South Dakota · Regulations
Chapter 20:06:53 — External and internal review
80 sections
80 sections
- ARSD 20:06:53:01ARSD 20:06:53:01. Definitions
- ARSD 20:06:53:02ARSD 20:06:53:02. Applicability
- ARSD 20:06:53:03ARSD 20:06:53:03. Notice of right to external review
- ARSD 20:06:53:04ARSD 20:06:53:04. Content of notices
- ARSD 20:06:53:05ARSD 20:06:53:05. Review procedures and authorization to accompany notice
- ARSD 20:06:53:06ARSD 20:06:53:06. Request for external review
- ARSD 20:06:53:07ARSD 20:06:53:07. Exhaustion of internal grievance process required
- ARSD 20:06:53:08ARSD 20:06:53:08. When exhaustion of internal grievance occurs
- ARSD 20:06:53:09ARSD 20:06:53:09. Request for expedited review
- ARSD 20:06:53:10ARSD 20:06:53:10. Determination of expedited review
- ARSD 20:06:53:11ARSD 20:06:53:11. Waiver of exhaustion requirement
- ARSD 20:06:53:12ARSD 20:06:53:12. Standard external review
- ARSD 20:06:53:13ARSD 20:06:53:13. Notification following preliminary review
- ARSD 20:06:53:14ARSD 20:06:53:14. Determination by the director and assignment of independent review organization
- ARSD 20:06:53:15ARSD 20:06:53:15. Independence of review decision
- ARSD 20:06:53:16ARSD 20:06:53:16. Health carrier required to provide information
- ARSD 20:06:53:17ARSD 20:06:53:17. Effect of failure to act on external review process
- ARSD 20:06:53:18ARSD 20:06:53:18. Independent review organization review of information
- ARSD 20:06:53:19ARSD 20:06:53:19. Carrier reconsideration
- ARSD 20:06:53:20ARSD 20:06:53:20. Information to be considered by independent review organization
- ARSD 20:06:53:21ARSD 20:06:53:21. Independent review organization decisions
- ARSD 20:06:53:22ARSD 20:06:53:22. Director assignment of independent review organization
- ARSD 20:06:53:23ARSD 20:06:53:23. Expedited external review
- ARSD 20:06:53:24ARSD 20:06:53:24. Notifications upon request for expedited external review
- ARSD 20:06:53:25ARSD 20:06:53:25. Director's determination of eligibility for expedited reviews
- ARSD 20:06:53:26ARSD 20:06:53:26. Director assignment of independent review organization for expedited reviews
- ARSD 20:06:53:27ARSD 20:06:53:27. Independent review organization decision for expedited reviews
- ARSD 20:06:53:28ARSD 20:06:53:28. Information to be considered by independent review organization for expedited review
- ARSD 20:06:53:29ARSD 20:06:53:29. Expedited review decision
- ARSD 20:06:53:30ARSD 20:06:53:30. Health carrier required to approve upon reversal by expedited review
- ARSD 20:06:53:31ARSD 20:06:53:31. Assignment of independent review organization for expedited reviews
- ARSD 20:06:53:32ARSD 20:06:53:32. Applicability of expedited reviews
- ARSD 20:06:53:33ARSD 20:06:53:33. External review of experimental or investigational treatment adverse determinations
- ARSD 20:06:53:34ARSD 20:06:53:34. Notifications upon request for external review of experimental or investigational treatment adverse determinations
- ARSD 20:06:53:35ARSD 20:06:53:35. Director's determination of eligibility and assignment for external review of experimental or investigational treatment
- ARSD 20:06:53:36ARSD 20:06:53:36. Health carrier preliminary review of request for experimental or investigational treatment reviews
- ARSD 20:06:53:37ARSD 20:06:53:37. Health carrier notification after preliminary review of request for experimental or investigational treatment reviews
- ARSD 20:06:53:38ARSD 20:06:53:38. Director's determination of request for experimental or investigational treatment reviews
- ARSD 20:06:53:39ARSD 20:06:53:39. Health carrier notification of eligibility for experimental or investigational treatment reviews
- ARSD 20:06:53:40ARSD 20:06:53:40. Independent review organization experimental or investigational treatment reviews
- ARSD 20:06:53:41ARSD 20:06:53:41. Independent review organization clinical reviewer written opinion for experimental or investigational treatment review
- ARSD 20:06:53:42ARSD 20:06:53:42. Records provided to independent review organization for experimental or investigational treatment reviews
- ARSD 20:06:53:43ARSD 20:06:53:43. Review of information by independent review organization for experimental or investigational treatment reviews
- ARSD 20:06:53:44ARSD 20:06:53:44. Reconsideration by health carrier for experimental or investigational treatment reviews
- ARSD 20:06:53:45ARSD 20:06:53:45. Clinical review opinion for experimental or investigational treatment reviews
- ARSD 20:06:53:46ARSD 20:06:53:46. Expedited review opinions for experimental or investigational treatment reviews
- ARSD 20:06:53:47ARSD 20:06:53:47. Clinical review criteria for experimental or investigational treatment reviews
- ARSD 20:06:53:48ARSD 20:06:53:48. Independent review organization decision and notice for experimental or investigational treatment reviews
- ARSD 20:06:53:49ARSD 20:06:53:49. Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews
- ARSD 20:06:53:50ARSD 20:06:53:50. Decision by independent review organization for experimental or investigational treatment reviews
- ARSD 20:06:53:51ARSD 20:06:53:51. Notice of written decision by independent review organization for experimental or investigational treatment reviews
- ARSD 20:06:53:52ARSD 20:06:53:52. Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational treatment reviews
- ARSD 20:06:53:53ARSD 20:06:53:53. Criteria for assignment of independent review organization for experimental or investigational treatment reviews
- ARSD 20:06:53:54ARSD 20:06:53:54. Binding nature of external review decision
- ARSD 20:06:53:55ARSD 20:06:53:55. Approval of independent review organizations
- ARSD 20:06:53:56ARSD 20:06:53:56. Continuation of approval for independent review organizations
- ARSD 20:06:53:57ARSD 20:06:53:57. Minimum qualifications for independent review organizations
- ARSD 20:06:53:58ARSD 20:06:53:58. Requirements for clinical reviewers
- ARSD 20:06:53:59ARSD 20:06:53:59. Subsidiaries of or ownership in independent review organizations
- ARSD 20:06:53:60ARSD 20:06:53:60. Independence of clinical reviewers
- ARSD 20:06:53:61ARSD 20:06:53:61. Nationally accredited independent review organizations
- ARSD 20:06:53:62ARSD 20:06:53:62. Unbiased independent review organization
- ARSD 20:06:53:63ARSD 20:06:53:63. Hold harmless for independent review organizations
- ARSD 20:06:53:64ARSD 20:06:53:64. External review reporting requirements
- ARSD 20:06:53:65ARSD 20:06:53:65. Independent review organization and health carrier recordkeeping
- ARSD 20:06:53:66ARSD 20:06:53:66. Funding of external review
- ARSD 20:06:53:67ARSD 20:06:53:67. Disclosure requirements
- ARSD 20:06:53:68ARSD 20:06:53:68. Adverse benefit determination -- Defined
- ARSD 20:06:53:69ARSD 20:06:53:69. Urgent care requests -- Timely notification of determination -- Initial benefit determination
- ARSD 20:06:53:70ARSD 20:06:53:70. Additional evidence
- ARSD 20:06:53:71ARSD 20:06:53:71. Avoiding conflicts of interest
- ARSD 20:06:53:72ARSD 20:06:53:72. Notice to enrollee
- ARSD 20:06:53:73ARSD 20:06:53:73. Failure to comply with internal claims and appeal process
- ARSD 20:06:53:74ARSD 20:06:53:74. Continued coverage and ongoing treatment
- ARSD 20:06:53:75ARSD 20:06:53:75. One level of internal appeals
- ARSD 20:06:53:76ARSD 20:06:53:76. Record keeping
- ARSD 20:06:53:77ARSD 20:06:53:77. Applicability
- ARSD 20:06:53:78ARSD 20:06:53:78. Strictly adhere -- Defined
- ARSD 20:06:53:79ARSD 20:06:53:79. Written explanation of violation
- ARSD 20:06:53:80ARSD 20:06:53:80. Procedure when immediate review request denied