S.D. Admin. R. 20:06:53:64

Current through Register Vol. 51, page 71, January 6, 2025

Section 20:06:53:64 - External review reporting requirements

An independent review organization assigned pursuant to §§ 20:06:53:12 to 20:06:53:32, inclusive, to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the director, as required under this section. The report must be in the format of Appendix C.

Each independent review organization required to maintain written records on all requests for external review pursuant to this section for which it was assigned to conduct an external review shall submit to the director, upon request, a report in the format specified by the director. The report shall include in the aggregate by state, and for each health carrier, the following:

(1) The total number of requests for external review;

(2) The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;

(3) The average length of time for resolution;

(4) A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the director; and

(5) The number of external reviews pursuant to § 20:06:53:19 that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person's authorized representative.

The director may request additional information to be included within the report or to be provided at an alternate date that relates to the independent review organization's compliance with this chapter.

S.D. Admin. R. 20:06:53:64

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.