20:06:40:09.  Notification of determinations on preexisting waiting periods and appeal and reconsideration procedures. Within a reasonable time following the receipt of the certificate or other evidence of coverage, a plan or carrier must determine the length of any preexisting condition waiting period that applies to the individual and notify the individual of its determination. Whether a determination and notification are made within a reasonable period of time depends upon the relevant facts and circumstances, including whether the application of the preexisting condition waiting period would prevent access to urgent medical services. The plan or carrier is required to notify the individual, however, only if, after considering the evidence, it has determined that a preexisting condition waiting period will be imposed on the individual. The basis of the determination, including the source and substance of any information on which the plan or carrier relied, must be included in the notification. The notification must also explain the plan’s appeal procedures and the opportunity of the individual to present additional evidence.

          The plan or carrier may reconsider and modify its initial determination if it determines that the individual did not have the claimed creditable coverage. In this circumstance, the plan or carrier must notify the individual of the reconsideration and, until a final determination is made, must act in accordance with its initial determination for purposes of approving medical services.

          Source: 24 SDR 35, effective September 29, 1997.

          General Authority: SDCL 58-18-79.

          Law Implemented: SDCL 58-18-43, 58-18-45, 58-18-48, 58-18-79.