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Policy and Procedure Name:
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Rehabilitation Injury Claims
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Policy #:
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CP-18-02
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Code/Rule Reference:
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O.R.C.
4121.68, O.A.C.
4123-18-14
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Effective Date:
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10/27/2021
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Approved:
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Ann M. Shannon, Chief of Claims Policy and Support
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Origin:
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Claims Policy
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Supersedes:
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All claims policies, directives or memos regarding
rehabilitation injury claims that predate the effective date of this policy.
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History:
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Previous versions of this policy are available upon
request
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I. POLICY PURPOSE
The purpose of this policy is to ensure that rehabilitation
injury claims are assigned the correct risk number and are processed properly.
II. APPLICABILITY
This policy applies to BWC staff and Managed Care
Organizations (MCOs) involved in the processing of rehabilitation injury
claims.
III. DEFINITIONS
Rehabilitation Injury: A new injury or occupational
disease sustained while the injured worker (IW) is participating in an approved
vocational rehabilitation plan.
Source Claim: The original claim in which the IW was
participating in an approved vocational rehabilitation program. For purposes of
this policy, the claim in which the IW sustained an injury while participating
in an approved vocational rehabilitation program.
IV. POLICY
A. Rehabilitation
Injury Claims
1. It is the policy
of BWC to open a new claim for a rehabilitation injury when:
a. An IW sustains
an injury while participating in a BWC-approved vocational rehabilitation
program; and
b. The vocational
rehabilitation program is related to a previously allowed workplace injury.
2. BWC shall charge
the costs of the rehabilitation injury claim to the Surplus Fund, provided the
employer in the source claim contributes to the Surplus Fund (i.e., a State
Fund Private Employer or a Public Employer County/City).
3. Claims for
injuries sustained after an IW returns to work, but during the period in which
the IW is receiving follow up services are not rehabilitation injury claims and
shall be assigned to the IW’s employer’s risk. See the Case
Management Follow-Up Services policy and procedure for details
about what follow-up services entail.
B. Rehabilitation
Injury Risk Number Assignment
1. It is the policy
of BWC to assign rehabilitation injury claims a risk number based on employer
type.
2. If the source
claim employer is a:
a. State Fund
Private Employer or a Public Employer County/City (PEC), the rehabilitation
injury claim shall be assigned one of two risk numbers (one for State Fund
Private Employers and one for PECs), ensuring that the costs of the claim are
charged to the Surplus Fund.
b. Public Employer
State (PES) agency, the rehabilitation injury claim shall be assigned the
source claim employer’s risk number, ensuring that the costs of the claim are
charged dollar-for-dollar to the source claim employer.
V. PROCEDURES
1. BWC staff shall
refer to the Standard
Claim File Documentation and Altered Documents policy and procedure for
claim note and documentation requirements; and
2. Shall follow any
other specific instructions for claim notes and documentation included in this procedure.
B. MCO Submission
of Rehabilitation Injury Claims
1. When an IW
sustains a new injury or occupational disease while participating in an
approved vocational rehabilitation plan and the source claim employer is a
State Fund Private Employer or PEC:
a. The source claim
MCO shall:
i. Submit
a First Report of an Injury, Occupational
Disease or Death (FROI) to BWC’s MCO; and
ii. Submit, as
applicable:
a) Medical
treatment notes from the new injury; and
b) The incident
report from the facility where the injury or occupational disease occurred.
b. BWC’s MCO shall:
i. Upon
notification of the new injury, inform the Disability Management Coordinator
(DMC) in the source claim that a rehabilitation injury claim has been filed;
and
ii. Electronically
file the claim via the initial 148 using the appropriate employer policy
number:
a) 00009999-0 for a
State Fund Private Employer claim; or
b) 30099901-0 for a
PEC claim.
2. If the source
claim employer is a PES:
a. The source claim
MCO shall:
i. Ensure
a FROI is submitted to BWC electronically via the initial 148 using the PES
source claim employer’s policy number; and
ii. Submit, as
applicable:
a) Medical
treatment notes from the new injury; and
b) The incident
report from the facility where the injury or occupational disease occurred.
b. BWC claims services
staff shall process PES rehabilitation injury claims in the same manner as all
other PES claims.
1. BWC shall assign
rehabilitation injury claims to BWC staff based on employer type.
2. If the source
claim employer is a:
a. State Fund
Private Employer or a PEC, the claim shall be assigned for processing to BWC’s
Central Claims Unit, Special Claims;
b. PES, the claim
shall be assigned to BWC claims services staff in the same manner as all other
PES agency claims.
1. For all
rehabilitation injury claims, claims services staff assigned to the rehabilitation injury claim shall:
a. Investigate and
make an initial decision to allow or deny the claim, pursuant to the Initial
Claim Determination policy and procedure; and
b. If the claim is
allowed:
i. Set
the Full Weekly Wage (FWW) and Average Weekly Wage (AWW) pursuant to the Wages
policy and procedure, using the wage information in the source claim;
ii. Use the
statewide average weekly wage (SAWW) for the year of the rehabilitation injury
or occupational disease, if different from the SAWW applicable to the source
claim, to determine the maximum and minimum compensation rate payable to the
IW;
iii. Ensure the DMC
responsible for the new claim, if different from the source claim, is informed;
and
iv. Continue to manage the
claim following all applicable policies and procedures.
2. Claims services
staff shall also ensure that the source claim employer and employer
representative are copied on written communications related to the initial
determination of the rehabilitation injury claim. If the source claim employer
is a:
a. State Fund
Public Employer or a PEC, claims services staff must manually generate and send
notices to the source claim employer and employer representative.
b. PES, the
employer and employer representative are automatically copied on notices in the
rehabilitation injury claim.
E. Rehabilitation
Injury Claim Staffing
1. For all
rehabilitation injury claims, the DMCs for each claim (if applicable), the
respective MCOs, and the Vocational Rehabilitation Case Manager (VRCM) from the
source claim shall:
a. Discuss the
interplay between both claims;
b. Determine if the
new injury impacts the IW’s participation in vocational rehabilitation services;
and
c. Decide whether
vocational rehabilitation services will:
i. Continue
as originally approved;
ii. Be
interrupted temporarily using a medical interrupt; or
iii. Be closed.
a) If the decision
is to close, the DMC shall determine if a medical hold is appropriate.
b) If, at any point
after closure, vocational rehabilitation services are requested, the DMC shall
determine:
i) Which
claim (source or new) has the more significant barriers to return to work; and
ii) In which
claim the vocational rehabilitation case will be addressed.
2. If claims
services staff is assigned what appears to be a State Fund Private Employer or
PEC rehabilitation injury claim, claims services staff assigned to the claim
shall:
a. Contact the
member of claims services staff in BWC’s Central Claims Unit, Special Claims
that is assigned to handle rehabilitation injury claims; and
b. Together they
shall staff the claim to determine whether the claim is, in fact, a
rehabilitation injury claim.
F. Waivers
During the Appeal Period
1. The following
procedure only applies to State Fund Private Employer and PEC rehabilitation
injury claims. For PES rehabilitation injury claims, claims services staff
shall follow the Orders,
Waivers, Appeals, and Hearings policy and procedure.
2. BWC Orders- To
carry out a BWC order prior to expiration of the appeal period, waiver of the
appeal period is only necessary from the IW or IW representative.
3. IC Orders
a. No waiver of
appeal is necessary to carry out any IC order ordering temporary total
compensation payable.
b. No waiver of
appeal is necessary to carry out a SHO order granting medical treatment or
benefits.
c. For State
Fund Private Employer and PEC rehabilitation injury claims, any waiver of
appeal that may be necessary from an IC order is only required from:
i. The
IW or IW representative; and
ii. BWC Legal
(as the representative of the Surplus Fund).