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

  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Oversight: Committee review of the activities of a Federal agency or program.
  • Person: includes natural persons, partnerships, associations, cooperative corporations, limited liability companies, and corporations. See South Dakota Codified Laws 2-14-2
  • Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
  • Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
  • State: when used in context signifying a jurisdiction other than the State of South Dakota, a state, the District of Columbia, a territory, commonwealth, or possession of the United States of America, or a province of the Dominion of Canada. See South Dakota Codified Laws 58-1-2
  • Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
  • written: include typewriting and typewritten, printing and printed, except in the case of signatures, and where the words are used by way of contrast to typewriting and printing. See South Dakota Codified Laws 2-14-2