47:03:04:01.  Definitions. Terms used in this chapter mean:

 

          (1)  "Assigned risk pool," the plan by which employers who are unable to procure workers' compensation policies by ordinary methods receive workers' compensation insurance coverage under SDCL 58-20-15;

 

          (2)  "Case management," on-going coordination of medical services to an injured employee;

 

          (3)  "Case management plan" or "plan," a plan certified by the department that is designed to manage the quality, cost, and utilization of medical services or treatment provided to an injured or disabled employee for injuries and diseases compensable under SDCL title 62;

 

          (4)  "Department," the Department of Labor and Regulation;

 

          (5)  "Emergency treatment," treatment provided to an individual who needs immediate medical care to prevent a serious health impairment, including treatment necessary to determine whether such an emergency exists;

 

          (6)  "Employee," an employee entitled to medical services or treatment for a compensable injury or disability under SDCL 62-4-1;

 

          (7)  "Insurer," an insurer providing workers' compensation insurance;

 

          (8)  "Medical provider," a health care provider licensed and practicing within the scope of a profession under the laws of the state in which services are being provided to an injured employee;

 

          (9)  "Medical services" or "treatment," any procedure, operation, consultation, supply, or product provided for the purposes of curing or relieving an employee of the effects of a compensable injury or disability;

 

          (10)  "Participating medical provider," a medical provider that the case management plan has engaged to provide medical services to injured or disabled employees;

 

          (11)  "Revocation," the termination of a case management plan's certification to provide services;

 

          (12)  "Self-insured employer's case management plan," a plan designed to provide case management and access to medical services for self-insured employers and employees;

 

          (13)  "Suspension," the discontinuance of a case management plan's authority to enter into contracts with insurers for a specific period of time;

 

          (14)  "Utilization review," objective evaluation of the necessity, appropriateness, efficiency, and quality of medical services provided to an injured or disabled employee.

 

          Source: 20 SDR 45, effective October 6, 1993; 21 SDR 225, effective July 5, 1995; 26 SDR 10, effective August 3, 1999; 38 SDR 105, effective December 12, 2011.

          General Authority: SDCL 58-20-24, 62-5-21.

          Law Implemented: SDCL 58-20-24, 62-5-21.