This bill amends South Dakota's legislation concerning preauthorization and utilization review for specific health care services and health benefit plans. It expands the definition of "adverse determination" to include denials based on medical necessity, appropriateness, and the experimental or investigational status of services. The bill also broadens the role of authorized representatives in the preauthorization process to include family members and health care professionals under certain conditions. A significant requirement introduced is that utilization review organizations must allow health care practitioners to discuss treatment plans prior to issuing adverse determinations. Additionally, the bill mandates that preauthorization processes align with the limitations and requirements set by insurers, while explicitly excluding the state Medicaid program.

Moreover, the bill establishes that health maintenance organizations (HMOs) and insurers must evaluate health care professionals for preauthorization exemptions annually, ensuring that providers with high approval rates may not need to obtain preauthorization for certain services. It clarifies that compliance with medical policies does not impact exemption status and allows HMOs or insurers to maintain exemptions without evaluating provider qualifications for specific periods. The bill also outlines the process for rescinding exemptions, mandates timely notifications regarding exemptions, and prohibits denial or reduction of payments for exempted services unless misrepresentation is evident. Importantly, health care professionals can appeal adverse determinations through independent review organizations without first undergoing internal appeals, and the provisions will take effect for requests made on or after July 1, 2025.

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