|
Policy
and Procedure Name:
|
Referrals,
Eligibility and Feasibility
|
|
Policy
#:
|
VR-18-01
|
|
Code/Rule
Reference:
|
OAC
4123-18-03
|
|
Effective
Date:
|
07/01/2021
|
|
Approved:
|
Deborah
Kroninger, Chief of Medical Operations
|
|
Origin:
|
Vocational
Rehabilitation Policy
|
|
Supersedes:
|
Policy
# VR-18-01, effective 10/07/2019
|
|
History:
|
Previous
versions of this policy are available upon request
|
I.
POLICY PURPOSE
The
purpose of this policy is to ensure that referrals and determinations for eligibility
and feasibility are processed and determined consistently and appropriately.
II.
APPLICABILITY
This
policy applies to:
·
BWC
staff;
·
Managed
care organization (MCO) staff; and
·
Vocational
rehabilitation case managers (VRCMs) assigned by the MCO.
III.
DEFINITIONS
See
Vocational
Rehabilitation Definitions.
IV.
POLICY
A. MCO and BWC
Roles
1. It is the
policy of BWC that the MCO shall designate a vocational rehabilitation program
coordinator to direct the MCO’s management of vocational rehabilitation
services. The vocational rehabilitation program coordinator’s role is to:
a.
Increase
accountability in the delivery of high quality vocational services; and
b.
Enhance
communication between BWC and the MCO.
2. It is the
policy of BWC to assign Disability Management Coordinators (DMC) to serve as resources
and points of contact for vocational rehabilitation program coordinators on vocational
rehabilitation issues.
B. Referral
1. It is the
policy of BWC to encourage and support a referral to vocational rehabilitation
as soon as the need is identified and viable services may be delivered.
2. It is the
policy of BWC that anyone may refer an injured worker (IW) for vocational
rehabilitation services, including referrals for job retention services.
3. BWC and the MCO
shall consider any information or statements received indicating the IW’s need
for vocational rehabilitation services, other than pre-referral staffing, as a
referral for vocational rehabilitation services.
4. The first
documented date of receipt of a vocational rehabilitation referral by BWC or
the MCO becomes the official referral date.
C. Eligibility
1. It is the
policy of BWC that the DMC is responsible for determining the IW’s eligibility
for vocational rehabilitation services.
2. To be eligible
for vocational rehabilitation services (other than as provided in section IV.C.4),
the IW must:
a.
Have
a claim:
i.
Allowed
by BWC or the Industrial Commission (IC), with eight or more days of lost time due
to a work-related injury; or
ii.
Certified
by a self-insuring employer.
b.
Be
experiencing a significant impediment to employment or the maintenance of
employment as a direct result of the allowed conditions in the referred claim;
and
c.
Have
at least one of the following present in the referred claim:
i.
The
IW is receiving or has been awarded temporary total, payments made in lieu of
temporary total compensation (e.g., salary continuation), non-working wage
loss, or permanent total compensation for a period of time that includes the
date of referral; or
ii.
The
IW was granted a scheduled loss award under RC 4123.57(B) (e.g., loss of use of
a finger or limb); or
iii.
The
IW is not currently receiving compensation and has job restrictions in the
claim, documented by the physician of record (POR) and dated not more than 180
days prior to the date of referral; or
iv.
The
IW is receiving job retention services to maintain employment, or satisfies the
criteria for job retention services pursuant to section IV.C.4 of this policy,
on the date of referral; or
v.
The
IW sustained a catastrophic injury claim and a vocational goal can be
established; or
vi.
If
the IW is an employee of a state agency or state university and does not meet
the conditions in Section IV.C.2.c.i-v above, the IW shall be eligible for
vocational rehabilitation services when:
b)
3. The IW must not
be working on the date of referral, with the exception of a referral for job
retention services.
4. Job Retention
Services: An IW shall be eligible for job retention services when:
a.
The
IW is working and experiences a significant work-related problem as a direct
result of the allowed condition(s) in the claim;
b.
The
IW has received temporary total compensation or salary continuation in an
allowed claim with eight or more days of lost time due to a work-related
injury;
c.
The
POR provides a written statement in office notes or correspondence indicating
that the IW has work limitations related to the allowed conditions in the claim
that negatively impact the IW’s ability to maintain employment; and
d.
The
IW’s employer describes the specific job task problems the IW is experiencing
to the MCO and the MCO documents these problems in the claim. The MCO shall
include a statement describing why the IW needs job retention services to
maintain employment.
5. An IW is not
eligible for vocational rehabilitation services when:
a.
The
IW enters into a lump sum settlement (medical and/or indemnity); or
b.
The
IC or a court order subsequently disallows the claim; or
c.
The
IW, after successfully completing a comprehensive vocational rehabilitation
plan, subsequently resigns from employment or is terminated for cause and the
resignation or termination is not due to the allowed conditions in the claim.
D. Initial Feasibility
1. It is the
policy of BWC that an IW’s initial feasibility to participate in vocational
rehabilitation services will be decided by the MCO.
2. An IW is feasible
for vocational rehabilitation services when all available information
demonstrates that:
a.
The
IW is willing to participate in vocational rehabilitation services;
b.
The
IW is able to participate in vocational rehabilitation services; and
c.
There
is a reasonable probability that the IW will benefit from vocational
rehabilitation services and return to work as a result of the services.
E. Immigration
Status
1. The IW’s
immigration status, including status as an undocumented worker, is not a factor
in determining eligibility and feasibility for vocational rehabilitation.
2. The VRCM shall
not provide job development or job placement services if the IW does not have
legal permission to work in the United States.
F. Decision
1. Approval
a.
It
is the policy of BWC that a decision approving the IW’s participation in a
vocational rehabilitation program shall be documented in a BWC order, which
shall address:
i.
Eligibility;
ii.
Feasibility;
and
iii.
Living
Maintenance (LM) compensation.
b.
Approval
of an IW to participate in a vocational rehabilitation program renders the IW
eligible to receive LM according to the criteria set forth in OAC 4123-18-04.
2. Denial
a.
It
is the policy of BWC that a decision denying the IW’s participation in a
vocational rehabilitation program shall be documented in a BWC order, which
shall address:
i.
Eligibility;
and
ii.
Feasibility.
b.
Denial
of an IW to participate in vocational rehabilitation services shall not affect
an IW’s right to compensation for which the IW otherwise qualifies.
V. PROCEDURE
A. Referral
Processing
1. The MCO shall
be responsible for management of all referrals through case resolution,
including those referrals submitted via a:
a.
Request
for Medical Service Reimbursement or Recommendation for Additional Conditions
for Industrial Injury or Occupational Disease (C-9);
b.
Physician’s
Report of Work Ability (MEDCO-14);
c.
Request
for Temporary Total Compensation (C-84);
d.
Recommendation
pursuant to an independent medical evaluation (IME); or
e.
Contact
from an interested party.
2. Processing
Referrals from Parties to the Claim, a POR, or Treating Physician
a.
When
the MCO receives a vocational rehabilitation referral from a party to the
claim, the POR, or the treating physician, the MCO will begin the initial
feasibility determination and eligibility verification process by:
b)
If
the MCO is unable to speak with the IW:
i)
The
MCO shall send a letter to the IW requesting that the IW contact the MCO; and
ii)
If
the IW does not respond to the MCO within 10 calendar days from the date the
letter was mailed, the MCO can proceed with the request for a determination
noting they were not able to contact the IW
Evaluating
a)
The
IW’s interest in returning to work;
b)
The
IW’s past participation in vocational rehabilitation plans or other BWC-provided
services;
c)
Documentation
of events that could impact the IW’s ability to participate in vocational
rehabilitation services (e.g., scheduled surgery, vacation, incarceration); and
d)
Documentation
of medical and psychological issues, including pain issues, and medication or
substance abuse issues, both related and unrelated to the allowed conditions in
the referred claim.
b.
The
MCO shall use the appropriate vocational rehabilitation screening tool
(Appendix A or B) or an equivalent tool to assist in collating and documenting
referral information.
c.
The
MCO shall request medical documentation from the POR to establish the IW’s
current restrictions as needed.
d.
The
MCO shall request an eligibility determination from the DMC.
i.
The
request shall include:
ii.
The
request shall be sent to the DMC within 18 calendar days of receipt of the
referral by the MCO. If the MCO is unable to meet this requirement, the MCO
must document why more time is needed in an email notice to BWC (see Appendix C
for template) and in a claim note.
3.
Processing
BWC or MCO Initiated Referrals and Referrals from Other Sources
a.
If
the MCO receives a vocational rehabilitation referral from a source not a party
to the claim, or the MCO or BWC determines that an IW may benefit from
vocational rehabilitation services, the MCO shall contact the IW and POR to
determine if the IW is interested and able to participate in vocational
rehabilitation services.
b.
If
the IW and POR indicate that the IW is not interested or is unable to
participate in vocational rehabilitation services at this time, the referral shall
not be sent to BWC for an eligibility determination. The MCO shall indicate in
MCO notes an explanation of the decision regarding the referral.
c.
If
the IW or POR indicate the IW is interested and able to participate in vocational
rehabilitation services, the referral shall continue to be processed consistent
with section V.A.2.
4. Special
Categories of Referrals
a.
Referrals
Received Via a C-84
i.
If
a C-84 is received and the IW has indicated an interest in vocational
rehabilitation services, the MCO shall determine if a referral is appropriate
at this time.
ii.
If
a referral is appropriate at this time, the C-84 shall be treated as a referral
and processed consistent with section V.A.2.
iii.
If
it does not appear to be an appropriate time for a referral, the MCO shall make
a note to review the claim in the future and notify the IW.
b.
Referrals
for Job Retention
i.
The
MCO shall process a referral for job retention services consistent with section
V.A., including obtaining, if not received with the referral:
a)
A
written statement from the POR, either in office notes or correspondence,
indicating that the IW has work limitations related to the allowed conditions
in the claim that negatively impact the IW’s ability to maintain employment;
and
b)
A
written or verbal statement from the employer describing the specific job task
problems the IW is experiencing.
ii.
The
MCO shall include in the request for eligibility determination a description of
why the IW needs job retention services to maintain employment using the Job
Retention Screening Tool.
c.
Referrals
When a Claim is Inactive
i.
When
a referral for vocational rehabilitation services is received by BWC or the MCO
in an inactive claim, the referral shall be considered a request for claim
reactivation and processed consistent with the Claim
Reactivation policy and procedure and the directions outlined
immediately below.
ii.
The
MCO shall send a feasibility recommendation to the DMC, who shall then assess
the IW’s eligibility, as outlined in this policy. The DMC shall then notify the
assigned claims service specialist (CSS) of the participation decision.
a)
If
the IW is approved to participate in a vocational rehabilitation program, the
CSS shall issue an order allowing reactivation of the claim, including approval
language regarding the IW’s ability to participate in a vocational
rehabilitation program, which includes eligibility, feasibility, and payment of
LM.
b)
If
the DMC did not find the IW able to participate in vocational rehabilitation,
the CSS shall issue an order denying reactivation and participation in
vocational rehabilitation with the supporting justification.
c)
If
there is other justification to reactivate the claim (e.g., request for
chiropractic treatment and vocational rehabilitation on one C-9), but the DMC
did not find the IW able to participate in vocational rehabilitation, the CSS
shall issue an order allowing reactivation of the claim but denying the IW’s
participation in vocational rehabilitation.
d.
New
Referrals While a Prior Vocational Rehabilitation Issue is Pending
i.
When
a referral for vocational rehabilitation services is received while a prior
referral is unresolved, the MCO may dismiss the new referral during:
a) The appeal
period of a vocational
rehabilitation case closure letter issued by the MCO;
b)
The
appeal period of a vocational rehabilitation participation order issued by BWC;
or
c)
The
IC hearing process for either of the issues above.
ii.
The
MCO shall notify the referring party of the dismissal in writing; and
iii.
If
applicable, the MCO and the DMC shall:
a)
Discuss
any new and changed circumstances that may impact the prior decision to
determine the need for any further action; and
b)
Ensure
that any new documents that have been received are imaged to the claim.
e.
Referrals
When a Claim Has Non-Vocational Rehabilitation Issues Pending Before the IC
i.
When
the DMC receives a request for determination for vocational rehabilitation and
the claim has any issues unrelated to vocational rehabilitation pending before
the IC that could affect the vocational rehabilitation participation decision
(e.g., compensation, claim allowance), the DMC shall not take action on the
referral until such matters have been resolved.
ii.
Once
the DMC is notified of resolution of the issues, provided the claim is still
active, the DMC shall process the referral as described in this procedure.
B. Eligibility Determination
by the DMC
1. The DMC shall
review the information provided by the MCO and other related documentation to
determine if the IW meets the criteria for eligibility.
2. If the
documentation is not already in the claim or has not yet been requested by the
MCO, the DMC shall request documentation of the IW’s restrictions from the MCO.
3. Within two business
days of receipt of the request for eligibility determination, the DMC shall:
a.
Ensure
the screening tool is imaged into the claim;
b.
Decide
whether to approve or deny the IW’s participation in vocational rehabilitation,
or, if the DMC requires additional information, to pend the decision for a
specific period of time; and
c.
Communicate
the decision:
i.
To
the MCO via email. If the DMC requested the MCO to seek additional medical
documentation from the POR, the decision shall be emailed to the MCO within:
a)
Two
business days of receipt of the documentation; or
b)
Within
ten calendar days from the date of the request to the POR, whichever is earlier.
ii.
To
the parties via order. The order shall address the IW’s participation in
vocational rehabilitation, which includes eligibility, feasibility, and payment
of LM.
iii.
The
DMC shall also provide the MCO with documentation of the eligibility decision
on the appropriate vocational rehabilitation screening tool (Appendix A or B) information concerning compensation rates (average weekly wage,
full weekly wage, and living maintenance rates) and if applicable, relevant
vocational information from any other claims for the injured worker. Once
completed, the DMC shall image the screening tool into the claim.
4. If the order
approves the IW’s participation in vocational rehabilitation, the DMC or the
MCO may:
a.
Discuss
with all parties their right to waive the appeal period; or
b.
Allow
the appeal period to run prior to assigning the VRCM.
APPENDIX A: Return
to Work Screening Tool
MCO
Feasibility Determination
|
Claim
Number
|
|
Injured
Worker
|
|
|
MCO
Name & Number
|
|
|
MCO
Voc Rehab Coord
|
|
Phone
Number
|
|
|
MCO
Contact
|
|
Phone
Number
|
|
|
Referral
Source
|
|
Referral
Date
|
|
(FROM
A FILE REVIEW PERSPECTIVE)
1. Is the injured
worker willing to participate in vocational rehabilitation services? Yes ☐ / No ☐ Click or tap here to
explain why.
2.
Is
the IW able to participate in vocational rehabilitation services? Yes ☐ / No ☐ Click or tap here to explain why.
3.
Is
there a reasonable probability that the injured worker will benefit from
vocational rehabilitation services and return to work as a result of the
services? Yes ☐ / No ☐ Click or tap here to explain why.
4.
Do
you recommend the IW to be feasible for vocational rehabilitation services? Yes
☐ / No ☐ Click or tap here to explain why.
BWC
Eligibility Determination
|
Claim
Number
|
|
DMC
Name
|
|
Date
of Determination
|
|
|
ELIGIBILITY
INFORMATION:
|
|
|
A
significant impediment to employment as a direct result of the allowed
conditions in the claim?
|
Yes
|
No
|
|
|
Temp
Total Disability compensation for date of referral?
|
Yes
|
No
|
|
Salary
Continuation in lieu of TT for date of referral?
|
Yes
|
No
|
|
Permanent
Total Compensation for date of referral?
|
Yes
|
No
|
|
Receiving
or awarded non-working wage loss for the date of referral?
|
Yes
|
No
|
|
Awarded
Scheduled Loss award?
|
Yes
|
No
|
|
Catastrophic
injury claim?
|
Yes
|
No
|
|
·
Vocational
goal able to be established? (REQUIRED)
|
Yes
|
No
|
|
Employee
of state agency or university?
|
Yes
|
No
|
|
·
Employer
of Record agrees with rehabilitation? (REQUIRED)
|
Yes
|
No
|
|
IW
not currently receiving compensation and POR documented work
restrictions/barriers within 180 days?
|
Yes
|
No
|
|
INELIGIBILITY
INFORMATION:
|
|
Is
this claim disallowed, denied or in hearing status?
|
Yes
|
No
|
|
Are
there 7 or fewer days of lost time allowed in this claim?
|
Yes
|
No
|
|
Is
this a settled claim (medical and/or indemnity)?
|
Yes
|
No
|
|
Is
the Injured Worker working on the date of referral?
|
Yes
|
No
|
|
Did
the IW RTW after successfully completing a vocational rehabilitation rehab
plan but subsequently resign and/or was terminated for cause and the
resignation or termination was not due to the allowed conditions in the
claim?
|
Yes
|
No
|
|
PARTICIPATION
DETERMINATION
|
|
Is
the IW approved to participate in return to work services?
|
Yes
|
No
|
|
The
above claim has been reviewed by the Disability Management Coordinator. The
above criteria for participation in return to work service was outlined
according to the Ohio Administrative Code OAC 4123-18-03
|
|
|
|
|
Additional
Referral Information
MCO
Provided
1.
Did
you ensure updated restrictions are documented within 180 days of referral?
Yes ☐ / No ☐ Click or tap
here to explain why.
2.
Is
this a re-referral for vocational rehabilitation? Yes ☐ / No ☐
If yes, what are the new or changed
circumstances now making the IW feasible for vocational rehabilitation services
geared toward RTW? Click or tap here to explain why.
3.
Other
relevant information including:
a.
Has
the Industrial Commission or Bureau ever denied any related services? Yes ☐ / No ☐Click or tap
here to explain why.
b.
Are
there specific Independent Medical Examination (IME) recommendations given for
the related services? Yes ☐ / No ☐ Click or tap
here to explain why.
DMC
Provided
Other
claim information
1.
Does
the IW have other BWC claims? Yes ☐ / No ☐
a.
If
yes, how many?
b.
How
many active lost time claims?
c.
How
many have had prior vocational rehabilitation referrals?
d.
What
was the outcome of those cases?
|
Claim
Number
|
Case
Number
|
Referral
Date
|
Case
Completion Date
|
Case
State
|
Case
Status
|
Case
Status Reason
|
Click
here to enter vocational case history from DMC query
.
Note: When the MCO
does not manage the other claim(s), the DMC should send the MCO closure reports
for cases assigned to vocational rehabilitation case managers, if the closure
occurred within the past 5 years. Upon completion of this form, the DMC shall
issue an order determining the IW’s ability to participate, image this document
to the claim, and email the completed screening tool notifying the MCO of your
decision.
APPENDIX B: Job
Retention Screening Tool
MCO
Feasibility Determination
|
Claim
Number
|
|
Injured
Worker
|
|
|
MCO
Name & Number
|
|
|
MCO
Voc Rehab Coord
|
|
Phone
Number
|
|
|
MCO
Contact
|
|
Phone
Number
|
|
|
Referral
Source
|
|
Referral
Date
|
|
(FROM
A FILE REVIEW PERSPECTIVE)
1.
Is
the injured worker willing to participate in job retention services? Yes ☐ / No ☐ Click or tap here to explain why.
2.
Is
the IW able to participate in job retention services? Yes ☐ / No ☐ Click or tap here to explain why.
3.
Is
there a reasonable probability that the injured worker will benefit from job
retention services and remain at work as a result of the services? Yes ☐ / No ☐ Click or tap here to explain why.
4.
Do
you recommend the IW to be feasible for job retention services? Yes ☐ / No ☐ Click or tap here to explain why.
BWC
Eligibility Determination
|
Claim
Number
|
|
DMC
Name
|
|
Date
of Determination
|
|
|
ELIGIBILITY
INFORMATION:
|
|
Has
the injured worker returned to work (RTW)?
|
Date
of RTW: Click here to enter text.
|
Yes
|
No
|
|
Received
temporary total compensation or salary continuation in the past in this
claim?
|
Yes
|
No
|
|
Physician
of record documented work limitations related to the allowed conditions that
negatively impact the injured worker’s ability to maintain their employment?
|
Yes
|
No
|
|
Employer
described the specific job tasks / problems the injured worker is
experiencing and explained the reason job retention services are needed to
maintain employment as provided in writing or documented by the MCO in claim
notes?
|
Yes
|
No
|
|
INELIGIBILITY
INFORMATION:
|
|
Is
this claim disallowed, denied or in hearing status?
|
Yes
|
No
|
|
Is
this a settled claim (medical and/or indemnity)?
|
Yes
|
No
|
|
Did
the IW RTW after successfully completing a vocational rehabilitation plan but
subsequently resign and/or was terminated for cause and it was not due to the
allowed conditions in the claim?
|
Yes
|
No
|
|
PARTICIPATION
DETERMINATION
|
|
Is
the IW approved to participate in job retention services?
|
Yes
|
No
|
|
The
above claim has been reviewed by the Disability Management Coordinator. The
above criteria for participation in return to work service was outlined
according to the Ohio Administrative Code OAC 4123-18-03
|
|
|
|
|
|
|
Additional
Referral Information
MCO
Provided
1.
Did
the employer describe the specific job task problems the injured worker is
experiencing to justify their request for job retention? Yes ☐ / No ☐ If yes, click
here to describe the problems.
2.
Did
you obtain documentation from the POR office notes or correspondence that
indicates the IW has limitations related to the allowed conditions that impacts
IW’s ability to maintain employment. (This could be documented in office notes,
prescription, correspondence, or a MEDCO-14)? Yes ☐ / No ☐ Click or tap
here to explain why.
3.
Other
relevant information including:
a. Has the
Industrial Commission or Bureau ever denied any related services? Yes ☐ / No ☐Click or tap here to explain
why.
b.
Are
there specific Independent Medical Examination (IME) recommendations given for
the related services? Yes ☐ / No ☐ Click or tap here to explain
why.
DMC
Provided
Other
claim information
1.
Does
the IW have other BWC claims? Yes ☐ / No ☐
a.
If
yes, how many?
b.
How
many active lost time claims?
c.
How
many have had prior vocational rehabilitation referrals?
d.
What
was the outcome of those cases?
|
Claim
Number
|
Case
Number
|
Referral
Date
|
Case
Completion Date
|
Case
State
|
Case
Status
|
Case
Status Reason
|
Click
here to enter vocational case history from DMC query
.
Note: When the MCO
does not manage the other claim(s), the DMC should send the MCO closure reports
for cases assigned to vocational rehabilitation case managers, if the closure
occurred within the past 5 years. Upon completion of this form, the DMC shall
issue an order approving or denying participation, image this document to the
claim, and email the completed screening tool notifying the MCO of the
decision.
APPENDIX C: Timeframe
Waiver
Upon
receipt of a vocational rehabilitation referral, the MCO has 18 calendar days
to submit their initial feasibility determination to the DMC. If the MCO
determines that they cannot submit their request within 18 calendar days, they
must submit a request for timeframe waiver.
The
MCO shall not request a timeframe waiver and shall process the request for
eligibility determination without additional delay when:
1.
The
physician or treating provider did not respond to a request for restrictions
within 10 calendar days
2.
The
IW or their representative did not respond to a written request for contact
within 10 calendar days
3.
The
EOR did not respond to a written request for information within 10 calendar days
The
MCO shall request a timeframe waiver when the MCO:
1.
Is
waiting for a response to a written request for:
a.
Medical
documentation from the POR; or
b.
Willingness
to participate from the IW, or their representative AOR; or
c.
Eligibility
information from the EOR, or their representative.
2.
Contacted
the POR, who indicated they would provide information at the next medical
appointment that is less than one month in the future.
3.
Has
not addressed the initial referral in a timely manner.
The
MCO will send a timeframe waiver to to the BWC Rehabilitation Policy Unit at Policy.R.1@bwc.ohio.gov. The email
must include the following information:
Email
Title:
“NN-XXXXNN Voc Timeframe Waiver”
Email
Body:
Injured
Worker Name: Jane Doe
Claim
Number: XX-XXXXXX
Referral
Date: XX/XX/XXXX
Justification
for Request:
Outline
the steps taken to document the IW’s willingness and ability to participate and
the reasonable probability the IW will benefit from services and return to work.
Include
the dates and types of attempts made to obtain the needed information.
Provide
the next steps and timeframes to obtain the necessary information to complete
the appropriate MCO Vocational Rehabilitation Screening Tool.