South Dakota 17C — Standards For Managed Care Plans
- 58-17C-1 — Definitions.
- 58-17C-2 — Medical director required for managed care plans.
- 58-17C-3 — Applicability of § 58-17C-2.
- 58-17C-4 — Applicability of 58-17C-4 and 58-17C-6.
- 58-17C-5 — Health carrier to provide written information to prospective enrollees--Specific information required.
- 58-17C-6 — Certain plans exempt from requirement of written information.
- 58-17C-7 — Applicability of §§ 58-17C-7 to 58-17C-26, inclusive.
- 58-17C-8 — Health carrier to maintain provider network sufficient to assure serviceswithout unreasonable delay--Emergency services--Determination ofsufficiency.
- 58-17C-9 — Where provider network is insufficient, covered benefit to be madeavailable at no greater cost.
- 58-17C-10 — Health carrier to ensure provider proximity to covered persons.
- 58-17C-11 — Health carrier to monitor provider ability, capacity, and authority--Financial capability to be monitored in capitated plans.
- 58-17C-12 — Factors to be considered in determining network adequacy.
- 58-17C-13 — Access plan required for managed care plans--Annual update--Contents--Discounted fee-for-service networks exempt.
- 58-17C-14 — Requirements for health carrier offering managed care plan.
- 58-17C-15 — Provisions governing contractual arrangements between health carriers andintermediaries.
- 58-17C-16 — Sample contract forms to be filed with director--Material changes to besubmitted to director--Certain changes not material--Director's inactionwithin certain time deemed approval--Contract copies to be provideddirector, department upon request.
- 58-17C-17 — Contract does not relieve health carrier of liability.
- 58-17C-18 — Remedies available to director against health carrier found not incompliance.
- 58-17C-19 — Director authorized to promulgate rules--Scope of rules.
- 58-17C-20 — Managed care contractors to register with director.
- 58-17C-21 — Health carrier to develop and maintain systems to measure quality ofservices--System requirements--Description of quality assessment programto be filed with director.
- 58-17C-22 — Health carrier issuing closed plan to develop quality improvementactivities--Minimum requirements of quality improvement activities.
- 58-17C-23 — Certain plans exempt from §§ 58-17C-7 to 58-17C-26, inclusive.
- 58-17C-24 — If private accrediting body satisfies requirements of §§ 58-17C-7 to 58-17C-26, inclusive, carrier may be deemed to have done so.
- 58-17C-25 — Health carriers offering individual policies exempt--Conditions.
- 58-17C-26 — Division of Insurance to monitor complaints against individual policies.
- 58-17C-27 — Health carrier to provide emergency services coverage without requiringprior authorization--Standards for determining whether emergency medicalcondition exists--Level of coverage.
- 58-17C-28 — Health carrier not to subsequently retract authorization after item orservice provided in reliance on authorization--Exceptions.
- 58-17C-29 — Emergency services coverage subject to limitations.
- 58-17C-30 — Access to representative for post-evaluation or post-stabilization services.
- 58-17C-31 — Access to emergency medical services.
- 58-17C-32 — Certain plans exempt from emergency medical service provisions.
- 58-17C-33 — If private accrediting body meets emergency medical coveragerequirements, health carrier may be deemed to have done so.
- 58-17C-34 — Applicability of chapter 17C.
- 58-17C-35 — Health carrier responsibility for utilization review activities.
- 58-17C-36 — Director to hold health carrier responsible for utilization reviewperformance of contractor.
- 58-17C-37 — Written utilization review program required--Contents of programdocument.
- 58-17C-38 — Utilization review program to use documented clinical review criteria--Criteria to be made available to authorized agencies upon request.
- 58-17C-39 — Program to be administered by qualified licensed health care professionals.
- 58-17C-40 — Determinations to be issued in a timely manner--Process to ensureconsistency.
- 58-17C-40.1 — Calculation of time period for determination for prospective andretrospective reviews.
- 58-17C-41 — Effectiveness and efficiency of program to be routinely reviewed.
- 58-17C-42 — Data systems must support program activities and generate managementreports.
- 58-17C-43 — Health carrier oversight of delegated activities--Requirements.
- 58-17C-44 — Utilization review to be coordinated with other medical managementactivity of health carrier.
- 58-17C-45 — Health carrier to provide free access to review staff.
- 58-17C-46 — Only information necessary for review or determination to be collected.
- 58-17C-47 — Prohibition against compensation influencing or based upon reviewdecisions.
- 58-17C-48 — Written procedures required for making determinations--Notification.
- 58-17C-49 — Prospective review determinations--Timing--Notification of requirements--Extension of time.
- 58-17C-50 — Concurrent review determinations--Timing--Notification requirements.
- 58-17C-51 — Retrospective review determinations--Timing--Notification requirements.
- 58-17C-52 — Notification of adverse determination--Contents.
- 58-17C-53 — Repealed.
- 58-17C-54 — Information required to be provided to covered persons and prospectivecovered persons.
- 58-17C-55 — Certain plans exempt from requirements of §§ 58-17C-34 to 58-17C-57,inclusive.
- 58-17C-56 — If private accrediting body meets requirements, health carrier may bedeemed to have met them.
- 58-17C-57 — Director authorized to promulgate rules--Scope of rules.
- 58-17C-58 — Establishment of grievance system by managed care plan or utilizationreview organization.
- 58-17C-59 — Record of grievances--Report.
- 58-17C-60 — Maintenance of grievance records--Accessibility.
- 58-17C-61 — Repealed.
- 58-17C-63 — Promulgation of rules for grievance system.
- 58-17C-64 — Registration of utilization review organizations--Required information.
- 58-17C-65 — Filing changes in registration information.
- 58-17C-66 — Requests of information from utilization review organizations.
- 58-17C-67 — Activities of nonregistered utilization review organizations prohibited.
- 58-17C-68 — Registration fee for utilization review organizations.
- 58-17C-69 — Application of §§ 58-17C-58 to 58-17C-68, inclusive.
- 58-17C-70 — "Urgent care request" defined.
- 58-17C-71 — Urgent care requests--Written procedures for receipt and determination ofrequests required.
- 58-17C-72 — Urgent care requests--Timely notification of determination.
- 58-17C-73 — Insufficient information for determination--Notice and statement ofnecessary information required.
- 58-17C-74 — Insufficient information for determination of prospective urgent carerequests.
- 58-17C-75 — Time within which to submit necessary information.
- 58-17C-76 — Urgent care requests--Notice of determination--Failure to submit necessaryinformation grounds for denial of certification--Notice of adversedeterminations.
- 58-17C-77 — Concurrent review urgent care requests--Requests for extended care--Timeto make determination and provide notice.
- 58-17C-78 — Calculation of time periods for determinations.
- 58-17C-79 — Notification of adverse determinations--Requirements.
- 58-17C-80 — Register of grievances required--Information to be compiled--Maintenance.
- 58-17C-81 — Report to director required--Contents of report.
- 58-17C-82 — Grievance procedures--Filing with director required--Certificate ofcompliance--Contact information required.
- 58-17C-83 — Review of adverse determinations--Time for filing--Designation andnotice of reviewers--Scope of review.
- 58-17C-84 — Review of adverse determinations--Rights of covered person or authorizedrepresentative--Access to documentation.
- 58-17C-85 — Review of adverse determinations--Time for issuing decisions andproviding notice--Calculation of time periods.
- 58-17C-86 — Issuance of decision--Required contents.
- 58-17C-87 — Health carrier to establish review procedures for grievances not involvingadverse determinations.
- 58-17C-88 — Standard review--Covered persons or authorized representatives entitledto submit written material only.
- 58-17C-89 — Designation of person(s) to conduct standard review--Notice to coveredperson or authorized representative.
- 58-17C-90 — Standard review--Time within which to notify covered person of decision--Extension of time.
- 58-17C-91 — Standard review--Required contents of written decision.
- 58-17C-92 — Additional voluntary review--Right of covered person to appear--Requirednotice--Not applicable to health indemnity plans.
- 58-17C-93 — Additional voluntary review--Required notice--Rights of coveredperson(s) or authorized representatives.
- 58-17C-94 — Appointment of panel for voluntary review of first level review decision--Scope of review--Composition of panel.
- 58-17C-95 — Standard review--Appointment of voluntary review panel--Compositionof panel.
- 58-17C-96 — Procedures for appearance before voluntary review panel--Legalrepresentation--Time for issuance of decision.
- 58-17C-97 — Notice and issuance of decision when covered person does not requestappearance--Time for issuance of decision.
- 58-17C-98 — Decision by voluntary review panel--Required contents.
- 58-17C-99 — Expedited review for adverse determinations involving urgent carerequests--Appointment of peers for review.
- 58-17C-100 — Expedited review not initial determination for benefits--Transmission ofnecessary information.
- 58-17C-101 — Expedited review decision not initial determination for benefits--Time ofnotification--Continuation of service involving concurrent review urgentcare requests.
- 58-17C-102 — Expedited review decision--Notification--Required contents.
- 58-17C-102.1 — Applicability of §§ 58-17C-40 to 58-17C-102, inclusive.
- 58-17C-103 — Promulgation of rules--Consistency with federal requirements.
- 58-17C-104 — Transferred.
- 58-17C-105 — Transferred.
- 58-17C-106 — Transferred.
- 58-17C-107 — Transferred.
- 58-17C-108 — Repealed.