South Dakota

My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • File a grievance;
  • Request an external review; and
  • File a complaint.

 How do I file a grievance?

If your insurer denies your claim, you have the right to file a grievance.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file a grievance, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can file a grievance.
  • Collect information. In addition to the determination letter, collect the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing a grievance, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the grievance process. Someone in his or her office might help you fill out the forms to request a grievance and draft a strong grievance letter.
  • Submit the grievance request. You or someone in your health care provider’s office should submit the grievance forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Request an expedited review of urgent care requests. You can request an expedited review if you require urgent care. Your request is urgent if:
    • Waiting 30 to 60 days to receive the requested service or treatment could seriously jeopardize your life, health, or ability to regain function;
    • You would be subjected to severe pain that cannot be adequately managed without the requested treatment or service, or
    • Your case involves an urgent care request involving an admission, availability of care, continued stay, or health care service and you have received emergency services but have not been discharged from the facility.[2]

Contact your insurer to ask for instruction on how to request an expedited internal appeal.

  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the grievance, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

How long should the grievance process take?

The grievance process should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.[3] If you have requested an expedited grievance, the process should take no more than 72 hours.[4]

In which circumstances can I apply for an external review?

During an external review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under South Dakota law, you are entitled to request an external review if your insurer denies your coverage after a grievance.

You can also request an expedited external appeal if:

  • Your medical situation is urgent and waiting would jeopardize your life or ability to function;
  • The initial denial of coverage is based on the health insurer’s determination that the treatment is experimental or investigational; or
  • Your physician certifies in writing that the requested service or treatment would be significantly less effective if not promptly initiated.[6]

You can request an expedited external review while you request an expedited grievance review.[7]

How do I request an external review?

You should submit your request for an external review to the South Dakota Division of Insurance within four months from when your insurer sent you the final decision.[8]

Information

You can find a copy of the external review request form here. Your request should include the following information:

  • The name of the applicant;
  • The name, address, email address, and telephone number of the insured/patient;
  • The name and address of the insurance company;
  • The name, email address, and telephone number of the insurance company contact person;
  • Insurance identification number and claim/reference number;
  • The name and telephone number of your employer;
  • The name and address of your health care provider;
  • The name and telephone number of the contact person at your health care provider’s office;
  • Your medical record number;
  • Reason for health care denial; and
  • Summary of external review request.[9]

Supporting documents

You should include the following documents with your request:

  • A filing fee of $25 (check or money order) made payable to the South Dakota Division of Insurance;
  • A copy of your insurance card or other evidence of coverage;
  • Final determination letter from your health insurer;
  • Copy of certificate of coverage or insurance policy benefit booklet;
  • Any relevant medical records;
  • Information from your health insurer related to the denial;
  • Any relevant peer literature or clinical studies;
  • Any additional information from your health care provider; and
  • Any new documentation or information not previously submitted during the grievance process.[10]

Submitting a standard external review

If you are requesting a standard external review, you should submit your request to the following address:

South Dakota Division of Insurance
124 S. Euclid Avenue, 2nd Floor
Pierre, SD 57501-3185[11]

Submitting an expedited review

If you are requesting an expedited external review, call the Division of Insurance at (605) 773-3563 for instructions on submitting your request.[12]

How long will the external review process take?

The external review process should take no more than 60 days.[13] If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.[14]

Should I file my complaint with the Division of Insurance or the Office of Attorney General?

Both the South Dakota Division of Insurance and the Office of Attorney General (“Office”) handle complaints involving health insurance companies. If your case involves a claim dispute (denial of service or treatment, payment for received services), you should file your complaint with the Division of Insurance. If your case involves possible fraud or misleading or deceptive practices, you should file your complaint with the Office. If you are unsure where to file your complaint, you should contact the Division of Insurance or Office of Attorney General prior to completing the complaint form and they can assist you.

How do I file a complaint with the Division of Insurance?

If you are a South Dakota resident and your claim is denied after the external review process, you can file a complaint with the Division of Insurance.

Complaint information

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured;
  • The name of the insurance company;
  • The type of insurance, policy number, and claim number; and
  • A description of the complaint.

Supporting documents

You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior grievances and complaints;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[15]

How to submit

The complaint may be submitted online here, faxed to (605) 773-5369, or mailed to the following address:

South Dakota Division of Insurance
124 S. Euclid Avenue, 2nd Floor
Pierre, SD 57501[16]

What happens after the Division of Insurance receives my complaint?

The Division of Insurance will investigate your complaint and notify you of its findings.

How do I file a complaint with the Office of Attorney General?

If you are a South Dakota resident, you can file a complaint with the South Dakota Office of Attorney General, Division of Consumer Protection (“Division of Consumer Protection”).

Complaint information

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name, address, and telephone number of insurance company;
  • Actions you have taken to resolve the issue; and
  • The details of the complaint.

Supporting documents

You should submit the following supporting documents with your complaint:

  • A signed medical records release form, available here;
  • A copy of your insurance card;
  • Copies of determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior grievances and complaints;
  • Supporting documentation from your doctor;
  • A copy of your insurance policy; and
  • All responses from your insurer.[17]

How to submit

The complaint may be submitted online here, faxed to (605) 773-7163, or mailed to the following address:

Office of Attorney General
Division of Consumer Protection
1302 E. Hwy. 14, Suite 3
Pierre, SD 57501-8053[18]

What happens after the Office of Attorney General receives my complaint?

Once the Office of Attorney General receives your complaint, an investigator will review it and forward a copy to your health insurer. Your health insurer will have 20 days to respond to your complaint. The Division of Consumer Protection may begin an investigation or mediate the claim between you and your health insurer.[19]

Who should I call if I have any questions about filing a complaint?

You can contact the South Dakota Office of Attorney General at (800) 300-1986 (in-state) or (605) 773-4400. The Attorney General’s Office is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.

You can contact the Division of Insurance at (605) 773-3563. The Division is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.


[1] Appealing a Health Plan Decision: How to Appeal an Insurance Company Decision, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/appeals/ (last visited Nov. 26, 2016).

[2] S.D. Codified Laws §§ 58-17I-3, 58-17I-12 (2016).

[3] S.D. Codified Laws § 58-17I-9 (2016).

[4] S.D. Codified Laws § 58-17I-14 (2016).

[5] Appealing a Health Plan Decision: External Review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 26, 2016).

[6] S.D. Admin. R. 20:06:53:09 (2016).

[7] Id.

[8] Standard External Health Review Process, S.D. Dept. of Labor and Regulation, http://dlr.sd.gov/insurance/companies/external_review_standard_health.aspx (last visited Nov. 26, 2016); see also Check List: South Dakota External Review Application, S.D. Division of Insurance, http://dlr.sd.gov/insurance/consumers/consumer_documents/external_review_checklist.pdf (last visited Nov. 26, 2016).

[9] Id.

[10] Id.

[11] Id.

[12] Id.

[13] Standard External Health Review Process, S.D. Dept. of Labor and Regulation, http://dlr.sd.gov/insurance/companies/external_review_standard_health.aspx (last visited Dec. 1, 2016).

[14] S.D. Admin. R. 20:06:53:29 (2016).

[15] Complaint to Federal Government Agency: Patient, Legal Action Ctr., https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx (last visited Oct. 17, 2016).

[16] Online Complaint Form, S.D. Division of Insurance, https://www.state.sd.us/eforms/secure/eforms/E1997V3-OnlineComplaintForm.pdf (last visited Nov. 26, 2016).

[17] Complaint to Federal Government Agency: Patient, Legal Action Center, https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx (last visited Oct. 17, 2016).

[18] Complaint Form, S.D. Office of Attorney General, http://consumer.sd.gov/complaintform.aspx (last visited Nov. 26, 2016).

[19] Id.