The bill amends South Dakota law to enhance the preauthorization and utilization review processes for certain health care services and health benefit plans. It expands the definition of "adverse determination" to include criteria such as medical necessity and whether a service is experimental. The legislation clarifies the role of an "authorized representative" and introduces new definitions for health maintenance organizations, managed care contractors, and utilization review organizations. A significant provision requires that before an adverse determination is made, the utilization review organization must allow health care practitioners a reasonable opportunity to discuss the treatment plan with a qualified physician or advanced practice professional.

Additionally, the bill establishes that preauthorization processes must align with the limitations and requirements set by insurers, while explicitly excluding the state Medicaid program. It mandates annual evaluations of health care professionals for preauthorization exemptions, ensuring that those with high approval rates may not need to obtain preauthorization for certain services. The legislation also protects against retroactive payment denials for exempted services, unless there is evidence of misrepresentation. It requires timely notifications regarding exemption status and emphasizes that the bill does not authorize services outside the scope of licensure, applying to preauthorization requests made on or after July 1, 2025. Overall, the bill aims to streamline the preauthorization process while ensuring fairness and transparency for health care providers.

Statutes affected:
Introduced, 01/30/2025: 58-17H-1