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Rule 20:06:53:17 Effect of failure to act on external review process.

          20:06:53:17.  Effect of failure to act on external review process. The failure by the health carrier or its utilization review organization to provide the documents and information within the time specified in § 20:06:53:16 may not delay the conduct of the external review except as follows:

 

          (1)  If the health carrier or its utilization review organization fails to provide the documents and information within the time specified in § 20:06:53:16, the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination; or

 

          (2)  Within one business day after making the decision under subdivision (1), the independent review organization shall notify the covered person, if applicable, the covered person's authorized representative, the health carrier, and 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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