Rule 20:06:53:28 Information to be considered by independent review organization for expedited review.
20:06:53:28. Information to be
considered by independent review organization for expedited review. In
addition to the documents and information provided or transmitted pursuant to
§ 20:06:53:26, the assigned independent review organization, to the extent
the information or documents are available and the independent review
organization considers them appropriate, shall consider the following in
reaching a decision:
covered person's pertinent medical records;
attending health care professional's recommendation;
reports from appropriate health care professionals and other documents
submitted by the health carrier, covered person, the covered person's
authorized representative, or the covered person's treating provider;
terms of coverage under the covered person's health benefit plan with the
health carrier to ensure that the independent review organization's decision is
not contrary to the terms of coverage under the covered person's health benefit
plan with the health carrier;
most appropriate practice guidelines, which shall include evidence-based
standards, and may include any other practice guidelines developed by the
federal government, or national or professional medical societies, boards, and
applicable clinical review criteria developed and used by the health carrier or
its designee utilization review organization in making adverse determinations;
opinion of the independent review organization's clinical reviewer or reviewers
after considering subdivisions (1) to (6), inclusive, to the extent the
information or documents are available and the clinical reviewer or reviewers
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.
Back to 20:06:53