State Law

South Dakota Codified Laws-Title 58-Chapter. 17H. Utilization Review and Benefit Determinations

08/24/2023 South Dakota Section 58-17H-29

Concurrent review determinations–Timing–Notification requirements

State Medical Necessity Decisions-Deadlines

For concurrent review determinations, if a health carrier has certified an ongoing course of treatment to be provided over a period of time or number of treatments:

(1) Any reduction or termination by the health carrier during the course of treatment before the end of the period or number treatments, other than by health benefit plan amendment or termination of the health benefit plan, shall constitute an adverse determination; and

(2) The health carrier shall notify the covered person of the adverse determination in accordance with § 58-17H-32 at a time sufficiently in advance of the reduction or termination to allow the covered person or, if applicable, the covered person’s authorized representative, to file a grievance to request a review of the adverse determination pursuant to §§ 58-17I-1 to 58-17I-15, inclusive, and obtain a determination with respect to that review of the adverse determination before the benefit is reduced or terminated.

The health care service or treatment that is the subject of the adverse determination shall be continued without liability to the covered person until the covered person has been notified of the determination by the health carrier with respect to the internal review request made pursuant to chapter 58-17I. (SL 2012, ch 239, § 1 provides: “The provisions of chapter 219 of the 2011 Session Laws shall be deemed repealed if the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010) is found to be unconstitutional in its entirety by a final decision of a federal court of competent jurisdiction and all appeals exhausted or time for appeals elapsed.”)