Rule 20:06:53:12 Standard external review.
20:06:53:12. Standard external
review. At any time during the four months after the date of receipt of a
notice of an adverse determination or final adverse determination pursuant to
§§ 20:06:53:03 to 20:06:53:05, inclusive, a covered person or the covered
person's authorized representative may file a request for an external review
with the director. Within one business day after the date of receipt of a
request for external review pursuant to this section, the director shall send a
copy of the request to the health carrier.
five business days following the date of receipt of the copy of the external
review request from the director under this section, the health carrier shall
complete a preliminary review of the request to determine whether:
individual is or was a covered person in the health benefit plan at the time
the health care service was requested or, in the case of a retrospective
review, was a covered person in the health benefit plan at the time the health
care service was provided;
health care service that is the subject of the adverse determination or the
final adverse determination is a covered service under the covered person's
health benefit plan, but for a determination by the health carrier that the
health care service is not covered because it does not meet the health
carrier's requirements for medical necessity, appropriateness, health care
setting, level of care, or effectiveness;
covered person has exhausted the health carrier's internal grievance process as
set forth in SDCL 58-17I-1 to 58-17I-16, inclusive, unless the covered person is not required to exhaust the health carrier's internal grievance process pursuant to �� 20:06:53:07 to 20:06:53:11, inclusive; and
covered person has provided all the information and forms required to process
an external review, including the release form provided under
§§ 20:06:53:04 and 20:06:53:05.
Source: 37 SDR 48, effective September
22, 2010; 37 SDR 241, effective July 1, 2011.
General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.
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