S.D. Admin. R. 20:06:21:92

Current through Register Vol. 51, page 67, December 16, 2024

Section 20:06:21:92 - Independent review process

Within five business days of receiving a written request for independent review, the insurer shall refer the request to the independent review organization that the insured or the insured's authorized representative has chosen from the list of organizations the insurer has provided to the insured. If the insured or the insured's authorized representative does not choose an approved independent review organization to perform the review, the insurer shall choose an independent review organization approved or certified by the director. The insurer shall vary its selection of authorized independent review organizations on a rotating basis.

The insurer shall refer the request for independent review of a benefit trigger determination to an independent review organization, subject to the following:

(1) The independent review organization shall be on a list of certified or approved independent review organizations that satisfy the requirements of a qualified long-term care insurance independent review organization contained in §§ 20:06:21:87 to 20:06:21:104, inclusive;

(2) The independent review organization may not have any conflicts of interest with the insured, the insured's authorized representative, if applicable, or the insurer; and

(3) Such review shall be limited to the information or documentation provided to and considered by the insurer in making its determination, including any information or documentation considered as part of the internal appeal process.

S.D. Admin. R. 20:06:21:92

36 SDR 209, effective 7/1/2010.

General Authority: SDCL 58-17B-4.

Law Implemented: SDCL 58-17B-4.