Division of Insurance - External Review

Experimental and Investigational External Health Review Process

External Review Request

Administrative Rule of South Dakota (ARSD) 20:06:53:33

At any time during four month following receipt of notice of adverse determination or final adverse determination:

Division of Insurance receives External Review Request Form and $25 filing fee along with Experimental and Investigational External Review Request Form, completed and signed by a physician.
Determination involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational.
An oral request can be made for expedited external review of the adverse determination or final adverse determination.
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.
The Division opens an official file and assigns a file number.
The Division sends the request to the external review contact as identified by the health carrier immediately.

Preliminary Review of the Request

ARSD 20:06:53:34

The health carrier completes the preliminary review of request immediately upon receipt. Review for the following:

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.

Not Complete or Ineligible

ARSD 20:06:53:37

The health carrier shall inform the covered person, if applicable, the covered person's authorized representative and the Division of Insurance in writing if not complete or ineligible within one business day.

Includes what is needed in order to complete the request.
Must include a statement that the health carrier's preliminary review determination may be appealed to the Division of Insurance.

Eligible for Review

ARSD 20:06:53:39

The Division of Insurance notifies the covered person and, if applicable, the covered person's authorized representative in writing of the requests eligibility and acceptance for external review within one business day.

The Division notifies the covered person and, if applicable, the covered person's authorized representative in writing of the request's eligibility and acceptance for external review within one business day.
The Division randomly assigns an Independent Review Organization (IRO) without a conflict of interest.
The Division notifies the health carrier and covered person, in writing, which IRO is chosen within one business day.
The health carrier must provide any documents and information considered in making the adverse determination to the IRO.
If information is not provided within five business days the IRO may terminate the external review and make a decision to reverse the adverse determination. (See ARSD 20:06:53:42).
The covered person may also submit additional information for review to the IRO.
IRO must forward any information provided by the covered person to the health carrier within one business day. (See ARSD 20:06:53:43).

Health Carrier May Reconsider to Reverse the Adverse or Final Determination

ARSD 20:06:53:44

The health carrier must notify the IRO, covered person and the Division in writing.
The external review is terminated upon receipt of notification.

IRO Decision

ARSD 20:06:53:40

IRO must select one or more clinical reviewers within one business day of notification of selection.
Clinical reviewers must provide their opinion to the IRO within 20 days (ARSD 20:06:53:45) unless the review is an expedited review for experimental and investigational, then the clinical reviewer must provide their opinion, orally or in writing, to the IRO expeditiously but no later than five calendar days. Oral opinions must have written confirmation provided within 48 hours (ARSD 20:06:53:46).
IRO must provide written notice to the health carrier, covered person and the Division to uphold or reverse the adverse determination within 20 days of receiving clinical review opinions. (ARSD 20:06:53:48).
If the review is an expedited review for experimental and investigational, the IRO must provide oral or written notice to health carrier, covered person and the Division within 48 hours of receipt of receiving clinical reviewer opinions. Oral notice must be followed up with written confirmation within 48 hours. (ARSD 20:06:53:49).

Notice shall include: (ARSD 20:06:53:51)

A general description of the reason for the request for external review;
The written opinion of each clinical reviewer, including their recommendation and rationale;
The date the independent review organization received the assignment from the Director 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, and;
The rationale for its decision.

The coverage that was subject shall 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.

Marcia Hultman

Cabinet Secretary