How to appeal a health insurance denial in South Dakota
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. South Dakota lets you ask an independent reviewer to decide, through South Dakota Division of Insurance (Department of Labor & Regulation). The deadline to ask: within four months of the denial.
Does this apply to you? State external review covers plans regulated by South Dakota: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in South Dakota
Within four months of the denial
Expedited external review is decided within 72 hours and requires your treating provider's certification (separate expedited request form). It can be requested at the same time as an expedited internal grievance; call the Division before sending paperwork.
Free (the former $25 filing fee was repealed effective November 28, 2023; the health carrier pays the IRO)
State-regulated plans (insurance bought in South Dakota or through an employer that buys insurance). Self-funded employer plans use the federal process.
File the Division's External Review Request Form with the Division of Insurance (124 S. Euclid Ave., 2nd Floor, Pierre, SD 57501; fax 605-773-5369) with your ID card copy, the final denial letter and your policy booklet; the Division forwards it to the insurer and assigns the IRO. Use the separate forms for expedited and experimental/investigational denials.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in South Dakota?
Within four months of the denial
Can I get a fast external review in South Dakota?
Expedited external review is decided within 72 hours and requires your treating provider's certification (separate expedited request form). It can be requested at the same time as an expedited internal grievance; call the Division before sending paperwork.
Does external review cost anything in South Dakota?
Free (the former $25 filing fee was repealed effective November 28, 2023; the health carrier pays the IRO)
Do South Dakota’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- SD Division of Insurance - External Review: Health Insurance/Major Medical
In order to be eligible, you must file within four months of the denial.
- ARSD 20:06:53:66 (Funding of external review)
The health carrier against which a request for any review subject to this chapter is filed shall pay the cost of the independent review organization for conducting the external review.
- ARSD 20:06:53:29 (Expedited review decision)
in no event more than 72 hours after the date of receipt of the request for an expedited external review
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.