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from participation any provider whose license is under suspension or has been
revoked by the licensing board;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.
