The bill amends South Dakota's legislation concerning preauthorization and utilization review for specific health care services and health benefit plans. A significant change is the expanded definition of "adverse determination," which now includes criteria such as medical necessity, appropriateness, and effectiveness. Additionally, before issuing an adverse determination, utilization review organizations are required to allow health care practitioners to discuss the treatment plan with a qualified physician or advanced practice professional. This provision will be effective for reviews requested on or after July 1, 2025. The bill also mandates that preauthorization processes for health benefit plans align with those of insurers, while explicitly excluding the state Medicaid program.

Moreover, the bill introduces provisions that ensure health maintenance organizations (HMOs) and insurers evaluate health care professionals for preauthorization exemptions annually, allowing providers with high approval rates to bypass preauthorization for certain services. It clarifies that compliance with medical policies does not impact exemption status and that health care professionals do not need to request exemptions to qualify. The bill also outlines the conditions for rescinding exemptions, including notification and appeal processes, and prohibits retroactive denial of payment for exempted services unless there is evidence of misrepresentation. These changes aim to enhance transparency and fairness in the preauthorization process, with the new regulations taking effect for requests made on or after July 1, 2025.

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