20:06:53:09.  Request for expedited review. At the same time a covered person or the covered person's authorized representative files a request for an expedited review of a grievance involving an adverse determination as set forth in SDCL 58-17I-12 to 58-17I-15, inclusive, the covered person or the covered person's authorized representative may file a request for an expedited external review of the adverse determination based upon:

          (1)  Under §§ 20:06:53:23 to 20:06:53:32, inclusive, if the covered person has a medical condition where the timeframe for completion of an expedited review of the grievance involving an adverse determination set forth in SDCL 58-17I-12 to 58-17I-15, inclusive, would seriously jeopardize the life or health of the covered person or would jeopardize the covered person's ability to regain maximum function; or

          (2)  Under §§ 20:06:53:33 to 20:06:53:53, inclusive, if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person's treating physician certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated.

          Source: 37 SDR 48, effective September 22, 2010; 37 SDR 241, effective July 1, 2011.

          General Authority: SDCL 58-17-87, 58-17H-49, 58-17I-16, 58-18-79.

          Law Implemented: SDCL 58-17-87, 58-18-79.