These are the required forms to use when reporting and managing workers' compensation claims in South Dakota. If you have specific questions about any of these forms or resources, contact your SFM claims representative.
Temporary prescription information sheet and cards
This prescription card allows employees to fill their initial work-related injury prescription without any out-of-pocket expense. Give it to your employee when he or she becomes injured and plans to see a doctor. A longer-term prescription card is mailed to the employee once SFM has received the First Report of Injury.
An employee in South Dakota who has sustained a work-related injury has the right to choose a treating physician but he must notify you of his choice prior to treatment, or as soon as reasonably possible after treatment. However, you, the employer, should suggest the employee go to your preferred clinic, one that is specialized in treating occupational injuries, but ultimately the choice is the employee's.
South Dakota law requires workers' compensation insurers, including SFM, to provide managed care services with their policies. Case management gives injured employees access to medical services quickly and effectively to return them to work as soon as medically able. Once a claim is reported to SFM, it is reviewed to determine whether case management services are needed. SFM will notify the contracted case management service provider to initiate medical management with the injured employee, if necessary. As a South Dakota employer, you do not need to do anything to facilitate this process other than notifying injured employees of their rights and responsibilities under the state-mandated managed care plan.
An employee who has been injured at work in South Dakota is required by state law to provide his employer with a written notice within three business days of the injury. Depending on the circumstances of the claim, an employee may risk forfeiting workers' compensation benefits if this requirement is not met.
However, if you don't receive a written notice of the injury within the timeframe, you must still submit the First Report of Injury to SFM within 24 hours. SFM will investigate the claim and determine whether it's compensable.
State laws allow employers to have access to injured employees' medical records so they can see work restrictions ordered by physicians, which are usually documented on a Report of Work Ability form.
It's good to clarify work restrictions and transitional job tasks with the physician. Remember to document everything and keep the employee informed.
Other rules for handling confidential medical records:
By law, you cannot combine medical records with the employee's personnel file. Keep a separate medical file.
Never give medical information to a third party without the employee's written consent.
Don't use medical information as grounds to fire or discriminate against an employee. Doing so violates several federal and state laws.
HIPAA's effect on workers' compensation
For the most part, Health Insurance Portability and Accountability Act (HIPAA) privacy rules do not apply to workers' compensation claims. Some provisions apply, but only to the workers' compensation insurance company or the self-insured employer, not the general employer.
The general guideline for employers on handling workers' compensation is that you have a right to discuss an injured employee's progress and existing medical history with the physician, as it relates to the injury.
Medical providers may be unclear about the HIPAA law as it applies to work comp and may be reluctant to give you information. If you're having trouble getting information from a provider, call your SFM claims representative at (800) 937-1181.
Insurance fraud may come in many different forms, including an injured employee who intentionally misrepresents information or hides the truth with the intent to receive money or other benefits from an insurance company.
Even if you suspect fraud, you must still report the injury to SFM. Your SFM claims representative will investigate the claim and determine whether the evidence falls under the state's legal definition of fraud.
If you suspect a claim is fraudulent, contact your SFM claims representative or SFM's Special Investigations Unit at 800-937-1181, ext. 4288.
If the injured employee is missing time from work—either directly following the injury or any time during the course of recuperating from the injury—it is essential that you notify your SFM claims representative. Unless you tell SFM that an injured employee is missing work, the employee won't receive the workers' compensation wage-replacement benefits he or she is entitled to by law. That may trigger state penalties or prompt the employee to contact an attorney.
If the employee is losing time from work directly following the injury, be sure to fill in the "Date of injury" box and the "Date returned to work" box on the First Report of Injury.
If the employee loses time from work after you've already submitted the First Report to SFM, call your claims representative immediately at (800) 937-1181 to let him or her know when the employee first began losing time from work. Your organization may be assessed a state penalty if you do not notify your SFM claims representative immediately after you have knowledge that the employee will miss time from work due to the injury.
State law requires a specific number of days to pass before an injured employee is eligible to receive workers' compensation wage-loss benefits. Additionally, most states require a specific number of days that the employee is off work before wage-loss benefits are retroactively paid from the beginning of the waiting period. The number of days in the so-called "waiting period" and the retroactive period varies by state. Each state also specifies which days count and what constitutes a day.
Employees who have been injured at work in South Dakota must wait seven days following an injury where they're losing time from work to be eligible to receive wage-loss benefits. Once an injured employee has passed the seventh consecutive day off work because of the injury, he or she is entitled to be retroactively paid wage-loss benefits starting from the first day of the waiting period.
If the employee is injured at work and misses, say, five calendar days of work, the employee would not receive any wage-loss benefits at all. If the employee is injured at work and misses, say, 10 calendar days of work, then SFM would pay wage-loss benefits retroactively for all 10 days off work.
A "day" is defined by South Dakota workers' compensation statute to be the first calendar day an employee misses work because of the injury.