S.D. Admin. R. 20:06:53:35
The director may determine that a request is eligible for external review under § 20:06:53:36 notwithstanding a health carrier's initial determination the request is ineligible and require that it be referred for external review. In making a determination under this section, the director's decision shall be made in accordance with the terms of the covered person's health benefit plan and is subject to all applicable provisions of this chapter.
Upon receipt of the notice that the expedited external review request meets the reviewability requirements of § 20:06:53:36, the director immediately shall assign an independent review organization to review the expedited request from the list of approved independent review organizations compiled and maintained by the director pursuant to §§ 20:06:53:55 and 20:06:53:56 and notify the health carrier of the name of the assigned independent review organization.
At the time the health carrier receives the notice of the assigned independent review organization pursuant to this section, the health carrier or its designee utilization review organization shall provide or transmit all necessary documents and information considered in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method.
S.D. Admin. R. 20:06:53:35
General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.