The bill amends South Dakota's existing laws concerning preauthorization and utilization review for certain health care services and health benefit plans. A significant change is the expanded definition of "adverse determination," which now includes denials based on medical necessity, appropriateness, and the experimental nature of services. Additionally, it requires utilization review organizations to provide health care practitioners with a reasonable opportunity to discuss treatment plans prior to issuing an adverse determination, effective for reviews requested on or after July 1, 2025. The bill also mandates that preauthorization processes align with the limitations and requirements set for insurers, while explicitly excluding the state Medicaid program.

Furthermore, the bill introduces provisions for exemptions from preauthorization requirements for health care professionals and providers. Health maintenance organizations or insurers are allowed to grant exemptions without reevaluating qualifications during specific periods and do not require professionals to request an exemption to qualify. The bill outlines the process for rescinding exemptions, including notification and appeal opportunities, and mandates that any rescission be based on a retrospective review of claims. It also prohibits retroactive denial of payment for exempted services unless there is evidence of misrepresentation or service failure, ensuring that health care providers are informed and protected throughout the process.

Statutes affected:
Introduced, 01/22/2025: 58-17H-1