Administrative Rule 47:03:04 | South Dakota Legislature

(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.

Rule 47:03:04:02 Application.

47:03:04:02. Application. Any person or entity may apply in writing to the department to have a plan certified that provides management of medical services or treatment to employees for injuries and diseases compensable under SDCL title 62. A certificate is valid for the period the department specifies in the certificate unless it is revoked or suspended. The application shall be made on a form provided by the department and shall include the following information:

(1) The names and addresses of any officers or directors of the case management plan;

(2) The name and title of the day-to-day administrator of the plan;

(3) The address of the place of business where the plan will be administered and records kept;

(4) The name, address, and phone number of a contact person for the plan;

(5) The names, addresses, and specialties of all participating medical providers who will provide services under the case management plan, together with a statement declaring that the providers have complied with any licensing or certification requirements for those providers to practice in South Dakota;

(6) A copy of the standard agreement that participating medical providers sign and a description of any other arrangements with medical providers who may deliver services to an employee;

(7) The names and credentials of the individuals who will be making final utilization review or medical case management decisions for the plan. The individuals must be licensed, registered, or certified health care providers under SDCL title 36;

(8) A description of the times, places, and manner of providing services under the plan to demonstrate that the case management plan meets the certification requirements of § 47:03:04:03;

(9) The treatment standards the plan has developed for medical services that the plan intends to use in reviewing medical services, including reference to the source of the treatment standards. No plan may be certified without comprehensive treatment standards developed for workers' compensation injuries and disabilities. Treatment standards developed by the plan are subject to review and approval by the department; and

(10) Any other materials requested by the department.

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

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

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

Rule 47:03:04:02.01 Renewal process.

47:03:04:02.01. Renewal process. Any case management plan which has previously been certified in this state shall, by July 1 of each year, renew and file any changes to the annual registration for the case management plan. Failure to file the renewal will result in a lapse in the case management plan certification.

The fee for initial or annual registration of a case management plan is $250.

Source: 21 SDR 4, effective July 18, 1994; 26 SDR 10, effective August 3, 1999; 34 SDR 310, effective June 19, 2008; 38 SDR 105, effective December 12, 2011.

General Authority: SDCL 58-20-24, 60-5-18, 62-5-21.

Law Implemented: SDCL 58-20-24, 60-5-18, 62-5-21.

Rule 47:03:04:03 Certification.

47:03:04:03. Certification. The department shall certify a case management plan if the department finds that the plan meets the following requirements:

(1) Provides access to all the medical and health care services required by SDCL title 62 in a prompt, effective, and convenient manner for the employee in accordance with the plan's treatment standards;

(2) Provides for access to medical providers within a reasonable distance from the employee's home or place of employment in accordance with § 47:03:04:04;

(3) Authorizes employees to make the initial selection of a medical provider who is not a participating member of the case management plan in accordance with § 47:03:04:05;

(4) Authorizes necessary medical treatment provided by a medical provider who is not a participating member of the case management plan in accordance with §§ 47:03:04:05 and 47:03:04:06;

(5) Does not discriminate against or exclude from participation in the plan any category of medical provider in accordance with § 47:03:04:07;

(6) Provides a procedure to ensure that each participating medical provider meets all licensing and certification requirements necessary to practice in South Dakota and to exclude from participation any provider whose license is under suspension or has been revoked by the licensing board;

(7) Provides methods of utilization review to prevent inappropriate, excessive, or medically unnecessary medical services and excludes participation in the plan by medical providers who violate its treatment standards;

(8) Provides aggressive case management services in accordance with § 47:03:04:08;

(9) Provides for cooperative efforts by employees, employers, and the case management plan to promote workplace health and safety;

(10) Provides an effective program of communicating to employees, employers, and medical providers the services provided by the case management plan and any requirements imposed by the plan. The plan must have a toll-free number for individuals to receive information and advice on a 24-hour basis regarding the medical services available under the plan. This information may be provided by recorded message after normal working hours if the recorded message contains information on how an employee can obtain access to medical services, including emergency services. The program must include procedures for reporting to the employer at least once a month on the medical status and return-to-work status of an employee and for informing medical providers of the applicable treatment standards of the plan;

(11) Provides a timely and accurate method of recording and reporting to the department information regarding medical service costs and utilization;

(12) Provides a procedure for prompt internal dispute resolution, including a method to resolve complaints by employees, medical providers, employers, and insurers in accordance with § 47:03:04:10;

(13) Provides a method to ensure continuity of care when an insurer's contract with a case management plan terminates or a contract between the case management plan and a participating medical provider terminates; and

(14) Establishes one place of business in South Dakota where the plan is administered and where the records are kept.

The department may consult with providers, insurers, the Bureau of Personnel, the Department of Health, and the Division of Insurance in regard to certificates and may accept findings, licenses, or certificates of other state agencies as satisfactory evidence of compliance with particular requirements of §§ 47:03:04:02 and 47:03:04:03. When the department grants certification to a case management plan, the department shall issue a certificate that states the effective date of the certification.

Source: 20 SDR 45, effective October 6, 1993; 21 SDR 225, effective July 5, 1995; 24 SDR 7, effective July 30, 1997; 26 SDR 10, effective August 3, 1999; 34 SDR 310, effective June 19, 2008; 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.

Rule 47:03:04:04 Access to medical providers and other case management services.

47:03:04:04. Access to medical providers and other case management services. The case management plan satisfies the requirements of subdivisions 47:03:04:03(1) and (2) by either of the following methods or through a combination of both methods:

(1) The plan establishes a network of participating medical providers who agree to provide medical services to the plan; or

(2) The plan establishes a procedure for an employee to receive medical services through a referral to a medical provider who is not a member of the case management plan, in accordance with § 47:03:04:05, in cases where the services are not available or reasonably accessible within the case management plan.

For the purpose of this chapter, access to a medical provider within a reasonable distance from the employee's home or place of employment requires consideration of the geographic area involved, the number of medical providers in the area, and the normal patterns of travel for medical care. The employer must notify the case management plan of any compensable injury or disability that requires medical treatment other than minor first aid within 24 hours after obtaining knowledge of the injury or disability. An employee who requests treatment for a compensable injury or disability from the case management plan must receive treatment by a participating medical provider or by referral to a qualified medical provider who is not a member of the managed plan within 48 hours after the employee's request for treatment unless it is impracticable considering the circumstances of the case.

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

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

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

Rule 47:03:04:05 Access to outside medical providers.

47:03:04:05. Access to outside medical providers. A medical provider who is not a participating provider in the case management plan may provide medical services to an employee in any of the following circumstances:

(1) When the employee makes the initial selection of a medical provider pursuant to SDCL 62-4-1 and 62-4-43 and notifies the case management plan of that selection before treatment or as soon as possible after treatment has been provided;

(2) When the employee requires emergency treatment;

(3) When the case management plan refers the employee or approves a referral to a medical provider outside the case management plan for medical services; or

(4) When compensability for an injury or disability is denied by the insurer. The employer is liable for reasonable and necessary medical services if the injury or disability is later determined compensable. At the point that the injury or disability is accepted as compensable by the insurer or is determined to be compensable, the medical provider must comply with the requirements of § 47:03:04:06.

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

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

Law Implemented: SDCL 58-20-24, 62-4-45, 62-5-21.

Rule 47:03:04:06 Provision of services by outside medical providers.

47:03:04:06. Provision of services by outside medical providers. To provide medical services under subdivisions 47:03:04:05(1), (2), and (3), the medical provider must comply with the following requirements:

(1) Agree to examine the employee within 48 hours of the employee's request for treatment or consultation unless it is impracticable under the circumstances of the case;

(2) Agree to supply the reports required by SDCL 62-4-44 and 62-4-45 to the case management plan;

(3) Agree to receive approval from the case management plan before any referral for other treatment the employee may require or before any diagnostic testing the employee may require, other than minor diagnostic testing exempted from the approval requirement under the plan's treatment standards; and

(4) Agree to abide by the provisions of this chapter and the terms and conditions of the case management plan.

The employee must notify the medical provider that the employee is covered by a case management plan before treatment is rendered. A medical provider who has been informed that an employee is covered by a case management plan and who fails to comply with the requirements of this section is subject to denial of payment for the services rendered to the employee. An employee who desires to change the initial selection of medical provider must receive written approval from the case management plan. A medical provider initially selected by an employee who refers the employee for specialized treatment or testing may continue to treat the employee if continued treatment is appropriate. The employer may assign to the case management plan its rights to notification, to approve a change in medical provider, and to receive reports under SDCL 62-4-43, 62-4-44, and 62-4-45.

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

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

Law Implemented: SDCL 58-20-24, 62-4-45, 62-5-21.

Rule 47:03:04:07 Access to all health care disciplines.

47:03:04:07. Access to all health care disciplines. The department may deny certification or may revoke or suspend the certification of a case management plan that unfairly restricts access within the case management plan to any medical provider. A plan unfairly restricts access when access is denied to a medical provider and the treatment or service sought is within the scope of practice of the profession and is proper under the treatment standards adopted by the plan and approved by the department. The plan must give employees convenient access to all categories of providers and flexibility to choose medical providers from among those who provide services under the plan.

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

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

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

Rule 47:03:04:08 Case management.

47:03:04:08. Case management. Case management includes the following:

(1) Developing a treatment plan to provide medical services to an injured or disabled employee;

(2) Systematically monitoring the treatment rendered and the medical progress of the injured or disabled employee;

(3) Ensuring that the injured or disabled employee is following the prescribed treatment plan; and

(4) Formulating a plan for return to work when medically and vocationally appropriate for the employee.

Source: 20 SDR 45, effective October 6, 1993.

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

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

Rule 47:03:04:09 Repealed.

47:03:04:09. Record and reporting requirements. Repealed.

Source: 20 SDR 45, effective October 6, 1993; 26 SDR 10, effective August 3, 1999; repealed, 34 SDR 310, effective June 19, 2008.

Rule 47:03:04:10 Dispute resolution.

47:03:04:10. Dispute resolution. Any person or entity aggrieved by the action of a certified case management plan must exhaust the dispute resolution procedure of the plan prior to filing a petition or otherwise seeking relief from the department on an issue related to case management. If the aggrieved party has exhausted the dispute resolution procedure of the case management plan or the plan has failed to resolve a dispute within 30 calendar days after the dispute was submitted to the plan, the party may petition the department for a hearing on the matter in dispute pursuant to SDCL chapter 1-26. The petition for a hearing must be mailed within 30 calendar days after written notice of the final decision of the case management plan is mailed to the aggrieved party.

Source: 20 SDR 45, effective October 6, 1993; 26 SDR 10, effective August 3, 1999.

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

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

Rule 47:03:04:11 Revocation, suspension, and denial of certification.

47:03:04:11. Revocation, suspension, and denial of certification. The department shall deny the certification or shall revoke or suspend the certification of a case management plan if the department finds that the plan fails to meet the requirements of this chapter or service under the plan is not being provided in accordance with the terms of a certified plan. If certification is denied, suspended, or revoked, the department shall explain in writing the grounds for the action. Any person or entity aggrieved by a denial, revocation, or suspension of the certification of a case management plan may petition the department for a hearing pursuant to SDCL chapter 1-26. The petition for a hearing must be mailed to the department within 30 calendar days after written notice of the denial, revocation, or suspension is mailed to the aggrieved party. The revocation or suspension is not effective until the time to petition for a hearing has expired. If a timely petition for a hearing is filed, the revocation or suspension is stayed pending the decision of the department after the hearing.

Source: 20 SDR 45, effective October 6, 1993; 26 SDR 10, effective August 3, 1999.

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

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

Rule 47:03:04:12 Conduct of hearings.

47:03:04:12. Conduct of hearings. When a petition for a hearing is filed under § 47:03:04:10 or 47:03:04:11, the following procedures apply in addition to those set forth in SDCL chapter 1-26. The department may resolve the dispute through mediation before conducting a hearing on the matter. If a party will not be prejudiced substantially, the department may resolve the dispute based on the submission of all or part of the evidence in written form, with or without opportunity for oral presentation. The department may conduct all or part of a mediation or hearing by teleconference as defined in SDCL 1-25-1.2.

Source: 20 SDR 45, effective October 6, 1993.

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

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

Rule 47:03:04:13 Repealed.

47:03:04:13. Compliance with SDCL 58-20-24. Repealed.

Source: 20 SDR 45, effective October 6, 1993; 26 SDR 10, effective August 3, 1999; repealed, 34 SDR 310, effective June 19, 2008.

Rule 47:03:04:13.01 Repealed.

47:03:04:13.01. Compliance with SDCL 62-5-21. Repealed.

Source: 21 SDR 225, effective July 5, 1995; 26 SDR 10, effective August 3, 1999; repealed, 34 SDR 310, effective June 19, 2008.

Rule 47:03:04:14 Charges and fees.

47:03:04:14. Charges and fees. Participating and nonparticipating medical providers are not entitled to payment from an insurer or employee for fees or services determined to be excessive under SDCL 62-7-8, medically unnecessary under the provisions of this chapter, or in violation of other requirements of § 47:03:04:06.

Source: 20 SDR 45, effective October 6, 1993; 21 SDR 225, effective July 5, 1995.

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

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

Rule 47:03:04:15 Repealed.

47:03:04:15. Effective dates. Repealed.

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

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