Dispute Resolution Form (Generic Form)

DISPUTE RESOLUTION For Case Management Plans The Dispute Resolution process is provided to ensure the prompt response and satisfactory resolution of all disputed issues. The following paragraph is abstracted from Article 47:03: CASE MANAGEMENT PLANS FOR WORKERS COMPENSATION: Article 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 submd to the plan, the party mitte ay 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. An acknowledgement of receipt of the dispute will be provided to the aggrieved party from the case management plan within 2 business days of the dispute being filed. The case management plan will provide a written notice of their resolution to the disputed issue(s) to the aggrieved party within 30 calendar days of receiving the complaint. The form on the following page may be used when filing a dispute. <<<<<<<<<********>>>>>>>>>>>>> 2 Dispute Resolution Form Date: ____________________ From: Name: _______________________ Address: _______________________ _______________________ Telephone Number: _______________________ RE: Claimant Name: ________________________ Date of Injury: _________________________ Claim Number: _________________________ Employer: _________________________ Description and Summary of Dispute: Please attach any supporting documentation that should be considered. Please submit to: The Administrator ofthe Certified Case Managem ent Plan It is the goal of the case management plan to resolve this issue within 30 days of receipt of this form. At that time, should resolution not be achieved, or there continues to be dissatisfaction of the results, an appeal mbe made to the South Dakota Departmay ent of Labor.