Chapter
UTILIZATION REVIEW AND BENEFIT DETERMINATIONS
- S.D. Codified Laws § 58-17H-1— Definitions
- S.D. Codified Laws § 58-17H-2— Health benefit plan defined
- S.D. Codified Laws § 58-17H-3— Urgent care request defined
- S.D. Codified Laws § 58-17H-4— Applicability of chapter
- S.D. Codified Laws § 58-17H-5— Health carrier to provide emergency services coverage without requiring prior authorization--Standards for coverage of emergency services
- S.D. Codified Laws § 58-17H-6— In-network emergency services
- S.D. Codified Laws § 58-17H-7— Cost-sharing requirements for out-of-network emergency services
- S.D. Codified Laws § 58-17H-8— Cost-sharing requirements for covered persons--Payments to out-of-network providers
- S.D. Codified Laws § 58-17H-9— Exceptions for payments by capitated and other plans without negotiated fees
- S.D. Codified Laws § 58-17H-10— Negotiated amounts for in-network providers for a particular emergency service
- S.D. Codified Laws § 58-17H-11— General cost-sharing requirements allowed
- S.D. Codified Laws § 58-17H-12— Access to representative for post-evaluation or post-stabilization services
- S.D. Codified Laws § 58-17H-13— Health carrier may be deemed to meet emergency medical coverage requirements if met by private accrediting body
- S.D. Codified Laws § 58-17H-14— Health carrier responsibility for utilization review activities
- S.D. Codified Laws § 58-17H-15— Director to hold health carrier responsible for utilization review performance of contractor
- S.D. Codified Laws § 58-17H-16— Written utilization review program required--Contents of program document
- S.D. Codified Laws § 58-17H-17— Utilization review program to use documented clinical review criteria--Criteria to be available to authorized agencies upon request
- S.D. Codified Laws § 58-17H-18— Program to be administered by qualified licensed health care professionals
- S.D. Codified Laws § 58-17H-19— Determinations to be issued in timely manner--Process to ensure consistency
- S.D. Codified Laws § 58-17H-20— Effectiveness and efficiency of program to be routinely reviewed
- S.D. Codified Laws § 58-17H-21— Data systems to support program activities and generate management reports
- S.D. Codified Laws § 58-17H-22— Health carrier oversight of delegated activities--Requirements
- S.D. Codified Laws § 58-17H-23— Utilization review to be coordinated with other medical management activity of health carrier
- S.D. Codified Laws § 58-17H-24— Health carrier to provide free access to review staff
- S.D. Codified Laws § 58-17H-25— Only information necessary for review or determination to be collected
- S.D. Codified Laws § 58-17H-26— Independence and impartiality required for utilization review
- S.D. Codified Laws § 58-17H-27— Written procedures required for making determinations--Notification
- S.D. Codified Laws § 58-17H-28— Prospective review determinations--Timing--Notification of requirements--Extension of time
- S.D. Codified Laws § 58-17H-29— Concurrent review determinations--Timing--Notification requirements
- S.D. Codified Laws § 58-17H-30— Retrospective review determinations--Timing--Notification requirements
- S.D. Codified Laws § 58-17H-30.1— Retroactive denial of paid claim--Restriction--Requirement--Exclusions--Enforcement
- S.D. Codified Laws § 58-17H-30.2— Retroactive denial of paid claim--Payment amount
- S.D. Codified Laws § 58-17H-31— Calculation of time period for determination for prospective and retrospective reviews
- S.D. Codified Laws § 58-17H-32— Notification of adverse determination--Contents
- S.D. Codified Laws § 58-17H-33— Information required to be provided to covered persons and prospective covered persons
- S.D. Codified Laws § 58-17H-34— Health carrier may be deemed to meet utilization review requirements if met by private accrediting body
- S.D. Codified Laws § 58-17H-35— Registration of utilization review organizations--Required information
- S.D. Codified Laws § 58-17H-36— Filing changes in registration information
- S.D. Codified Laws § 58-17H-37— Requests for information from utilization review organizations
- S.D. Codified Laws § 58-17H-38— Activities of nonregistered utilization review organizations prohibited
- S.D. Codified Laws § 58-17H-39— Registration fee for utilization review organizations
- S.D. Codified Laws § 58-17H-40— Urgent care requests--Written procedures required for receipt and determination of requests
- S.D. Codified Laws § 58-17H-41— Insufficient information for determination--Notice and statement of necessary information
- S.D. Codified Laws § 58-17H-42— Insufficient information for determination of prospective urgent care requests
- S.D. Codified Laws § 58-17H-43— Urgent care requests--Timely notification of determination
- S.D. Codified Laws § 58-17H-44— Time within which to submit necessary information
- S.D. Codified Laws § 58-17H-45— Urgent care requests--Notice of determination--Failure to submit necessary information as grounds for denial of certification
- S.D. Codified Laws § 58-17H-46— Concurrent review urgent care requests--Extended care requests--Time for determination and notice
- S.D. Codified Laws § 58-17H-47— Calculation of time periods for determination
- S.D. Codified Laws § 58-17H-48— Notification of adverse determination--Requirements
- S.D. Codified Laws § 58-17H-49— Promulgation of rules
- S.D. Codified Laws § 58-17H-50— Coverage for cancer treatment medication
- S.D. Codified Laws § 58-17H-51— Reclassification of benefits with respect to cancer treatment medications
- S.D. Codified Laws § 58-17H-52— Medical management practices complying with chapter
- S.D. Codified Laws § 58-17H-53— Step therapy protocols
- S.D. Codified Laws § 58-17H-54— Step therapy protocols--Process--Transparency
- S.D. Codified Laws § 58-17H-55— Step therapy override exceptions
- S.D. Codified Laws § 58-17H-56— Limitations
- S.D. Codified Laws § 58-17H-57— Utilization review organization or health carrier--Annual review--Report--Contents--Publication
- S.D. Codified Laws § 58-17H-58— Utilization review organization or health carrier--Health care service review--Prior authorization requirement elimination
- S.D. Codified Laws § 58-17H-59— Utilization review organization or health carrier--Health care service review--Annual report--Contents--Publication
- S.D. Codified Laws § 58-17H-60— Utilization review organization or health carrier--Health care service--Excluded services