Utilization Review And Benefit Determinations

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  2. South Dakota Codified Laws
  3. Insurance
  4. Utilization Review And Benefit Determinations

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Section
58-17H-1

Definitions.

Section
58-17H-2

Health benefit plan defined.

Section
58-17H-3

Urgent care request defined.

Section
58-17H-4

Applicability of chapter.

Section
58-17H-5

Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services.

Section
58-17H-6

In-network emergency services.

Section
58-17H-7

Cost-sharing requirements for out-of-network emergency services.

Section
58-17H-8

Cost-sharing requirements for covered persons--Payments to out-of-network providers.

Section
58-17H-9

Exceptions for payments by capitated and other plans without negotiated fees.

Section
58-17H-10

Negotiated amounts for in-network providers for a particular emergency service.

Section
58-17H-11

General cost-sharing requirements allowed.

Section
58-17H-12

Access to representative for post-evaluation or post-stabilization services.

Section
58-17H-13

Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body.

Section
58-17H-14

Health carrier responsibility for utilization review activities.

Section
58-17H-15

Director to hold health carrier responsible for utilization review performance of contractor.

Section
58-17H-16

Written utilization review program required--Contents of program document.

Section
58-17H-17

Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request.

Section
58-17H-18

Program to be administered by qualified licensed health care professionals.

Section
58-17H-19

Determinations to be issued in timely manner--Process to ensure consistency.

Section
58-17H-20

Effectiveness and efficiency of program to be routinely reviewed.

Section
58-17H-21

Data systems to support program activities and generate management reports.

Section
58-17H-22

Health carrier oversight of delegated activities--Requirements.

Section
58-17H-23

Utilization review to be coordinated with other medical management activity of health carrier.

Section
58-17H-24

Health carrier to provide free access to review staff.

Section
58-17H-25

Only information necessary for review or determination to be collected.

Section
58-17H-26

Independence and impartiality required for utilization review.

Section
58-17H-27

Written procedures required for making determinations--Notification.

Section
58-17H-28

Prospective review determinations--Timing--Notification of requirements--Extension of time.

Section
58-17H-29

Concurrent review determinations--Timing--Notification requirements.

Section
58-17H-30

Retrospective review determinations--Timing--Notification requirements.

Section
58-17H-31

Calculation of time period for determination for prospective and retrospective reviews.

Section
58-17H-32

Notification of adverse determination--Contents.

Section
58-17H-33

Information required to be provided to covered persons and prospective covered persons.

Section
58-17H-34

Health carrier may be deemed to meet utilization review requirements if met by private accrediting body.

Section
58-17H-35

Registration of utilization review organizations--Required information.

Section
58-17H-36

Filing changes in registration information.

Section
58-17H-37

Requests for information from utilization review organizations.

Section
58-17H-38

Activities of nonregistered utilization review organizations prohibited.

Section
58-17H-39

Registration fee for utilization review organizations.

Section
58-17H-40

Urgent care requests--Written procedures required for receipt and determination of requests.

Section
58-17H-41

Insufficient information for determination--Notice and statement of necessary information.

Section
58-17H-42

Insufficient information for determination of prospective urgent care requests.

Section
58-17H-43

Urgent care requests--Timely notification of determination.

Section
58-17H-44

Time within which to submit necessary information.

Section
58-17H-45

Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification.

Section
58-17H-46

Concurrent review urgent care requests--Extended care requests--Time for determination and notice.

Section
58-17H-47

Calculation of time periods for determination.

Section
58-17H-48

Notification of adverse determination--Requirements.

Section
58-17H-49

Promulgation of rules.

Section
58-17H-50

Coverage for cancer treatment medication.

Section
58-17H-51

Reclassification of benefits with respect to cancer treatment medications.

Section
58-17H-52

Medical management practices complying with chapter.

Section
58-17H-53

Step therapy protocols.

Section
58-17H-54

Step therapy protocols--Process--Transparency.

Section
58-17H-55

Step therapy override exceptions.

Section
58-17H-56

Limitations.