<html xmlns:v="urn:schemas-microsoft-com:vml" xmlns:o="urn:schemas-microsoft-com:office:office" xmlns:w="urn:schemas-microsoft-com:office:word" xmlns="http://www.w3.org/TR/REC-html40"> <head> <title>Rule 20:06:47:05 Adverse benefit notification.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:47:05"> <META NAME="Description" Content="Administrative Rules 20:06:47:05 Adverse benefit notification."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=ProgId content=Word.Document> <meta name=Generator content="Microsoft Word 10"> <meta name=Originator content="Microsoft Word 10"> <link rel=File-List href="2006470000500d_files/filelist.xml"> <!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>lrpr14533</o:Author> <o:LastAuthor>lrpr14296</o:LastAuthor> <o:Revision>2</o:Revision> <o:TotalTime>0</o:TotalTime> <o:Created>2011-07-13T13:58:00Z</o:Created> <o:LastSaved>2011-07-13T13:58:00Z</o:LastSaved> <o:Pages>1</o:Pages> <o:Words>256</o:Words> <o:Characters>1463</o:Characters> <o:Company>State of South Dakota</o:Company> <o:Lines>12</o:Lines> <o:Paragraphs>3</o:Paragraphs> <o:CharactersWithSpaces>1716</o:CharactersWithSpaces> <o:Version>10.6870</o:Version> </o:DocumentProperties> </xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:PunctuationKerning/> <w:DrawingGridHorizontalSpacing>5.5 pt</w:DrawingGridHorizontalSpacing> <w:DisplayHorizontalDrawingGridEvery>2</w:DisplayHorizontalDrawingGridEvery> <w:DisplayVerticalDrawingGridEvery>2</w:DisplayVerticalDrawingGridEvery> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> </w:WordDocument> </xml><![endif]--> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4; mso-font-charset:0; mso-generic-font-family:swiss; mso-font-pitch:variable; mso-font-signature:-1610611985 1073750139 0 0 159 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; font-family:Calibri; mso-fareast-font-family:Calibri; mso-bidi-font-family:"Times New Roman";} p.MsoFooter, li.MsoFooter, div.MsoFooter {mso-style-link:" Char"; margin-top:0in; margin-right:0in; margin-bottom:0in; margin-left:-.7pt; margin-bottom:.0001pt; text-align:justify; mso-pagination:widow-orphan; tab-stops:.4in 40.5pt .9in 1.1in 1.4in 1.6in 1.9in 2.1in 2.4in 2.6in 2.9in center 3.0in left 3.1in 3.4in 3.6in 3.9in 4.1in right 6.0in; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman";} span.Char {mso-style-name:" Char"; mso-style-link:Footer; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; font-family:"Times New Roman"; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style> <!--[if gte mso 10]> <style> /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:Calibri;} </style> <![endif]--><!--[if gte mso 9]><xml> <o:shapedefaults v:ext="edit" spidmax="2050"/> </xml><![endif]--><!--[if gte mso 9]><xml> <o:shapelayout v:ext="edit"> <o:idmap v:ext="edit" data="1"/> </o:shapelayout></xml><![endif]--> </head> <body lang=EN-US style='tab-interval:.5in'> <div class=Section1> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>20:06:47:05.&nbsp;&nbsp;Adverse benefit notification.</b> The plan shall provide a covered person or, if applicable, the person's authorized representative, with written or electronic notification of any adverse benefit determination in a manner calculated to be understood by the covered person. The notification shall include the following:</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(1)&nbsp;&nbsp;The specific reason or reasons for the determination;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(2)&nbsp;&nbsp;Reference to the specific plan provision on which the determination was based;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(3)&nbsp;&nbsp;A description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(4)&nbsp;&nbsp;A description of review procedures and applicable time frames;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(5)&nbsp;&nbsp;A statement of the person's right to bring a civil action under applicable law;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(6)&nbsp;&nbsp;The specific rule, guideline, protocol, or other similar criterion used in making the adverse determination, or a statement that such items were relied upon and are available free of charge to the covered person upon request;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(7)&nbsp;&nbsp;An explanation of the scientific or clinical judgment used in the determination based on medical necessity or experimental treatment or similar exclusion or limitation, or a statement that such explanation will be provided free of charge upon request; and</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(8)&nbsp;&nbsp;The statement &quot;You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and the South Dakota Division of Insurance.&quot;</p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Source:</b> 30 SDR 39, effective September 28, 2003; 37 SDR 241, effective July 1, 2011.</p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17H-49">58-17H-49.</A></p> <p class=MsoFooter style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><b style='mso-bidi-font-weight:normal'>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17H-49">58-17H-49.</A></p> <p class=MsoFooter style='margin-left:0in'><o:p>&nbsp;</o:p></p> </div> </body> </html>