What is external review?
External review is an independent look at certain final denials by a Division of Insurance–assigned independent review organization (IRO) with no connection to your health carrier.
Under ARSD 20:06:53 (implementing South Dakota external review law), external review addresses denials based on medical necessity, appropriateness, health care setting, level of care, or effectiveness—including experimental or investigational treatment. The IRO decision is binding on the health carrier. There is no cost to you; the carrier pays IRO fees.
General overview: Appeals roadmap. Complete South Dakota internal appeals first unless deemed exhaustion or waiver applies.
Who can use South Dakota review?
Division of Insurance external review generally applies when:
- You have SD-regulated commercial coverage (many HealthCare.gov and fully insured employer plans)
- The service is a covered benefit but denied for medical necessity, appropriateness, setting, level of care, or effectiveness—not pure contractual exclusions or eligibility-only disputes
- You exhausted internal grievance under SDCL 58-17I—or qualify for deemed exhaustion, waiver, or expedited bypass
Usually does not apply to:
- Self-funded ERISA employer plans (federal external review may still apply)
- Medicare, Medicaid, and other federal plans
- Services that are not covered benefits under your policy
The Division randomly assigns a certified IRO without a conflict of interest (Standard external review process).
Deadlines & exhaustion
Four months (ARSD 20:06:53:12)
File a written external review request with the Division of Insurance within four months after receipt of an adverse determination or final adverse determination.
Exhaust internal grievance first
Complete the carrier's SDCL 58-17I grievance unless the carrier waives exhaustion, you are deemed exhausted after 30 days without a written decision, or you qualify for expedited simultaneous review (ARSD 20:06:53:07).
Carrier preliminary review
Within 5 business days after the Division forwards your request, the carrier determines eligibility. If incomplete, the carrier must tell you what is needed; you may appeal a preliminary denial to the Division.
How to file
- Complete internal grievance when required and obtain a final adverse determination with external review rights.
- Submit the External Review Request Form to the Division of Insurance (forms linked from the external review page) within 4 months.
- For expedited review, call the Division at 605-773-3563 for filing instructions and include treating-provider certification that the standard timeline would jeopardize life, health, or ability to regain maximum function.
- After IRO assignment, submit additional records directly to the IRO; the carrier must forward its file within 5 business days or the IRO may reverse the denial for failure to cooperate.
Links hub: South Dakota external appeals links.
How long it takes
- Division opens file and forwards to carrier within 1 business day
- Carrier preliminary eligibility review within 5 business days
- Standard external review: IRO written decision within 45 days after assignment
- Expedited external review: shorter timeline when clinically urgent—contact Division for current expedited standards (ARSD 20:06:53:23–32)
- If the IRO reverses the denial, the carrier must immediately approve coverage
Is the decision binding?
For qualifying external reviews, the IRO decision is binding on the health carrier. If upheld, you may seek legal guidance; the Division cannot provide legal advice.
If the carrier fails to comply with an IRO decision, contact the Division of Insurance and consider remedies under applicable state law.
Medicaid & Medicare
South Dakota Medicaid: Request a fair hearing per the deadline on your DSS notice (Fair hearings, 605-773-6851)—not Division of Insurance commercial IRO review.
Medicare & Medicare Advantage: Federal Medicare appeals through CMS; South Dakota SHIP help via DAKOTA SHIP at dakotaoha.org/ship.
More: Medicaid managed care · Medicare appeals.