Rule 20:06:40:09 Notification of determinations on preexisting waiting periods and appeal and reconsideration procedures.
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.
24 SDR 35, effective September 29, 1997.
Authority: SDCL 58-18-79.
Implemented: SDCL 58-18-43, 58-18-45, 58-18-48, 58-18-79.
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