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Rule 20:06:53:13 Notification following preliminary review.

          20:06:53:13.  Notification following preliminary review. Within one business day after completion of the preliminary review, the health carrier shall notify the director and covered person and, if applicable, the covered person's authorized representative in writing whether:

 

          (1)  The request is complete; and

          (2)  The request is eligible for external review.

 

          If the request is not complete, the health carrier shall inform the covered person and, if applicable, the covered person's authorized representative and the director in writing and include in the notice what information or materials are needed to make the request complete. If the request is not eligible for external review, the health carrier shall inform the covered person, if applicable, the covered person's authorized representative and the director in writing and include in the notice the reasons for its ineligibility.

 

          The notice of initial determination shall include a statement informing the covered person and, if applicable, the covered person's authorized representative that a health carrier's initial determination that the external review request is ineligible for review may be appealed to the director.

 

          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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