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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.

 

          Within 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:

 

          (1)  The 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;

 

          (2)  The 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;

 

          (3)  The 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 ยงยง 20:06:53:07 to 20:06:53:11, inclusive; and

 

          (4)  The 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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