<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 20:06:53:12 Standard external review.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:53:12"> <META NAME="Description" Content="Administrative Rules 20:06:53:12 Standard external review."> <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="2006530001200d_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>319</o:Words> <o:Characters>1822</o:Characters> <o:Company>State of South Dakota</o:Company> <o:Lines>15</o:Lines> <o:Paragraphs>4</o:Paragraphs> <o:CharactersWithSpaces>2137</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-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 3.1in 3.4in 3.6in 3.9in 4.1in; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-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=MsoNormal 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'>20:06:53:12.&nbsp;&nbsp;Standard external review.</b> At any time during the four months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to &#167;&#167;&nbsp;20:06:53:03 to 20:06:53:05, inclusive, a covered person or the covered person's authorized representative may file a request for an external review with the director. Within one business day after the date of receipt of a request for external review pursuant to this section, the director shall send a copy of the request to the health carrier.</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Within five business days following the date of receipt of the copy of the external review request from the director under this section, the health carrier shall complete a preliminary review of the request to determine whether:</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(1)&nbsp;&nbsp;The individual is or was a covered person in the health benefit plan at the time the health care service was requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time the health care service was provided;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(2)&nbsp;&nbsp;The health care service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person's health benefit plan, but for a determination by the health carrier that the health care service is not covered because it does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness;</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(3)&nbsp;&nbsp;The covered person has exhausted the health carrier's internal grievance process as set forth in SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17I-1">58-17I-1</A> to <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17I-16">58-17I-16</A>, inclusive, unless the covered person is not required to exhaust the health carrier's internal grievance process pursuant to §§&nbsp;20:06:53:07 to 20:06:53:11, inclusive; and</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal style='margin-left:0in'><span style='mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>(4)&nbsp;&nbsp;The covered person has provided all the information and forms required to process an external review, including the release form provided under &#167;&#167;&nbsp;20:06:53:04 and 20:06:53:05.</p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> <p class=MsoNormal 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> 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 1, 2011.</p> <p class=MsoNormal 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=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17H-49">58-17H-49</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17I-16">58-17I-16</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></p> <p class=MsoNormal 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=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></p> <p class=MsoNormal style='margin-left:0in'><o:p>&nbsp;</o:p></p> </div> </body> </html>