State Law

South Dakota Admin. Rules-Rule 20-06-Chapter 20-06-53. External and Internal Review

08/24/2023 South Dakota Section 20:06:53:69

Urgent care requests-Timely notification of determination-Initial benefit determination

State Medical Necessity Decisions-Deadlines

For an urgent care request in the context of an initial benefit determination, unless the covered person or the covered person’s authorized representative has failed to provide sufficient information for the health carrier to determine whether, or to what extent, the benefits requested are covered benefits or payable under the health carrier’s health benefit plan, the health carrier shall notify the covered person or, if applicable, the covered person’s authorized representative of the health carrier’s determination with respect to the request, whether or not the benefit determination is an adverse determination, as soon as possible, taking into account the medical condition of the covered person, but in no event later than twenty-four hours after the date of the receipt of the request by the health carrier.