Rule 20:06:53:14 Determination by the director and assignment of independent review organization.
20:06:53:14. Determination by
the director and assignment of independent review organization. The
director may determine that a request is eligible for external review under
§ 20:06:53:12 notwithstanding a health carrier's initial determination
that the request is ineligible and require that it be referred for external
review. In making a determination under this section, the director's decision
shall be made in accordance with the terms of the covered person's health
benefit plan and is subject to all applicable provisions of this chapter.
the director receives a notice that a request is eligible for external review
following the preliminary review conducted pursuant to § 20:06:53:13,
within one business day after the date of receipt of the notice, the director
an independent review organization from the list of approved independent review
organizations compiled and maintained by the director pursuant to
§§ 20:06:53:55 and 20:06:53:56, to conduct the external review and notify
the health carrier of the name of the assigned independent review organization;
in writing the covered person and, if applicable, the covered person's
authorized representative of the request's eligibility and acceptance for
external review. The director shall include in the notice provided to the
covered person and, if applicable, the covered person's authorized
representative a statement that the covered person or the covered person's
authorized representative may submit in writing to the assigned independent
review organization at any time during the five business days following the
date of receipt of the notice provided pursuant to § 20:06:53:14
additional information that the independent review organization shall consider
when conducting the external review. The independent review organization is not
required to, but may, accept and consider additional information submitted
after five business days.
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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