S.D. Admin. R. 20:06:21:101

Current through Register Vol. 50, page 159, June 17, 2024

Section 20:06:21:101 - Certification of long-term care insurance independent review organizations

The director shall consider a long-term care insurance independent review organization to be qualified in this state, if the independent review organization demonstrates that it is unbiased and has either been certified by another state with substantially similar qualifications as contained in Appendix M or meets the following qualifications:

(1) Have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured's functional or cognitive impairment (e.g. physical therapy, occupational therapy, neurology, physical medicine, and rehabilitation) to conduct the review;

(2) Neither it nor any of its licensed health care professionals may, in any manner, be related to or affiliated with an entity that previously provided medical care to the insured;

(3) Utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured;

(4) Neither it nor its licensed health care professional who conducts the reviews may receive compensation of any type that is dependent on the outcome of the review;

(5) Be state-approved or certified to conduct such reviews if the state requires such approvals or certifications;

(6) Provide a description of the fees to be charged by it for independent reviews of a long-term care insurance benefit trigger decision. Such fees shall be reasonable and customary for the type of long-term care insurance benefit trigger decision under review;

(7) Provide the name of the medical director or health care professional responsible for the supervision and oversight of the independent review procedure; and

(8) Have on staff or contract with a licensed health care practitioner as defined in subdivision 20:06:21:01(21), who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract.

S.D. Admin. R. 20:06:21:101

36 SDR 209, effective 7/1/2010.

General Authority: SDCL 58-17B-4.

Law Implemented: SDCL 58-17B-4.