S.D. Admin. R. 20:06:53:60

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

Section 20:06:53:60 - Independence of clinical reviewers

In addition to the requirements set forth in §§ 20:06:53:57, 20:06:53:58, and 20:06:53:59, to be approved pursuant to §§ 20:06:52:55 and 20:06:53:56 to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical reviewer assigned by the independent organization to conduct the external review may have a material professional, familial, or financial conflict of interest with any of the following;

(1) The health carrier that is the subject of the external review;

(2) The covered person whose treatment is the subject of the external review or the covered person's authorized representative;

(3) Any officer, director, or management employee of the health carrier that is the subject of the external review;

(4) The health care provider or the health care provider's medical group or independent practice association recommending the health care service or treatment that is the subject of the external review;

(5) The facility at which the recommended health care service or treatment would be provided; or

(6) The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose treatment is the subject of the external review.

In determining whether an independent review organization or a clinical reviewer of the independent review organization has a material professional, familial, or financial conflict of interest for purposes of this section, the director shall take into consideration situations where the independent review organization to be assigned to conduct an external review of a specified case or a clinical reviewer to be assigned by the independent review organization to conduct an external review of a specified case may have an apparent professional, familial, or financial relationship or connection with a person described in this section, but that the characteristics of that relationship or connection are such that they are not a material professional, familial, or financial conflict of interest that results in the disapproval of the independent review organization or the clinical reviewer from conducting the external review.

S.D. Admin. R. 20:06:53:60

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.