|
Policy and Procedure Name:
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Referrals, Eligibility and Feasibility
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|
Policy #:
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VR-18-01
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Code/Rule Reference:
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O.A.C.
4123-18-03
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Effective Date:
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07/01/21
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Approved:
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Deborah Kroninger, Chief of Medical Operations
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Origin:
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Vocational Rehabilitation Policy
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Supersedes:
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Policy # VR-18-01, effective 10/07/19
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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 R.C. 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
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
|
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|
MCO Name & Number
|
Choose an item.
|
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MCO Voc Rehab Coord
|
|
Phone Number
|
|
|
MCO Contact
|
|
Phone Number
|
|
|
Referral Source
|
Choose an item.
|
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
|
Choose an item.
|
Date of Determination
|
|
|
ELIGIBILITY INFORMATION:
|
|
|
A significant impediment to employment as a direct result
of the allowed conditions in the claim?
|
|
|
|
|
Temp Total Disability compensation for date of referral?
|
|
|
|
Salary Continuation in lieu of TT for date of referral?
|
|
|
|
Permanent Total Compensation for date of referral?
|
|
|
|
Receiving or awarded non-working wage loss for the date of
referral?
|
|
|
|
Awarded Scheduled Loss award?
|
|
|
|
Catastrophic injury claim?
|
|
|
|
·
Vocational goal able to be established? (REQUIRED)
|
|
|
|
Employee of state agency or university?
|
|
|
|
·
Employer of Record agrees with rehabilitation? (REQUIRED)
|
|
|
|
IW not currently receiving compensation and POR documented
work restrictions/barriers within 180 days?
|
|
|
|
INELIGIBILITY INFORMATION:
|
|
Is this claim disallowed, denied or in hearing status?
|
|
|
|
Are there 7 or fewer days of lost time allowed in this
claim?
|
|
|
|
Is this a settled claim (medical and/or indemnity)?
|
|
|
|
Is the Injured Worker working on the date of referral?
|
|
|
|
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?
|
|
|
|
PARTICIPATION DETERMINATION
|
|
Is the IW approved to participate in return to work
services?
|
|
|
|
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
|
Claim Number
|
|
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
|
Choose an item.
|
|
MCO Voc Rehab Coord
|
|
Phone Number
|
|
|
MCO Contact
|
|
Phone Number
|
|
|
Referral Source
|
Choose an item.
|
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
|
Choose an item.
|
Date of Determination
|
|
|
ELIGIBILITY INFORMATION:
|
|
Has the injured worker returned to work (RTW)?
|
Date of RTW: Click
here to enter text.
|
|
|
|
Received temporary total compensation or salary
continuation in the past in this claim?
|
|
|
|
Physician of record documented work limitations related to
the allowed conditions that negatively impact the injured worker’s ability to
maintain their employment?
|
|
|
|
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?
|
|
|
|
INELIGIBILITY INFORMATION:
|
|
Is this claim disallowed, denied or in hearing status?
|
|
|
|
Is this a settled claim (medical and/or indemnity)?
|
|
|
|
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?
|
|
|
|
PARTICIPATION DETERMINATION
|
|
Is the IW approved to participate in job retention
services?
|
|
|
|
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
|
Claim Number
|
|
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.state.oh.us.
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.