S.D. Admin. R. 20:06:21:90
If the insurer's original determination is upheld upon internal appeal, the notice of the internal appeal decision shall describe any additional internal appeal rights offered by the insurer. Nothing in this chapter requires the insurer to offer any internal appeal rights other than those described in §§ 20:06:21:89 and 20:06:21:90.
If the insurer's original determination is upheld after the internal appeal process has been exhausted, and new or additional information has not been provided to the insurer, the insurer shall provide a written description of the insured's right to request an independent review of the benefit determination as described in §§ 20:06:21:91 to 20:06:21:100, inclusive, to the insured and the insured's authorized representative, if applicable.
As part of the written description of the insured's right to request an independent review, an insurer shall include the following, or substantially equivalent, language:
"We have determined that the benefit eligibility criteria ("benefit trigger") of your [policy] [certificate] has not been met. You have the right to an independent review of our decision conducted by long-term care professionals who are not associated with us. Please send a written request for independent review to us at [address]. You must inform us, in writing, of your election to have this decision reviewed within 120 days of receipt of this letter. Listed below are the names and contact information of the independent review organizations approved or certified by the director to conduct long-term care insurance benefit eligibility reviews. If you wish to request an independent review, please choose one of the listed organizations and include its name with your request for independent review. If you elect independent review, but do not choose an independent review organization with your request, we will choose one of the independent review organizations for you and refer the request for independent review to that organization."
If the insurer does not believe the benefit trigger decision is eligible for independent review, the insurer shall inform the insured and the insured's authorized representative, if applicable, and the director in writing and include in the notice the reasons for its determination of independent review ineligibility.
The appeal process described in §§ 20:06:21:89 and 20:06:21:90 is not deemed to be a new service or provider as referenced in § 20:06:21:82; and therefore does not trigger the notice requirements of that section.
S.D. Admin. R. 20:06:21:90
General Authority: SDCL 58-17B-4.
Law Implemented: SDCL 58-17B-4.