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, 2^nd 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]