Marcia Hultman

Cabinet Secretary

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Division of Insurance - Filing a Complaint and Your Rights


South Dakota Division of Insurance Complaint Process

Consumers have a right to file a complaint against an insurance company, health maintenance organization (HMO), insurance agents, adjusters, and other miscellaneous entities that operate within the insurance industry that are licensed or registered with the Division of Insurance.

If you have a complaint, contact the entity involved first. Many complaints can be resolved by talking to them about your issue. If you are in a dispute with your health plan insurance carrier over appropriate care or benefit coverage, the carrier will have an internal appeals process that you MUST go through prior to filing a complaint with the Division.

If you are still unable to resolve your complaint, you can file a complaint with the Division of Insurance online here:

 

 

File a Complaint

or you can contact the Division at 605.773.3563 and speak to a division representative about your issue. The Division Complaint process is outlined here.

 

When Your Health Insurance Carrier Says "No"

Health carriers usually evaluate any requests by your health care provider to allow you to have certain medical procedures performed or to see a specialist. A utilization review completed by a medical professional employed by the health carrier determined if the requested services are medically necessary, appropriate, efficient or effective.

If an adverse determination for benefits for covered services that you and your health care provider feel are medically necessary or are supported by medical evidence proving that the services are not subject to a contractual exclusion is issued by your health carrier, you have the right to challenge that decision.

When a request for benefits for covered services is denied, your health insurance carrier must notify you and your health care provider. The notice of adverse determination must include the following:

  • The specific reason(s) for the denial including any reference to the plan provisions(s) that is the basis for the denial.
  • A description of an additional material or information that may support the benefit request and why that material or information is necessary.
  • A copy of any law, rule, bulletin, guidance, etc., used by the carrier to issue the adverse determination or information on how to request a copy of this material.
  • An explanation of the clinical or scientific basis for a denial based on medical necessity or experimental treatment or information on how to request a copy of this material
  • Notification of your right to appeal including the health insurance carrier's review (appeal) procedures and the applicable time limits.

If you are not satisfied with your health carrier's decisions, you have the right to appeal them. details of your carrier's specific appeal procedures can be found in your member handbook or by calling your health carrier's customer service department.

If you are denied benefits for health services and do not agree with your health carriers adverse determination, you may be able to request an independent external review.

Medicare follows a different set of rules for appeals. Contact the Senior Health Information and Insurance Education program at 800.536.8197 or at shine.net for assistance with Medicare's appeal rules.

People on Medicaid may have additional appeal rights. Call Medicaid at 800.597.1603 or send an email to medical@state.sd.us.

 

 

Contact the Division of Insurance