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State guide

South Dakota

Pick the kind of plan you have to see who to call first. South Dakota can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

The short version for South Dakota

South Dakota runs its own external review process through the Division of Insurance: you send the request form to the Division, which assigns an independent review organization at random. The state has no dedicated Consumer Assistance Program or health care ombudsman, so the Division of Insurance and legal aid are the main sources of free help. State law gives you a step therapy exception process that is automatically granted if the insurer misses its deadline.

At a glance: independent review for plans South Dakota regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
South Dakota Department of Labor and Regulation, Division of Insurance · 605.773.3563
Independent review
A state process (External Review)
Deadline to request it
Within four months after you receive the notice of the denial (adverse determination or final adverse determination)
Cost
No fee is mentioned on the Division's page or request form; state rule says the health carrier pays the cost of the independent review organization
Decision time
The independent review organization must decide within 45 days; the Division says the whole process can take up to two months. For experimental or investigational denials, clinical reviewers have 20 days and the organization then has 20 more days.; fast track: As fast as your condition requires and no more than 72 hours after the request is received

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

The Division of Insurance says federal law (the Employee Retirement Income Security Act) preempts state authority over self-insured private employer plans. The state external review request form asks whether your employer coverage is a self-funded plan and says to check with your employer if you are not certain.

Independent (external) review

Process
A state process. Run by South Dakota Division of Insurance, which randomly assigns an approved independent review organization.
Where you file
regulator
How
Complete the External Review Request Form and send it to the South Dakota Division of Insurance, Attn: External Review, 124 S. Euclid Ave., 2nd Floor, Pierre, SD 57501 (fax 605.773.5369, email SDComplaints@state.sd.us). Include a copy of your insurance card, the insurer's final denial letter, and your policy or benefit booklet. For an urgent (expedited) request, call the Division first at 605.773.3563; a physician must complete the separate expedited form.
Which denials qualify
Denials where the insurer decided a covered service does not meet its requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and denials because a treatment is considered experimental or investigational.
Appeal to the plan first?
Yes. Exceptions in state rule: you filed a grievance and got no written decision within 30 days (this does not apply to denials of care already received); the insurer agrees to waive the requirement; your situation is urgent and qualifies for expedited external review; or the insurer failed to strictly follow the required internal appeal process.

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in South Dakota

Medicare and Medicaid in South Dakota

Medicare counseling
Senior Health Information and Insurance Education (SHIINE) · 1-888-854-5321 . Free help with Medicare appeals.
Medicaid agency
South Dakota Department of Social Services (South Dakota Medicaid)
Fair hearing deadline
Within 30 days from the date you received the written notice; the Department says the exact deadline is stated on your notice. Your notice states the deadline that applies to you.
Good to know
Send a written hearing request to the Department of Social Services, Office of Administrative Hearings, 700 Governors Drive, Pierre, SD 57501 (phone 605.773.6851, email admhrngs@state.sd.us), saying what action you are appealing. In most cases the administrative law judge must issue a final decision within 90 days of your request. The Department's pages do not state the deadline for keeping benefits during the appeal; check your notice.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • External review. Gives you four months to ask the Division of Insurance for an independent external review, with a 45-day standard decision, a 72-hour expedited decision, and the insurer paying for the review.

    Administrative Rules of South Dakota chapter 20:06:53

  • Step therapy. Insurers must offer a clear process to request a step therapy override and must decide within five calendar days (72 hours if urgent); if they miss the deadline the exception is deemed granted, and a denial can be appealed through the grievance process.

    South Dakota Codified Laws 58-17H-54 and 58-17H-55

  • Prior authorization. Insurers must review their prior authorization requirements every year, drop them for services that are routinely approved, and report approval and denial numbers that the Division of Insurance publishes.

    2026 House Bill 1199; South Dakota Codified Laws 58-17H-57

  • Mental health parity. Health insurance policies must cover biologically-based mental illnesses (schizophrenia and other psychotic disorders, bipolar disorder, major depression and obsessive-compulsive disorder) with the same dollar limits, deductibles, coinsurance and restrictions as other illnesses.

    South Dakota Codified Laws 58-17-98

  • Other. Every health carrier must have an internal grievance procedure for reviewing denials, including an expedited review for urgent care requests; a cancellation of coverage (rescission) also counts as a denial you can appeal.

    South Dakota Codified Laws chapter 58-17I

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Division of Insurance: External Review - Health Insurance/Major Medical
  2. South Dakota External Review Application checklist and request form
  3. Division of Insurance: Standard External Health Review Process
  4. Division of Insurance: Expedited External Review Process
  5. Division of Insurance: Experimental and Investigational External Health Review Process
  6. Administrative Rule 20:06:53 (external review), South Dakota Legislature
  7. Division of Insurance: Insurance Consumer Information
  8. Division of Insurance: Complaint Process
  9. Division of Insurance: Health Insurance
  10. Division of Insurance: Health Care Bills - How to Appeal a Denied Claim
  11. Centers for Medicare & Medicaid Services: State External Appeals Review Processes
  12. Centers for Medicare & Medicaid Services: Consumer Assistance Program contacts, South Dakota
  13. Senior Health Information and Insurance Education (SHIINE)
  14. State Health Insurance Assistance Program National Technical Assistance Center: South Dakota
  15. South Dakota Department of Social Services: Fair Hearings
  16. South Dakota Department of Social Services: Medicaid rights and responsibilities
  17. Administrative Rule 67:17:02:04 (time limits for requesting hearing)
  18. Codified Law 58-17H (utilization review and step therapy)
  19. 2026 House Bill 1199 (prior authorization)
  20. Codified Law 58-17-98 (biologically-based mental illness coverage)
  21. Codified Law 58-17I (grievance procedure)
  22. About Legal Aid in South Dakota (SD Law Help)
Not confirmed (8)
  • The cost of independent review. no official page says in so many words that filing is free; the Division's page and form list no fee and rule 20:06:53:66 makes the health carrier pay the independent review organization
  • A searchable list of past decisions. no published database of past decisions found on the Division's site
  • Published results of independent review. no officially published overturn rate found
  • Which denials qualify for independent review. taken from the preliminary review test in rule 20:06:53:12 and the request form; whether rescissions and eligibility denials also qualify was not confirmed
  • Free consumer help programs. the federal directory lists no Consumer Assistance Program for South Dakota; the legal aid entry has no phone because SD Law Help takes applications online
  • The Medicaid fair hearing deadline. the 30 days from receipt wording is on the Medicaid rights page (written about application decisions); the fair hearing page only says the deadline is on the notice, and rule 67:17:02:04 says thirty days after notice of the action
  • Notes on Medicaid appeals. deadline to keep benefits during an appeal not found on a state page
  • State laws that help. House Bill 1199 confirmed as codified at 58-17H-57 (section 1); the codified section numbers for the rest of the bill were not checked

Sources last checked . Found a mistake? Report it.