Rule 20:06:53:19 Carrier reconsideration.
reconsideration. Upon receipt of the information, if any, required to be
forwarded pursuant to § 20:06:53:18, the health carrier may reconsider its
adverse determination or final adverse determination that is the subject of the
external review. Reconsideration by the health carrier of its adverse
determination or final adverse determination pursuant to this section may not
delay or terminate the external review.
external review may only be terminated if the health carrier decides, upon
completion of its reconsideration, to reverse its adverse determination or
final adverse determination and provide coverage or payment for the health care
service that is the subject of the adverse determination or final adverse
determination. Within one business day after making a decision to reverse its
adverse determination or final adverse determination, as provided in this
section, the health carrier shall notify the covered person, if applicable, the
covered person's authorized representative, the assigned independent review
organization, and the director in writing of its decision.
assigned independent review organization shall terminate the external review
upon receipt of the notice of a reversal from the health carrier sent pursuant
to this section.
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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