determines that the individual did not
have the claimed creditable coverage. In this circumstance, the plan or carrier
must notify the individual of the reconsideration and, until a final
determination is made, must act in accordance with its initial determination
for purposes of approving medical services.
24 SDR 35, effective September 29, 1997; 39 SDR 203, adopted June 13, 2013,
repealed January 1, 2014.
Authority: SDCL 58-18-79.
Implemented: SDCL 58-18-43, 58-18-45, 58-18-48, 58-18-79.
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