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Rule 20:06:53:19 Carrier reconsideration.

          20:06:53:19.  Carrier 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.

 

          The 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.

 

          The 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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