Expedited External Health Review Process
Expedited External Review Request — Administrative Rule of South Dakota (ARSD) 20:06:53:09
- DOI receives External Review Request Form and $25 filing fee along with Request for Expedited External Review.
- DOI opens file and assigns file number.
- Determination involves a medical condition which the timeframe for an expedited internal review would seriously jeopardize the life or health of the covered person.
- If the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated.
Preliminary Review of Request — ARSD 20:06:53:24
- Director immediately sends a copy of the request to the health carrier.
- Health carrier upon immediate receipt of request determines whether the request meets requirements.
- Health carrier immediately notifies the Director and covered person of its determination.
- Notice shall include a statement informing the covered person a health carrier's initial determination of ineligibility may be appealed to the Director.
Determination of Expedited Review — ARSD 20:06:53:26
- Director assigns IRO and immediately notifies the health carrier of which was chosen.
- Upon receipt the health carrier shall provide all information considered in making the adverse determination or final adverse determination to the IRO.
Information to be considered by IRO — ARSD 20:06:53:28
- Covered person's pertinent medical records.
- Attending health care professional's recommendation.
- Consulting reports from appropriate health car professionals.
- Terms of coverage.
- Most appropriate practice guidelines.
- Any applicable clinical reviews.
Expedited IRO Decision — ARSD 20:06:53:29
As expeditiously as the covered person's medical condition or circumstance requires, but in no event more than 72 hours after the receipt of the request for an expedited external review the IRO shall:
- Make a decision to uphold or reverse the adverse determination.
- Notify the covered person, health carrier and Director of the decision in writing.
Notice shall include:
- A general description of the reason for the request for external review;
- The date the independent review organization received the assignment from the Director to conduct the external review;
- The date the external review was conducted;
- The date of its decision;
- The principal reason or reasons for its decision, including what applicable, if any, evidence based standards were a basis for its decision;
- The rationale for its decision; and
- References to the evidence or documentation, including the evidence-based standards, considered in reaching its decision.
- The coverage that was subject should be immediately approved by the health carrier if the IRO reverses the initial determination.
Expedited External Review Funding — ARSD 20:06:53:66
- DOI sends $25 refund of filing fee to covered person if decision was reversed.
- DOI sends $25 filing fee to the health carrier if decision was upheld.
DOI closes file and sends correspondence to covered person and/or authorized representative.