Marcia Hultman

Cabinet Secretary

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Division of Insurance - External Review


Expedited External Health Review Process

Expedited External Review Request

Administrative Rule of South Dakota (ARSD) 20:06:53:09
  • Division of Insurance receives External Review Request Form and $25 filing fee along with Request for Expedited External Review, completed and signed by a physician.
  • The Division opens an official file and assigns a file number.
  • Determination involves a medical condition which the time frame for an expedited internal review would seriously jeopardize the life or health of the covered person.
  • If the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated.

Preliminary Review of the Request

ARSD 20:06:53:24
  • The Division of Insurance immediately sends a copy of the request to the health carrier.
  • The health carrier upon immediate receipt of request determines whether the request meets requirements.
  • The health carrier immediately notifies the Director and covered person of its determination.
  • Notice shall include a statement informing the covered person a health carrier's initial determination of ineligibility may be appealed to the Director.

Determination of Expedited Review

ARSD 20:06:53:26
  • The Director assigns an Independent Review Organization (IRO) and immediately notifies the health carrier which IRO was chosen
  • Upon receipt the health carrier shall provide all information considered in making the adverse determination or final adverse determination to the IRO.

Information to be Considered by IRO

ARSD 20:06:53:28
  • Covered person's pertinent records.
  • Attending health care professional's recommendation.
  • Consulting reports from appropriate health care professionals.
  • Terms of coverage.
  • Most appropriate practice guidelines.
  • Any applicable clinical reviews.

Expedited IRO Decision

ARSD 20:06:53:29

As expeditiously as the covered person's medical condition or circumstance requires, but in no event more than 72 hours after the receipt of the request for an expedited review, the IRO shall:

  • Make a decision to uphold or reverse the adverse determination.
  • Notify the covered person, health carrier and the Division of Insurance of the decision in writing. Notice shall include:
    • A general description of the reason for the request for external review;
    • The date the independent review organization received the assignment from the Division to conduct the external review;
    • The date the external review was conducted;
    • The date of its decision;
    • The principal reason or reasons for its decision, including what applicable evidence based standards were a basis for its decision, if any;
    • The rationale for its decision; and
    • References to the evidence or documentation, including the evidence-based standards, considered in reaching its decision.
  • The coverage that was subject should be immediately approved by the health carrier if the IRO reverses the initial adverse determination.

External Review Funding

ARSD 20:06:53:66
  • The Division sends a refund of the $25 filing fee to the covered person if the decision was reversed.
  • The Division sends the $25 filing fee to the health carrier if the decision was upheld.

The Division closes the file and sends correspondence to covered person and/or authorized representative.


Return to External Review Process webpage

 

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