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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.

 

          Whenever 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 shall:

 

          (1)  Assign 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; and

 

          (2)  Notify 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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