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ARSD 20:06:53 – External and Internal Review | Midpage
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Administrative Rules of South Dakota
Title 20
20:06
Chapter 20:06:53
ARSD 20:06:53
External and Internal Review
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Definitions.
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Applicability.
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Notice of right to external review.
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Content of notices.
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Review procedures and authorization to accompany notice.
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Request for external review.
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Exhaustion of internal grievance process required.
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When exhaustion of internal grievance occurs.
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Request for expedited review.
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Determination of expedited review.
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Waiver of exhaustion requirement.
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Standard external review.
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Notification following preliminary review.
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Determination by the director and assignment of independent review organization.
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Independence of review decision.
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Health carrier required to provide information.
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Effect of failure to act on external review process.
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Independent review organization review of information.
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Carrier reconsideration.
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Information to be considered by independent review organization.
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Independent review organization decisions.
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Director assignment of independent review organization.
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Expedited external review.
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Notifications upon request for expedited external review.
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Director's determination of eligibility for expedited reviews.
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Director assignment of independent review organization for expedited reviews.
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Independent review organization decision for expedited reviews.
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Information to be considered by independent review organization for expedited review.
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Expedited review decision.
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Health carrier required to approve upon reversal by expedited review.
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Assignment of independent review organization for expedited review.
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Applicability of expedited reviews.
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External review of experiment or investigational treatment adverse determinations.
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Notifications upon request for external review of experimental or investigational treatment adverse determinations.
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Director's determination of eligibility and assignment for external review of experimental or investigational treatment.
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Health carrier preliminary review of request for experimental or investigational treatment reviews.
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Health carrier notification after preliminary review of request for experimental or investigational treatment reviews.
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Director's determination of request for experimental or investigational treatment reviews.
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Health carrier notification of eligibility for experimental or investigational treatment reviews.
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Independent review organization experimental or investigational treatment reviews.
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Independent review organization clinical reviewer written opinion for experimental or investigational treatment reviews.
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Review of information by independent review organization for experimental or investigational treatment reviews.
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Reconsideration by health carrier for experimental or investigational treatment reviews.
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Clinical review opinion for experimental or investigational treatment reviews.
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Expedited review opinions for experimental or investigational treatment reviews.
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Clinical review criteria for experimental or investigational treatment reviews.
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Independent review organization decision and notice for experimental or investigational treatment reviews.
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Expedited reviews upon receipt of clinical review opinion for experimental or investigational treatment reviews.
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Decision by independent review organization for experimental or investigational reviews.
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Notice of written decision by independent review organization for experimental or investigational treatment reviews.
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Health carrier requirement upon notice of decision reversing adverse determination for experimental or investigational reviews.
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Criteria for assignment of independent review organization for experimental or investigational treatment reviews.
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Binding nature of external review decision.
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Approval of independent review organizations.
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Continuation of approval for independent review organizations.
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Minimum qualifications for independent review organizations.
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Requirements for clinical reviewers.
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Subsidiaries of or ownership in independent review organizations.
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Independence of clinical reviewers.
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Nationally accredited independent review organizations.
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Unbiased independent review organizations.
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Hold harmless for independent review organizations.
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External review reporting requirements.
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Independent review organization and health carrier recordkeeping.
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Funding for external review.
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Disclosure requirements.
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Adverse benefit determination -- Defined.
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Urgent care requests -- Timely notification of determination -- Initial benefit determination.
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Additional evidence.
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Avoiding conflicts of interest.
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Notice to enrollee.
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Failure to comply with internal claims and appeal process.
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Continued coverage and ongoing treatment.
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One level of internal appeals.
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Record keeping.
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Applicability.
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Strictly adhere -- Defined.
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Written explanation of violation.
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Procedure when immediate review request denied.
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Model Notice of Appeal Rights.
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Model External Review Request Form.
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Independent Review Organization External Review Annual Report Form.
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Model Health Carrier External Annual Report Form.