South Dakota Administrative Rules › Title 47 - Department of Labor And Regulation › Article 47:03 - Workers' compensation › Chapter 47:03:04 - Case management plans for workers' compensation › Section 47:03:04:03 - Certification

Current through Register Vol. 51, page 10, July 15, 2024
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to practice in South Dakota and to exclude from participation any provider whose license is under suspension or has been revoked by the licensing board;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.
General Authority:
SDCL  58-20-24,  62-5-21.
Law Implemented:
SDCL  58-20-24,  62-5-21.