S.D. Admin. R. 20:06:53:08

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

Section 20:06:53:08 - When exhaustion of internal grievance occurs

A covered person shall be considered to have exhausted the health carrier's internal grievance process for purposes of this section, if the covered person or the covered person's authorized representative:

(1) Has filed a grievance involving an adverse determination pursuant to SDCL 58-17I-7 to 58-17I-11, inclusive; and

(2) Except to the extent the covered person or the covered person's authorized representative requested or agreed to a delay, has not received a written decision on the grievance from the health carrier within 30 days following the date the covered person or the covered person's authorized representative filed the grievance with the health carrier. However, a covered person or the covered person's authorized representative may not make a request for an external review of an adverse determination involving a retrospective review determination made pursuant to SDCL 58-17I-7 to 58-17I-11, inclusive, until the covered person has exhausted the health carrier's internal grievance process.

S.D. Admin. R. 20:06:53:08

37 SDR 48, effective 9/22/2010; 37 SDR 241, effective 7/1/2011.

General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.

Law Implemented: SDCL 58-17-87, 58-18-79.