WORKERS' COMPENSATION
Chapter
47:03:01 Workers' compensation hearings.
47:03:02 Workers' compensation insurance.
47:03:03 Safety in the workplace.
47:03:04 Case management plans for workers' compensation.
47:03:05 Medical fee schedules.
47:03:06 Optimal recovery guidelines.
47:03:07 Independent contractors.
47:03:08 Educational benefits for surviving dependents.
47:03:09 Medical bill submissions.
47:03:10 Independent contractor affidavit of exempt status.
WORKERS' COMPENSATION HEARINGS
Section
47:03:01:01 Procedure for setting hearings.
47:03:01:01.01 Petition for hearing.
47:03:01:02 Contents of petition.
47:03:01:02.01 Notice of filing petition for hearing -- Response.
47:03:01:03 Transferred.
47:03:01:04 Transferred.
47:03:01:05 Repealed.
47:03:01:05.01 Continuing duty to supplement or amend.
47:03:01:05.02 Sanctions.
47:03:01:05.03 Additional discovery.
47:03:01:06 Naming of additional parties.
47:03:01:07 Commutation of compensation payment.
47:03:01:07.01 Computation of weekly benefit after partial lump sum payment.
47:03:01:08 Summary judgment.
47:03:01:09 Dismissal for want of prosecution.
47:03:01:10 Transferred.
47:03:01:11 Prehearing conferences.
47:03:01:12 Scheduling order.
47:03:01:13 Subjects to be discussed at prehearing conferences.
47:03:01:14 Final prehearing conference.
47:03:01:15 Prehearing orders.
47:03:01:16 Sanctions.
47:03:01:17 Mediation.
47:03:01:18 Small claims hearing petition.
47:03:01:19 Notification.
47:03:01:20 Setoff or counterclaim.
47:03:01:21 Amending petition or answer.
47:03:01:22 Multiple defendants
47:03:01:23 Adding parties.
47:03:01:24 Continuances.
47:03:01:25 Petitioner's failure to appear.
47:03:01:26 Defendant's failure to appear.
47:03:01:27 Setting aside default.
47:03:01:28 Conduct of hearings.
Appendix A Workers' Compensation Life Expectancy Table.
DEPARTMENT OF LABOR
DIVISION OF LABOR AND MANAGEMENT
WORKERS' COMPENSATION LIFE EXPECTANCY TABLE
Chapter 47:03:01
APPENDIX A
SEE: § 47:03:01:07
Source: 27 SDR 1, effective July 19, 2000.
APPENDIX A
WORKERS' COMPENSATION LIFE EXPECTANCY TABLE
|
Age |
Life expectancy for males |
Life expectancy for females |
|
|
|
|
|
0 |
73.6 |
79.4 |
|
1 |
73.1 |
78.9 |
|
2 |
72.2 |
77.9 |
|
3 |
71.2 |
76.9 |
|
4 |
70.2 |
75.9 |
|
5 |
69.3 |
75.0 |
|
6 |
68.3 |
74.0 |
|
7 |
67.3 |
73.0 |
|
8 |
66.3 |
72.0 |
|
9 |
65.3 |
71.0 |
|
10 |
64.3 |
70.0 |
|
11 |
63.3 |
69.0 |
|
12 |
62.3 |
68.0 |
|
13 |
61.4 |
67.0 |
|
14 |
60.4 |
66.1 |
|
15 |
59.4 |
65.1 |
|
16 |
58.5 |
64.1 |
|
17 |
57.5 |
63.1 |
|
18 |
56.6 |
62.2 |
|
19 |
55.6 |
61.2 |
|
20 |
54.7 |
60.2 |
|
21 |
53.8 |
59.2 |
|
22 |
52.9 |
58.3 |
|
23 |
51.9 |
57.3 |
|
24 |
51.0 |
56.3 |
|
25 |
50.1 |
55.4 |
|
26 |
49.2 |
54.4 |
|
27 |
48.2 |
53.4 |
|
28 |
47.3 |
52.4 |
|
29 |
46.4 |
51.5 |
|
30 |
45.4 |
50.5 |
|
31 |
44.5 |
49.5 |
|
32 |
43.6 |
48.6 |
|
33 |
42.7 |
47.6 |
|
34 |
41.7 |
46.7 |
|
35 |
40.8 |
45.7 |
|
36 |
39.9 |
44.7 |
|
37 |
39.0 |
43.8 |
|
38 |
38.1 |
42.8 |
|
39 |
37.1 |
41.9 |
|
40 |
36.2 |
40.9 |
|
41 |
35.3 |
40.0 |
|
42 |
34.4 |
39.1 |
|
43 |
33.5 |
38.1 |
|
44 |
32.7 |
37.2 |
|
45 |
31.8 |
36.3 |
|
46 |
30.9 |
35.4 |
|
47 |
30.0 |
34.4 |
|
48 |
29.2 |
33.5 |
|
49 |
28.3 |
32.6 |
|
50 |
27.4 |
31.7 |
|
51 |
26.6 |
30.8 |
|
52 |
25.8 |
29.9 |
|
53 |
24.9 |
29.0 |
|
54 |
24.1 |
28.2 |
|
55 |
23.3 |
27.3 |
|
56 |
22.5 |
26.4 |
|
57 |
21.7 |
25.6 |
|
58 |
20.9 |
24.7 |
|
59 |
20.2 |
23.9 |
|
60 |
19.4 |
23.1 |
|
61 |
18.7 |
22.3 |
|
62 |
18.0 |
21.5 |
|
63 |
17.3 |
20.7 |
|
64 |
16.6 |
19.9 |
|
65 |
15.9 |
19.2 |
|
66 |
15.2 |
18.4 |
|
67 |
14.6 |
17.7 |
|
68 |
13.9 |
16.9 |
|
69 |
13.3 |
16.2 |
|
70 |
12.7 |
15.5 |
|
71 |
12.1 |
14.8 |
|
72 |
11.5 |
14.1 |
|
73 |
11.0 |
13.4 |
|
74 |
10.4 |
12.8 |
|
75 |
9.9 |
12.1 |
|
76 |
9.4 |
11.5 |
|
77 |
8.9 |
10.9 |
|
78 |
8.4 |
10.3 |
|
79 |
7.9 |
9.7 |
|
80 |
7.5 |
9.1 |
|
81 |
7.0 |
8.6 |
|
82 |
6.6 |
8.0 |
|
83 |
6.2 |
7.5 |
|
84 |
5.8 |
7.1 |
|
85 |
5.5 |
6.6 |
|
86 |
5.2 |
6.2 |
|
87 |
4.8 |
5.8 |
|
88 |
4.6 |
5.4 |
|
89 |
4.3 |
5.0 |
|
90 |
4.0 |
4.7 |
|
91 |
3.8 |
4.4 |
|
92 |
3.6 |
4.1 |
|
93 |
3.4 |
3.8 |
|
94 |
3.2 |
3.6 |
|
95 |
3.0 |
3.4 |
|
96 |
2.9 |
3.1 |
|
97 |
2.7 |
3.0 |
|
98 |
2.6 |
2.8 |
|
99 |
2.5 |
2.6 |
|
100+ |
2.4 |
2.5 |
47:03:01:01. Procedure for setting hearings. Hearings shall be conducted by the division pursuant to SDCL 1-26 as contested cases at the earliest convenient date. Notice of hearing shall be served by the division upon all parties of record to the hearing.
Source: SL 1975, ch 16, § 1; 9 SDR 81, 9 SDR 124, effective July 1, 1983.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:02. Contents of petition. The petition shall be in writing and need follow no specified form. It shall state clearly and concisely the cause of action for which hearing is sought, including the name of the claimant, the name of the employer, the name of the insurer, the time and place of accident, the manner in which the accident occurred, the fact that the employer had actual knowledge of the injury within 3 business days or that written notice of injury was served upon the employer, and the nature and extent of the disability of the employee. A general equitable request for an award shall constitute a sufficient prayer for awarding compensation, interest on overdue compensation, and costs to the claimant. A letter which embodies the information required in this section is sufficient to constitute a petition for hearing.
Source: SL 1975, ch 16, § 1; transferred from § 47:03:01:03, 9 SDR 81, 9 SDR 124, effective July 1, 1983; transferred from § 47:03:01:04, 27 SDR 1, effective July 19, 2000.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:02.01. Notice of filing petition for hearing -- Response. The division shall mail notice of the filing of a petition for hearing to all parties. Any adverse party has 30 days after the date of the mailing of the notice to file a response. The response shall be in writing and need follow no specific form. The response shall state clearly and concisely an admission or denial as to each allegation contained in the petition for hearing.
Source: 27 SDR 1, effective July 19, 2000.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:03. Transferred to § 47:03:01:02.
47:03:01:04. Transferred to § 47:03:01:02.
47:03:01:05. Depositions.Repealed.
Source: SL 1975, ch 16, § 1; 9 SDR 81, 9 SDR 124, effective July 1, 1983; repealed, 27 SDR 1, effective July 19, 2000.
47:
Source: 27 SDR 1, effective July 19, 2000.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 1-26-19.2, 62-2-5, 62-7-12.
Cross Reference: Failure to comply with order, SDCL 15-6-37(b).
47:03:01:05.03. Additional discovery. On agreement of the parties or for good cause shown, the Division of Labor and Management may modify the time limits set forth in this chapter.
Source: 27 SDR 1, effective July 19, 2000.
General Authority: SDCL 62-2-5.
47:03:01:06. Naming of additional parties. Upon application of a party of record at a hearing, the division at its discretion may name a party interested or potentially interested in the hearing as an additional party plaintiff or defendant and shall send notice of hearing to the additional party in the manner required by § 47:02:02:01. The rights and liabilities of the party may be considered by the division and an award entered as though the party had been named in the original petition.
Source: SL 1975, ch 16, § 1; 9 SDR 81, 9 SDR 124, effective July 1, 1983.
General Authority: SDCL 62-2-5.
47:03:01:07. Commutation of compensation payment. Lump sum commutation for permanent partial disability shall equal the sum of the probable future payments capitalized at their present value on the basis of interest calculated at the rate of ten-year treasury notes on the date of injury as determined by the records of the federal reserve library, rounded to the nearest one-fourth of one percent, using the following formula:
Pn = V1/52 - Vn/52
1 - V1/52
where
P = Present value of $1.00 a week payable for n weeks
V = Present value of $1.00 due at the end of the year
n = Number of weeks for which payments are to be made
Lump sum commutation for permanent total disability shall be calculated in the same manner except that the interest rate shall be reduced one percent as a setoff for the cost-of-living allowance provided by SDCL 62-4-7. The number of weeks for which payments are made shall be determined by the life expectancy tables found in Appendix A at the end of this chapter. The interest rate used, exclusive of the cost-of-living allowance setoff, may not vary more than two percent above or below the interest rate on ten-year treasury notes on March 4, 1992, as determined from the records of the federal reserve library.
Source: 11 SDR 22, effective August 13, 1984; 16 SDR 226, effective June 24, 1990; resolution of suspension, 17 SDR 22, effective July 27, 1990; 17 SDR 191, effective June 20, 1991; 18 SDR 138, effective March 4, 1992; 21 SDR 4, effective July 18, 1994; 27 SDR 1, effective July 19, 2000.
General Authority: SDCL 62-7-6.
Law Implemented: SDCL 62-7-6.
Note: For information to contact the Federal Reserve Library, call the Division of Labor and Management at 605-773-3681.
47:03:01:07.01. Computation of weekly benefit after partial lump sum payment. If a partial lump sum payment is made under SDCL 62-7-6, the amount of the weekly benefit shall be reduced by the same percentage that the partial lump sum bears to the total lump sum computation.
Source: 20 SDR 45, effective October 6, 1993.
General Authority: SDCL 62-7-6.
Law Implemented: SDCL 62-7-6.
47:03:01:08. Summary judgment. A claimant or an employer or its insurer may, anytime after expiration of 30 days from the filing of a petition, move with supporting affidavits for a summary judgment. The division shall grant the summary judgment immediately if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.
Source: 16 SDR 226, effective June 24, 1990.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:09. Dismissal for want of prosecution. With prior written notice to counsel of record, the division may, upon its own motion or the motion of a defending party, dismiss any petition for want of prosecution if there has been no record of activity for at least one year, unless good cause is shown to the contrary. The "record" for purposes of establishing good cause shall include the following non-exhaustive list: settlement negotiations between the parties or their counsel, formal or informal discovery proceedings, the exchange of any pleadings, and written evidence of agreements between the parties or counsel which justifiably result in delays in prosecution. Dismissal under this section shall be without prejudice.
Source: 16 SDR 226, effective June 24, 1990; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
Collateral Reference: LaPlante v GG NSC Madison, South Dakota, LLC d/b/a Golden Living Center- Madison and Insurance Company of the State of Pennsylvania, 2020 SD 13.
47:03:01:10. Transferred to § 47:03:02:01.
47:03:01:11. Prehearing conferences. In any action, the Division of Labor and Management may in its discretion direct the attorneys for the parties and any unrepresented parties to appear by telephonic conference before a hearing for such purposes as the following:
(1) Expediting the disposition of the petition for hearing;
(2) Not allowing the case to become protracted;
(3) Requiring thorough preparation; and
(4) Facilitating settlement.
Source: 19 SDR 8, effective July 29, 1992.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:12. Scheduling order. The Division of Labor and
Management may, after consulting with the attorneys for the parties and
unrepresented parties, enter a scheduling order that does the following:
(1) Limits
the time to join other parties and to amend the pleadings;
(2) Limits the time to file
and hear motions;
(3) Limits the time to
complete discovery;
(4) Sets the date for
prehearing conferences, a final prehearing conference, and hearing; and
(5) Addresses any other
matters necessary.
The division shall issue the
scheduling order as soon as practicable but no more than 120 days after the
petition is filed, unless justice is served by issuing the order at a later
date. A schedule may not be modified except by order of the Division of Labor
and Management upon a showing of good cause.
Source:
19 SDR 8, effective July 29, 1992; 33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-5.
Law
Implemented: SDCL 62-7-12.
47:03:01:13. Subjects to be discussed at prehearing conferences. The participants at any prehearing conference may consider and take action on the following:
(1) Statements and simplification of the issues, including the elimination of frivolous claims or defenses;
(2) The necessity or desirability of amendments to the pleadings;
(3) The possibility of obtaining admissions of fact and of documents which will avoid unnecessary proof, stipulation regarding the authenticity of documents, and advanced rulings from the Division of Labor and Management on the admissibility of evidence;
(4) The avoidance of unnecessary proof and of cumulative evidence;
(5) The identification of witnesses and documents, the need and schedule for filing the exchanging of pretrial briefs, and the date or dates for further conferences and for hearing;
(6) The possibility of settlement;
(7) The form and substance of the prehearing order;
(8) The disposition of pending motions; and
(9) Any other matters that may aid in the disposition of the petition for hearing.
Source: 19 SDR 8, effective July 29, 1992.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:15. Prehearing orders. After any prehearing conference held pursuant to §§ 47:03:01:11 to 47:03:01:14, inclusive, the Division of Labor and Management shall enter an order reciting the action taken. This order shall control the subsequent course of the petition for hearing unless it is modified by a subsequent order. The order following a final prehearing conference may be modified only to prevent manifest injustice.
Source: 19 SDR 8, effective July 29, 1992.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:16. Sanctions. If a party or the party's attorney fails to obey a scheduling or prehearing order, if no appearance is made on behalf of the party at a scheduling or prehearing conference, or if a party or the party's attorney fails to participate in good faith, the Division of Labor and Management, upon motion or its own initiative, may make such orders with regard thereto that it considers just.
Source: 19 SDR 8, effective July 29, 1992.
General Authority: SDCL 62-2-5.
Law Implemented: SDCL 62-7-12.
47:03:01:17. Mediation. Upon receipt of a request for mediation from the employer or its insurer or from the injured employee, the division shall schedule it at a location convenient to the parties or by telephonic conference.
Source: 20 SDR 45, effective October 6, 1993.
General Authority: SDCL 62-7-37.
Law Implemented: SDCL 62-7-37.
47:03:01:18. Small claims hearing petition. The
petitioner or the petitioner's agent seeking a small claims hearing shall file
with the Division of Labor and Management a petition for small claims hearing
form provided by the department. The petition must state the facts upon which
the claim is based. If the department deems the petition unclear or
insufficient, the department may refuse the petition, or order that a clearer
or more sufficient claim be made.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
47:03:01:19. Notification. The division shall, by
registered or certified mail, notify any adverse parties of the filing of the
petition for small claims hearing. Any adverse party or its agent has 20 days
after the party's receipt of the notice to file an answer to the petition. The
answer shall clearly and concisely state an admission or denial as to each
claim contained in the petition.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
47:03:01:20. Setoff or counterclaim. An adverse party may
assert a claim for setoff or counterclaim in its answer. The setoff or
counterclaim shall be in writing, and be stated clearly and concisely. If the
department deems the claim for offset or counterclaim unclear or insufficient,
the department may refuse the claim, or order that a clearer or more sufficient
claim be made.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
47:03:01:22. Multiple defendants. A petitioner may name
more than one defendant in a small claims petition for hearing, but only if the
claims against each adverse party are related to or connected with each other.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
47:03:01:25. Petitioner's failure to appear. If the
petitioner fails to appear at the time and place specified for the hearing, the
department is satisfied that proper notice has been given, and the defendant
makes the minimum showing to support its claims, the department may enter a
default order against the petitioner.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
47:03:01:26. Defendant's failure to appear. If the
defendant fails to appear at the time and place specified for the hearing, the
department is satisfied that proper notice has been given, and the petitioner
makes the minimum showing to support its claims, the department may enter a
default order against the defendant.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
47:03:01:27. Setting aside default. Upon good cause shown
the department may, within thirty days after entering a default order, vacate
such order and reschedule the hearing of the original claim. Following the
expiration of thirty days, the party adversely affected by the order may seek a
reversal of the order only upon the filing of an independent action.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
47:03:01:28. Conduct of hearings. The department shall
conduct the hearing on a small claim in as informal a manner as possible. The
department may allow a party to participate by telephone or Dakota Digital
Network.
Source:
33 SDR 43, effective September 20, 2006.
General
Authority: SDCL 62-2-13.
Law
Implemented: SDCL 62-2-14.
CHAPTER 47:03:02
WORKERS' COMPENSATION INSURANCE
Section
47:03:02:01 Application fee for self-insurance.
47:03:02:01. Application fee for self-insurance. The application fee for self-insurance under SDCL 62-5-5 is $2,250.
Source: 17 SDR 37, effective September 10, 1990; transferred from § 47:03:01:10, effective July 29, 1992; 21 SDR 4, effective July 18, 1994; SL 2018, ch 285, § 2, effective July 1, 2018.
General Authority: SDCL 62-2-5, 62-5-5.
Law Implemented: SDCL 62-5-5.
CHAPTER 47:03:04
CASE MANAGEMENT PLANS FOR WORKERS' COMPENSATION
Section
47:03:04:01 Definitions.
47:03:04:02 Application.
47:03:04:02.01 Renewal process.
47:03:04:03 Certification.
47:03:04:04 Access to medical providers and other case management services.
47:03:04:05 Access to outside medical providers.
47:03:04:06 Provision of services by outside medical providers.
47:03:04:07 Access to all health care disciplines.
47:03:04:08 Case management.
47:03:04:09 Repealed.
47:03:04:10 Dispute resolution.
47:03:04:11 Revocation, suspension, and denial of certification.
47:03:04:12 Conduct of hearings.
47:03:04:13 Repealed.
47:03:04:13.01 Repealed.
47:03:04:14 Charges and fees.
47:03:04:15 Repealed.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
CHAPTER 47:03:05
MEDICAL FEE SCHEDULES
Section
47:03:05:01 Definitions.
47:03:05:02 Incorporation of Relative Values for Physicians.
47:03:05:02.01 Incorporation of Relative Values for Dentists.
47:03:05:03 and 47:03:05:04 Repealed.
47:03:05:05 Reimbursement criteria.
47:03:05:06 Dispute resolution.
47:03:05:07 Mediation.
47:03:05:08 Repealed.
47:03:05:09 Reimbursement for copies.
47:03:05:10 Repealed.
47:03:05:10.01 Reimbursement for anesthesia services.
47:03:05:11 Repealed.
47:03:05:12 Reimbursement for other medical services.
47:03:05:13 Reimbursement for dental services
47:03:05:14 Reimbursement for drugs.
Appendix A Physician Fee Schedule, repealed, 38 SDR 105, effective December 12, 2011.
Appendix B Facilities Subject to 20% Reduction.
Appendix C Supplemental Anesthesia Schedule, repealed, 38 SDR 105, effective December 12, 2011.
DEPARTMENT
OF LABOR
WORKERS'
COMPENSATION
PHYSICIAN
FEE SCHEDULE
Chapter
47:03:05
APPENDIX
A
SEE:
§ 47:03:05:10
(Repealed)
Source:
23 SDR 23, effective August 22, 1996; 24 SDR 7, effective July 30, 1997; 25 SDR
72, effective November 22, 1998; 27 SDR 1, effective July 19, 2000; 29 SDR 55,
effective October 28, 2002; 29 SDR 182, effective July 6, 2003; 31 SDR 220,
effective July 12, 2005; 32 SDR 209, effective June 14, 2006; 33 SDR 66,
effective October 24, 2006; 33 SDR 226, effective June 27, 2007; 34 SDR 310,
effective June 19, 2008; repealed, 38 SDR 105, effective December 12, 2011.
DEPARTMENT OF LABOR AND REGULATION
WORKERS' COMPENSATION
FACILITIES SUBJECT TO 20% REDUCTION
Chapter 47:03:05
APPENDIX B
SEE: § 47:03:05:12
Source: 23 SDR 23, effective August 22, 1996; 25 SDR 72, effective November 22, 1998; 29 SDR 55, effective October 28, 2002; 32 SDR 209, effective June 14, 2006; 34 SDR 209, effective February 14, 2008; 39 SDR 219, effective June 26, 2013.
FACILITIES SUBJECT TO 20% REDUCTION
Avera Heart Hospital
Avera McKennan Hospital
Avera Queen of Peace Hospital
Avera Sacred Heart Hospital
Avera St. Luke's Hospital
Avera St. Mary's Hospital
Black Hills Surgical Hospital
Brookings Ambulatory Surgical Center
Brookings Hospital
Dakota Plains Surgical Center
Huron Regional Medical Center
Lewis and Clark Specialty Hospital
Mallard Point Surgical Center
Prairie Lakes Hospital
Prairie States Surgical Center
Rapid City Regional Hospital
Same Day Surgery Center
Sanford Aberdeen Medical Center
Sanford USD Medical Center
Sioux Falls Specialty Hospital
Sioux Falls Surgical Hospital
Siouxland Surgery Center
Yankton Medical Clinic Surgicenter
DEPARTMENT
OF LABOR
WORKERS'
COMPENSATION
SUPPLEMENTAL
ANESTHESIA SCHEDULE
Chapter
47:03:05
APPENDIX
C
SEE:
§ 47:03:05:01, 47:03:05:10.01
(Repealed)
Source: 33 SDR 226,
effective June 27, 2007; repealed, 38 SDR 105, effective December 12, 2011.
47:03:05:01. Definitions. Terms used in this chapter mean:
(1) "Anesthesia services," administration of any drug or combination of drugs with the purpose of creating sedation or analgesia;
(2) "Base unit value," the number value assigned to services in Relative Values for Physicians;
(3) "Dental services," the examination, diagnosis, treatment, planning, and care of conditions within the human oral cavity and its adjacent tissues and structures, for any disease, pain, deformity, deficiency, injury, or physical condition of the human tooth, teeth, alveolar process, gums, or jaw or adjacent or associated structures;
(4) "Department," the Department of Labor and Regulation;
(5) "Employee," an employee entitled to medical services, dental services, or treatment for a compensable injury or disability under SDCL 62-4-1;
(6) "Health care provider," a person or entity providing medical services, dental services, or treatment to an employee for a compensable injury or disability;
(7) "Insurer," an entity providing workers' compensation insurance, including self-insured employers;
(8) "Medical services" or "treatment," a procedure, operation, consultation, supply, or product provided for the purpose of curing or relieving an employee of the effects of a compensable injury or disability;
(9) "Medical fee schedule," the maximum allowable fee for medical services or treatment determined according to the procedures established in this chapter;
(10) "Physical status modifier unit value," the number value assigned to physical status modifiers for anesthesia services in Relative Values for Physicians;
(11) "Procedure code," a numerical code used to identify a specific medical service, article, or supply;
(12) "Professional services," examination of a patient, performance or supervision of a medical procedure, dental procedure, or laboratory test, interpretation or written report concerning an examination or laboratory test, consultation with referring physicians, or similar services;
(13) "Qualifying circumstances unit value," the number value assigned to qualifying circumstances for anesthesia services in Relative Values for Physicians;
(14) "Technical services," performance of laboratory or radiological diagnostic procedures;
(15) "Unit value," the number value assigned to a dental service in Relative Values for Dentists;
(16) "Usual and customary charges," charges or fees that prevail in the community regardless of payer source.
Source: 21 SDR 67, effective October 13, 1994; 23 SDR 23, August 22, 1996; 24 SDR 7, effective July 30, 1997; 25 SDR 72, effective November 22, 1998; 32 SDR 209, effective June 14, 2006; 33 SDR 226, effective June 27, 2007; 34 SDR 310, effective June 19, 2008; 38 SDR 105, effective December 12, 2011; 39 SDR 219, effective June 26, 2013; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 185, effective June 25, 2018; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
References: Relative Values for Dentists, 2009 edition, published by Relative Value Studies, Inc. Copies may be obtained from Relative Value Studies, Inc., 1675 Larimer Street, Suite 410, Denver, CO 80202; https://www.rvsdata.com/rvs-bin/order1a.cgi#oprvd. Cost: $70.
Relative Values for Physicians, Relative Value Studies, Inc., 2020, published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost: $329.95.
47:03:05:02. Incorporation of Relative Values for Physicians. Except as otherwise provided in this chapter, the definitions and procedures for determining reimbursement for medical services or treatment are those set forth in Relative Values for Physicians, Relative Value Studies, Inc.
Source: 21 SDR 67, effective October 13, 1994; 25 SDR 72, effective November 22, 1998; 29 SDR 55, effective October 28, 2002; 29 SDR 182, effective July 6, 2003; 31 SDR 220, effective July 12, 2005; 32 SDR 209, effective June 14, 2006; 33 SDR 226, effective June 27, 2007; 34 SDR 310, effective June 19, 2008; 38 SDR 105, effective December 12, 2011; 39 SDR 100, effective December 6, 2012; 39 SDR 219, effective June 26, 2013; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 185, effective June 25, 2018; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Reference: Relative Values for Physicians, Relative Value Studies, Inc., 2020, published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost: $329.95.
47:03:05:02.01. Incorporation of Relative Values for Dentists. The definitions and procedures for determining reimbursement for dental services or treatment are those set forth in Relative Values for Dentists, 2024.
Source: 25 SDR 72, effective November 22, 1998; 31 SDR 220, effective July 12, 2005; 38 SDR 105, effective December 12, 2011; 51 SDR 54, effective November 12, 2024.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Reference: Relative Values for Dentists, 2024 edition, published by Relative Value Studies, Inc. Copies may be obtained from Relative Value Studies, Inc., 12921 S. Vista Station Blvd., Ste 200, Draper, UT 84020. Available for order by telephone at 1-800-464-3649, option 1. Cost: $700 base cost, plus an additional $25 per user.
47:03:05:03. Determining reimbursement -- Conversion factors.Repealed.
Source: 21 SDR 67, effective October 13, 1994, and July 1, 1995; 21 SDR 225, effective July 5, 1995; repealed, 23 SDR 23, effective August 22, 1996.
47:03:05:04. Physical medicine.Repealed.
Source: 21 SDR 67, effective October 13, 1994; 21 SDR 225, effective July 5, 1995; repealed, 23 SDR 23, effective August 22, 1996.
47:03:05:05. Reimbursement criteria. To be reimbursed, the charge must be for reasonable and necessary services for the cure or relief of the effects of a compensable injury or disability. A health care provider is not entitled to payment from an insurer or employee for fees in excess of the maximum reimbursement allowed under this chapter.
Except as otherwise provided in this chapter, to determine the maximum reimbursement for services, the base unit value for a procedure code is multiplied by the following factors:
Procedure Code Factor
10000-69999 $100.80
70000-79999 $ 19.07
80000-89999 $ 15.28
90000-95906 $ 6.57
95907-95913 $ 8.39
95914-97150 $ 6.57
97161 $ 21.11
97162 $ 13.20
97163 $ 6.61
97164 $ 15.08
97165 $ 21.11
97166 $ 13.20
97167 $ 6.61
97168 $ 15.08
97169-99071 $ 6.57
99075 $ 14.37 1st hour, $1.78 each additional 15 min
99076-99199 $ 6.57
99201-99450 $ 8.00
99455-99456 $ 19.33 1st hour, $2.41 each additional 15 min
99460-99499 $ 8.00
99500-99607 $ 6.57
If a code is properly submitted for one of these services, but is not listed in Relative Values for Physicians, or the base unit value is RNE or BR, the reimbursement is 80% of the provider's charge.
Source: 21 SDR 67, effective October 13, 1994; 23 SDR 23, effective August 22, 1996; 38 SDR 105, effective December 12, 2011; 39 SDR 100, effective December 6, 2012; 39 SDR 219, effective June 26, 2013; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 185, effective June 25, 2018; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Cross-Reference: Properly submitted medical bill, § 47:03:09:01.
Reference: Relative Values for Physicians, Relative Value Studies, Inc., 2020, published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost $329.95.
47:03:05:06. Dispute resolution. A person or entity aggrieved by the action of an insurer regarding medical fees must exhaust the dispute resolution procedure of the insurer before filing a petition or otherwise seeking relief from the department. If the aggrieved party has exhausted the dispute resolution procedure of the insurer or the insurer has failed to resolve a dispute within 30 calendar days after the dispute was submitted to the insurer, 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 insurer is mailed to the aggrieved party.
Source: 21 SDR 67, effective October 13, 1994.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:07. Mediation. When a petition for a hearing is filed under § 47:03:05:06, the Department may grant a request for mediation before conducting a hearing under SDCL chapter 1-26 on the matter if the department determines that a party will not be prejudiced substantially.
Source: 21 SDR 67, effective October 13, 1994.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:08. Reimbursement
for evaluation and management services. Repealed.
Source:
21 SDR 225, effective July 5, 1995; repealed, 38 SDR 105, effective December
12, 2011.
47:03:05:09. Reimbursement for copies. The maximum reimbursement for copies of provider records is ten dollars for the first ten pages, and thirty-three cents for each additional page.
Source: 21 SDR 225, effective July 5, 1995; 23 SDR 23, effective August 22, 1996.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:10. Reimbursement
for physician, technical, or professional services. Repealed.
Source:
23 SDR 23, effective August 22, 1996; 24 SDR 7, effective July 30, 1997;
repealed, 38 SDR 105, effective December 12, 2011.
47:03:05:10.01. Reimbursement for anesthesia services. The reimbursement for anesthesia services may not exceed the amount determined by adding the base unit value, the physical status modifier unit value, and the qualifying circumstances unit value, and multiplying the result by $40.28. An amount not to exceed $40.28 may be added for each additional fifteen minutes of anesthesia time. Any amount of anesthesia time that is less than fifteen minutes but at least five minutes may be rounded to the next fifteen minute increment.
Source: 24 SDR 7, effective July 30, 1997; 32 SDR 209, effective June 14, 2006; 42 SDR 177, effective June 28, 2016.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:11. Reimbursement
for professional or technical services rendered by a hospital or ambulatory
surgical center. Repealed.
Source:
23 SDR 23, effective August 22, 1996; 24 SDR 7, effective July 30, 1997;
repealed, 38 SDR 105, effective December 12, 2011.
47:03:05:12. Reimbursement for other medical services. The maximum reimbursement for medical services not otherwise identified in this chapter is eighty percent of the amount charged. Only those medical facilities identified in Appendix B are subject to the provisions of this section.
Source: 23 SDR 23, effective August 22, 1996; 29 SDR 55, effective October 28, 2002.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
47:03:05:13. Reimbursement for dental services. To determine the maximum reimbursement for dental services, the unit value for a procedure code is multiplied by a factor of $70.26.
Source: 25 SDR 72, effective November 22, 1998; 29 SDR 55, effective October 28, 2002; 33 SDR 226, effective June 27, 2007; 39 SDR 100, effective December 6, 2012; 42 SDR 177, effective June 28, 2016; 51 SDR 54, effective November 12, 2024.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
CHAPTER 47:03:06
OPTIMAL RECOVERY GUIDELINES
(Repealed. 38 SDR 105, effective December 12, 2011)
CHAPTER 47:03:07
INDEPENDENT CONTRACTORS
Section
47:03:07:01 Definitions.
47:03:07:02 Application.
47:03:07:03 Certification as independent contractor.
47:03:07:04 Revocation, suspension, and denial of certification.
47:03:07:01. Definitions.
Terms used in this chapter mean:
(1) "Department,"
the Department of Labor and Regulation;
(2) "Owner-operator,"
an individual, partner, or corporate shareholder who owns a vehicle licensed
and registered as a truck, road tractor, or truck tractor by a governmental
agency.
Source:
21 SDR 225, effective July 5, 1995; 38 SDR 105, effective December 12, 2011.
General
Authority: SDCL 62-1-14.
Law
Implemented: SDCL 62-1-10 to 62-1-12.
47:03:07:02. Application. An owner-operator may apply in writing to the department to be certified as an independent contractor. The application must be made on a form provided by the department.
Source: 21 SDR 225, effective July 5, 1995.
General Authority: SDCL 62-1-14.
47:03:07:03. Certification as independent contractor. If the department grants certification to an owner-operator, the department shall issue a certificate verifying the owner-operator's status. The certificate is valid for the period the department specifies in the certificate unless it is revoked or suspended.
Source: 21 SDR 225, effective July 5, 1995.
General Authority: SDCL 62-1-14.
47:03:07:04. Revocation, suspension, and denial of certification. The department shall deny the certification or shall revoke or suspend the certification of an owner-operator if the department finds that the owner-operator fails to meet the requirements of this chapter. If certification is denied, suspended, or revoked, the department shall explain in writing the grounds for the action. An owner-operator aggrieved by a denial, revocation, or suspension of a certificate may request the department for a hearing pursuant to SDCL chapter 1-26.
Source: 21 SDR 225, effective July 5, 1995.
General Authority: SDCL 62-1-14.
CHAPTER 47:03:08
EDUCATIONAL BENEFITS FOR SURVIVING DEPENDENTS
Section
47:03:08:01 Definitions.
47:03:08:02 Payment for costs of attendance.
47:03:08:03 Certifying attendance.
47:03:08:04 Payments for five academic years.
47:03:08:01. Definitions. Terms used in this chapter mean:
(1) "Academic year," two consecutive semesters, three consecutive trimesters, or four consecutive quarters;
(2) "Cost of attendance," tuition, educational fees, supplies, and housing expenses incurred by a student in connection with attending eligible institutions;
(3) "Eligible institution," an educational institution beyond high school, located in South Dakota, which the South Dakota Department of Education and Cultural Affairs has determined to be regularly accredited to offer postsecondary educational services;
(4) "Student," a person eligible to receive payments under the requirements of SDCL 62-4-8.1 and this chapter.
Source: 25 SDR 72, effective November 22, 1998.
General Authority: SDCL 62-4-8.1.
Law Implemented: SDCL 62-4-8.1.
47:03:08:02. Payment for costs of attendance. An employer shall pay up to $2,000 per academic year for the student's cost of attendance for that year. The payment shall be made directly to the eligible institution with which the student is enrolled.
Source: 25 SDR 72, effective November 22, 1998.
General Authority: SDCL 62-4-8.1.
Law Implemented: SDCL 62-4-8.1.
47:03:09:01. Properly submitted medical bill. A properly
submitted medical bill is a request by a provider for payment of health care
services that meets the following requirements:
(1) Submitted to the
employer according to the applicable reporting and coding standards of the
Centers for Medicare and Medicaid Studies, the National Council for
Prescription Drug Programs, or the American Dental Association; and
(2) Accompanied by
sufficient medical records or reports that the employer can determine the
reasonableness and necessity of the treatment provided.
A submission to a self-insured
employer, insurer, medical bill reviewer, medical case management plan, third
party administrator, claims adjuster, trustee, guarantor, or other entity
having a similar association to the employer is considered submission to all
such entities simultaneously. The employer may waive the requirements of this
section.
Source:
34 SDR 322, effective June 30, 2008.
General
Authority: SDCL 62-4-1.2.
Law
Implemented: SDCL 62-4-1.1, 62-4-1.2.
Note:
The Centers for Medicare and Medicaid Studies publishes its bill processing
requirements at www.cms.hhs.gov/QuarterlyProviderUpdates.
For pharmacy-related bill processing, information is available at NCPDP, Inc.
4201 North 24th Street, Suite 365, Phoenix, AZ 85016-6268, (602)
957-9105. For dental bill processing, information is available at www.ada.org, 211 East Chicago Ave., Chicago, IL
60611-2678, (312) 440-2500.
INDEPENDENT CONTRACTOR AFFIDAVIT OF EXEMPT STATUS
Section
47:03:10:01 Method for completing affidavit of exempt status.
47:03:10:02 Filing of affidavit of exempt status.
47:03:10:03 Applicability of affidavit of exempt status.
Appendix A Affidavit of Exempt Status.
Appendix B Exempt Status Fact Sheet.
DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
AFFIDAVIT OF EXEMPT STATUS
Chapter 47:03:10
APPENDIX A
SEE: § 47:03:10:01
Source: 41 SDR 219, effective July 1, 2015.
APPENDIX A
STATE OF SOUTH DAKOTA )
) SS AFFIDAVIT OF EXEMPT STATUS
COUNTY OF ______________
I state under oath as follows:
1. I, ______________________, operating as_____________________________________, (Independent Contractor) (Independent Contractor's Business Name)
have agreed to provide services for ____________________ during calendar year _____.
(General Contractor) (Year)
2. I have read, signed, and attached the Exempt Status Fact Sheet and understand that an Independent Contractor is one who engages to perform certain services for another, according to his own manner and method, free from control and direction of the contractor in all matters connected with the performance of the service, except as to the result or product of the work.
3. I understand that based upon the representations in this Affidavit of Exempt Status that I have signed, I am requesting that the Contractor identified above consider my business to be that of an independent contractor; that I am not an employee under the Workers' Compensation Act and the policy issued by ___________________________________.
General Contractor's Insurance Carrier
4. I am an independent contractor, not an employee of the contractor, and I do not want workers' compensation insurance.
5. I am not an employer for the purposes of the Workers' Compensation Act.
6. I have read, signed, and attached the Exempt Status Fact Sheet describing what an Independent Contractor is and the information provided is not the result of force, threats, coercion, compulsion, or duress.
7. I understand that the execution of this affidavit shall establish a rebuttable presumption that I am not an employee for purposes of the Workers' Compensation Act.
8. I understand that by signing this affidavit I will not be eligible for compensation under the South Dakota Workers' Compensation Law.
9. I understand the execution of this affidavit does not affect the rights or coverage of any employee of the individual executing the affidavit.
10. I understand that soliciting or providing false information on this affidavit with actual knowledge is a Class 2 misdemeanor.
_______________________________ ___________
Independent Contractor Signature Date
_______________________________ _______________________________
Independent Contractor Name Title
Subscribed and sworn to before me this ________ day of _____________, 20 _____.
________________________________
Notary Public- South Dakota
(Seal)
My commission expires:_____________
________________________________ ___________
General Contractor Signature Date
________________________________ _______________________________
General Contractor Name Title
Subscribed and sworn to before me this _________ day of _____________, 20 _____.
_________________________________
Notary Public-South Dakota
(Seal)
My commission expires:_____________.
DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
FORM OF EXEMPT STATUS FACT SHEET ATTACHMENT TO
AFFIDAVIT OF EXEMPT STATUS
Chapter 47:03:10
APPENDIX B
SEE: § 47:03:10:01
Source: 41 SDR 219, effective July 1, 2015.
APPENDIX B
EXEMPT STATUS FACT SHEET
An independent contractor is defined by law as one who engages to perform certain services for another, according to his own manner and method, free from control and direction of the contractor in all matters connected with the performance of the service, except as to the result or product of the work. Below are statements to help you decide if you are an independent contractor. No one statement is controlling, and your status is based on all the facts in your situation.
1. The nature of the contract between you and the contractor shows you are independent from the contractor. For example: Is there a written contract where you agree that you are an independent contractor? Do you maintain commercial general liability insurance or other business insurance?
2. The contractor exercises no control over the details of your work or independence. Do you exercise control over the details of the work? Do you create plans or specifications for the job? Do you set your own work hours?
3. You are engaged in a distinct occupation or business for others. Do you work for a company or individual other than the Contractor? Do you work for a competitor of the Contractor? Does your business have a logo or uniform?
4. Do you have a sales tax license? Do you have a contractor's excise tax license?
5. You cannot complete the affidavit if you are a subcontractor who is also an employer. Do you have employees?
6. Is your business incorporated? If you do business as a corporate entity you are typically considered an employee of the corporation and cannot complete the affidavit.
7. Your job is the kind of occupation where the work is usually performed by a specialist without supervision, and not under the direction of the contractor.
8. Your occupation requires special skills, license, education, or training.
9. The contractor does not supply the things needed to perform your job such as the tools and the place of work. Do you operate a vehicle owned by the contractor? Was the work performed at your business or the contractor's business location or jobsite?
10. The length of the job and how long you have worked for the Contractor does not show that you are really an employee. For example: Is this a one-time job, or will you be doing this for the contractor regularly?
11. You are paid as a separate contractor, not as an employee. Do you invoice the Contractor for your services? Do you file a federal income tax return for your business? Do you expect to receive an IRS Form 1099 from the Contractor?
12. Your work is not the regular business of the Contractor.
13. You do not have the right to terminate the relationship without liability. For example: If you quit before the job is finished, is there a penalty?
Based upon these factors, do you believe that you are an independent contractor with exempt status?
_______________________ Signature ________________________________________
(WRITE YES OR NO) (INDEPENDENT CONTRACTOR/EXECUTOR)
Note: An employer who knowingly solicits or requires an employee or subcontractor to execute an affidavit when the employer knows that the employee or subcontractor is required to be covered under a workers' compensation insurance policy is guilty of a Class 2 misdemeanor.
47:03:10:01. Method for completing affidavit of exempt status. If an independent contractor elects to complete the affidavit of exempt status as provided in Appendix A, the following are applicable:
(1) The affidavit of exempt status and the exempt status fact sheet attachment, as provided in Appendix B, must be completed before beginning work on the project specified in the affidavit for the general contractor;
(2) Both the independent contractor and the general contractor shall sign the affidavit of exempt status; and
(3) A copy of the completed affidavit of exempt status must be provided to the independent contractor and the general contractor.
Source: 41 SDR 219, effective July 1, 2015.
General Authority: SDCL 62-1-20.
Law Implemented: SDCL 62-1-20.
47:03:10:02. Filing of affidavit of exempt status. If the affidavit of exempt status and the exempt status fact sheet is completed, the general contractor shall provide copies to the general contractor's workers' compensation insurance carrier.
Source: 41 SDR 219, effective July 1, 2015.
General Authority: SDCL 62-1-20.
Law Implemented: SDCL 62-1-20.
47:03:10:03. Applicability of affidavit of exempt status. The affidavit of exempt status may not be executed by an owner-operator, a person deemed an employee, or a person deemed an employer by Title 62.
Source: 41 SDR 219, effective July 1, 2015.
General Authority: SDCL 62-1-20.
Law Implemented: SDCL 62-1-20.
