S.D. Admin. R. 20:06:53:50
If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should be covered, the independent review organization shall make a decision to reverse the health carrier's adverse determination or final adverse determination. If a majority of the clinical reviewers recommend that the recommended or requested health care service or treatment should not be covered, the independent review organization shall make a decision to uphold the health carrier's adverse determination or final adverse determination.
If the clinical reviewers are evenly split as to whether the recommended or requested health care service or treatment should be covered, the independent review organization shall obtain the opinion of an additional clinical reviewer in order for the independent review organization to make a decision based on the opinions of a majority of the clinical reviewers.
The additional clinical reviewer selected under this section shall use the same information to reach an opinion as the clinical reviewers who have already submitted their opinions pursuant to § 20:06:53:47. The selection of the additional clinical reviewer under this section does not extend the time within which the assigned independent review organization is required to make a decision based on the opinions of the clinical reviewers selected under §§ 20:06:53:39 to 20:06:53:41, inclusive.
S.D. Admin. R. 20:06:53:50
General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.