S.D. Admin. R. 20:06:21:99

Current through Register Vol. 51, page 57, November 12, 2024

Section 20:06:21:99 - Review decision requirements

The independent review organization shall provide the insured and the insured's authorized representative, if applicable, the insurer, and the director written notice of its decision, within 30 calendar days from receipt of the referral to the independent review organization by the insurer pursuant to § 20:06:21:92. If the independent review organization overturns the insurer's decision, the independent review organization shall:

(1) Establish the precise date within the specific period of time under review that the benefit trigger was deemed to have been met;

(2) Specify the specific period of time under review for which the insurer declined eligibility, but during which the independent review organization deemed the benefit trigger to have been met; and

(3) For tax-qualified long-term care insurance contracts, provide a certification made by a licensed health care practitioner as defined by subdivision 20:06:21:01(21) that the insured is a chronically ill individual.

The independent review organization's determination shall be used solely to establish liability for benefit trigger decisions, and is intended to be admissible in any proceeding only to the extent it establishes the eligibility of benefits payable. Nothing in §§ 20:06:21:87 to 20:06:21:104, inclusive, restricts the insured's right to submit a new request for benefit trigger determination after the independent review decision, if the independent review organization upholds the insurer's decision.

The decision of the independent review organization with respect to whether the insured met the benefit trigger will be final and binding on the insurer, except to the extent the insurer has other remedies available under applicable state or federal law. However, if the decision of the independent review organization is that a benefit trigger has been met and the insurer has sought other applicable state or federal remedies in lieu of accepting the decision of the independent review organization, then the insurer shall provide notice to the director within 30 days of that decision. Nothing in this section prevents the director upon receipt of notice from initiating administrative proceedings pursuant to § 20:06:21:108, SDCL 58-6-46, 58-6-47, or 58-33-67.

S.D. Admin. R. 20:06:21:99

36 SDR 209, effective 7/1/2010.

General Authority: SDCL 58-17B-4.

Law Implemented: SDCL 58-17B-4.