The bill amends South Dakota's existing laws on 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 whether services are experimental or investigational. The bill mandates that utilization review organizations must provide health care practitioners with a reasonable opportunity to discuss treatment plans with a qualified physician before issuing an adverse determination, effective for reviews requested on or after July 1, 2025. Additionally, it requires that preauthorization processes for health benefit plans align with those used by insurers, while explicitly excluding the state Medicaid program.

The legislation also introduces provisions for exemptions from preauthorization requirements for health care professionals and providers. Health maintenance organizations and insurers can maintain these exemptions without regular evaluations for certain periods, and professionals are not required to request exemptions to qualify. The bill establishes a rescission process for exemptions, including provider notification and appeal rights, and prohibits retroactive denial of services based on rescinded exemptions. It ensures that providers are not penalized for services covered under the exemption and mandates timely notification regarding exemption status. Overall, the bill aims to streamline the exemption process while safeguarding the rights of health care providers.

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