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Rule 20:06:53:21 Independent review organization decisions.

          20:06:53:21.  Independent review organization decisions. Within 45 days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the covered person, the covered person's authorized representative, the health carrier, and the director.

 

          The independent review organization shall include in the notice sent pursuant to this section the following:

 

          (1)  A general description of the reason for the request for external review;

          (2)  The date the independent review organization received the assignment from the director to conduct the external review;

          (3)  The date the external review was conducted;

          (4)  The date of its decision;

          (5)  The principal reason or reasons for its decision, including what applicable, if any, evidence-based standards were a basis for its decision;

          (6)  The rationale for its decision; and

          (7)  References to the evidence or documentation, including the evidence-based standards, considered in reaching its decision.

 

          Upon receipt of a notice of a decision pursuant to this section reversing the adverse determination or final adverse determination, the health carrier immediately shall approve the coverage that was the subject of the adverse determination or final adverse determination.

 

          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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