S.D. Admin. R. 20:06:48:09
If a claim is denied, the aggrieved party may appeal in writing to the claims administrator within 180 days of the date of the denial at the address listed on the explanation of benefits (EOB) or in the written utilization review denial. If the claims administrator again denies the claim, the aggrieved party may appeal in writing to the administrator of the risk pool, c/o the Bureau of Human Resources, 124 South Euclid Avenue, 2nd Floor, Pierre, SD 57501, within 30 days of receiving notification of the denial. The administrator of the risk pool shall issue a written decision within 30 days from the date that the appeal is received. If the administrator of the risk pool denies the claim, the aggrieved party may appeal in writing to the risk pool board within 30 days of receiving notification of the denial and the board shall issue a written decision on the appeal. If the risk pool board denies the claim, the aggrieved party may request a hearing before the Office of Hearing Examiners within 30 days of receiving notification of the denial.
If the subject matter of the appeal is not a claim, the aggrieved party shall file an appeal directly to the administrator of the risk pool within 180 days of the date of the decision, and if not satisfied with the decision of the administrator of the risk pool, may appeal to the board within 30 days of the date of that decision. If the aggrieved party is not satisfied with the decision of the board, the aggrieved party may request a hearing before the Office of Hearing Examiners within 30 days of receiving notification of the board's decision.
Prior to the board hearing an appeal the chair of the risk pool board shall appoint a member of the board to serve as the final decision maker. The final decision maker may not participate in the appeal or in any discussions related to the appeal. The final decision maker may accept, reject, or modify the findings, conclusions, and decisions of the hearing examiner pursuant to SDCL 1-26D-6. The aggrieved party may appeal any final decision to the circuit court in accordance with SDCL chapter 1-26.
If an aggrieved party fails to appeal within the time limits provided in this section, no further action is required.
S.D. Admin. R. 20:06:48:09
General Authority: SDCL 58-17-124(5)(7)(9).
Law Implemented: SDCL 58-17-124(5)(7)(9).