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South Dakota Codified Laws
Title 58
Chapter 58-17H
S.D. Codified Laws ch. 58-17H
Utilization Review and Benefit Determinations
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58-17H-1
Definitions.
58-17H-2
Health benefit plan defined.
58-17H-3
Urgent care request defined.
58-17H-4
Applicability of chapter.
58-17H-5
Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.
58-17H-6
In-network emergency services.
58-17H-7
Cost-sharing requirements for out-of-network emergency services.
58-17H-8
Cost-sharing requirements for covered persons--Payments to out-of-network providers.
58-17H-9
Exceptions for payments by capitated and other plans without negotiated fees.
58-17H-10
Negotiated amounts for in-network providers for a particular emergency service.
58-17H-11
General cost-sharing requirements allowed.
58-17H-12
Access to representative for post-evaluation or post-stabilization services.
58-17H-13
Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.
58-17H-14
Health carrier responsibility for utilization review activities.
58-17H-15
Director to hold health carrier responsible for utilization review performance of contractor.
58-17H-16
Written utilization review program required--Contents of program document.
58-17H-17
Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.
58-17H-18
Program to be administered by qualified licensed health care professionals.
58-17H-19
Determinations to be issued in timely manner--Process to ensure consistency.
58-17H-20
Effectiveness and efficiency of program to be routinely reviewed.
58-17H-21
Data systems to support program activities and generate management reports.
58-17H-22
Health carrier oversight of delegated activities--Requirements.
58-17H-23
Utilization review to be coordinated with other medical management activity of health carrier.
58-17H-24
Health carrier to provide free access to review staff.
58-17H-25
Only information necessary for review or determination to be collected.
58-17H-26
Independence and impartiality required for utilization review.
58-17H-27
Written procedures required for making determinations--Notification.
58-17H-28
Prospective review determinations--Timing--Notification of requirements--Extension of time.
58-17H-29
Concurrent review determinations--Timing--Notification requirements.
58-17H-30
Retrospective review determinations--Timing--Notification requirements.
58-17H-30.1
Retroactive denial of paid claim--Restriction--Requirement--Exclusions--Enforcement.
58-17H-30.2
Retroactive denial of paid claim--Payment amount.
58-17H-31
Calculation of time period for determination for prospective and retrospective reviews.
58-17H-32
Notification of adverse determination--Contents.
58-17H-33
Information required to be provided to covered persons and prospective covered persons.
58-17H-34
Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.
58-17H-35
Registration of utilization review organizations--Required information.
58-17H-36
Filing changes in registration information.
58-17H-37
Requests for information from utilization review organizations.
58-17H-38
Activities of nonregistered utilization review organizations prohibited.
58-17H-39
Registration fee for utilization review organizations.
58-17H-40
Urgent care requests--Written procedures required for receipt and determination of requests.
58-17H-41
Insufficient information for determination--Notice and statement of necessary information.
58-17H-42
Insufficient information for determination of prospective urgent care requests.
58-17H-43
Urgent care requests--Timely notification of determination.
58-17H-44
Time within which to submit necessary information.
58-17H-45
Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.
58-17H-46
Concurrent review urgent care requests--Extended care requests--Time for determination and notice.
58-17H-47
Calculation of time periods for determination.
58-17H-48
Notification of adverse determination--Requirements.
58-17H-49
Promulgation of rules.
58-17H-50
Coverage for cancer treatment medication.
58-17H-51
Reclassification of benefits with respect to cancer treatment medications.
58-17H-52
Medical management practices complying with chapter.
58-17H-53
Step therapy protocols.
58-17H-54
Step therapy protocols--Process--Transparency.
58-17H-55
Step therapy override exceptions.
58-17H-56
Limitations.
58-17H-57
Utilization review organization or health carrier--Annual review--Report--Contents--Publication.
58-17H-58
Utilization review organization or health carrier--Health care service review--Prior authorization requirement elimination.
58-17H-59
Utilization review organization or health carrier--Health care service review--Annual report--Contents--Publication.
58-17H-60
Utilization review organization or health carrier--Health care service--Excluded services.