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
independent review organization shall include in the notice sent pursuant to
this section the following:
general description of the reason for the request for external review;
date the independent review organization received the assignment from the
director to conduct the external review;
date the external review was conducted;
date of its decision;
principal reason or reasons for its decision, including what applicable, if
any, evidence-based standards were a basis for its decision;
rationale for its decision; and
to the evidence or documentation, including the evidence-based standards,
considered in reaching its decision.
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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