This bill amends South Dakota's laws concerning preauthorization and utilization review for certain health care services and health benefit plans. It redefines "adverse determination" to include denials based on medical necessity, appropriateness, and the experimental or investigational status of services. A significant new requirement mandates that utilization review organizations must offer health care practitioners a reasonable opportunity to discuss treatment plans and the clinical basis for any adverse determinations with a qualified physician or advanced practice professional before such determinations are issued. Additionally, the bill ensures that preauthorization processes align with the limitations and requirements set by insurers.

The legislation also introduces provisions for evaluating exemptions from preauthorization for health care professionals and providers, requiring health maintenance organizations and insurers to assess these exemptions every six months. Providers with a high approval rate for preauthorization requests may be exempt from obtaining preauthorization for certain services. The bill clarifies that exemptions remain effective until specific conditions are met and outlines the process for rescinding exemptions, including the need for retrospective reviews and advance notifications. Importantly, it prohibits retroactive denial of services based on rescinded exemptions unless there is evidence of misrepresentation or failure to perform the service. These changes will take effect for utilization reviews requested on or after July 1, 2025.

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