Policy and Procedure Name:
|
Interruptions to Assessment or Comprehensive Plan and Medical Hold
|
Policy #:
|
VR-09-02
|
Code/Rule Reference:
|
O.A.C.
4123-18-04
|
Effective Date:
|
07/01/21
|
Approved:
|
Deborah Kroninger, Chief of Medical Operations
|
Origin:
|
Vocational Rehabilitation Policy
|
Supersedes:
|
Policy # VR-09-02,
effective 10/10/16
|
History:
|
Previous versions of this policy are available upon
request
|
I. POLICY PURPOSE
The purpose of this policy is to ensure interruptions to an
assessment plan or to a comprehensive plan and medical holds are handled in a consistent,
reasonable and efficient manner.
II. APPLICABILITY
This policy applies to the:
·
BWC disability management coordinators (DMC);
·
Managed care organization (MCO) staff involved in the
coordination and management of the vocational rehabilitation program; and
·
Vocational rehabilitation case managers (VRCM) assigned by the
MCO.
III. DEFINITIONS
See Vocational
Rehabilitation Definitions.
IV. POLICY
It is the policy of BWC to evaluate an interruption of an injured
worker’s (IW’s) participation in an assessment plan or comprehensive plan and to
determine the most appropriate action.
V. PROCEDURE
A. Non-Medical
Interruption
1.
Upon becoming aware that an IW will not be participating in the
assessment or comprehensive plan for one or more days, the VRCM shall notify
the MCO and DMC within the same business day, by phone, fax, or email.
a. If the interruption
is expected to be five business days or less, the DMC shall consider the
circumstances and determine if living maintenance compensation (LM) will
continue.
b. If the
interruption is expected to be more than five business days, the VRCM, MCO and
DMC shall staff the plan to consider if closure is appropriate.
2. When the IW is
participating in a training plan, and through no fault of the IW courses are not
available for a one-term period and the plan will be interrupted, the DMC shall
communicate with the claim service specialist (CSS) to ensure:
a. LM is
discontinued during the plan interruption; and
b. Any other form
of compensation for which the IW is eligible is reinstated.
B. Medical
Interruption
1.
Upon becoming aware that an IW will not be participating in the
assessment or comprehensive plan for one or more days, the VRCM shall notify
the MCO and DMC within the same business day. Notification shall be by phone,
fax, or email.
2. During an
assessment plan: When it appears the IW’s medical instability (which may or may
not be related to the allowed condition) will cause the IW to be unable to
participate in the assessment plan for less than 30 days, the VRCM shall
prepare and submit to the MCO an amended assessment plan using the Vocational
Rehabilitation Assessment Plan form (RH-43) and a request for the
medical interrupt with continuation of LM if appropriate.
3. During a
comprehensive plan: When it appears the IW’s medical instability (which may or
may not be related to the allowed condition) will cause the IW to be unable to
participate in the comprehensive plan for less than 30 days, the VRCM shall
prepare and submit to the MCO a progress report and an authorization request
for the medical interrupt with payment of LM, if appropriate.
4. The MCO shall
notify the DMC within 24 hours of being notified by the VRCM of the medical
interruption. Notification to the DMC shall be by phone, fax, or email.
5. The DMC shall:
a. Review and
evaluate the diagnosis, prognosis and the medical condition’s expected impact
on participation in the assessment or comprehensive plan; and
b. Determine the
reasonableness of maintaining the vocational rehabilitation case in a medical
interrupt while the medical condition resolves or further information about the
condition is gathered.
6. If the DMC
determines it is appropriate, the vocational rehabilitation case may be
maintained in medical interrupt for up to 30 calendar days. In exceptional
situations, the DMC may approve the medical interrupt for an additional 30
calendar days.
7. LM during a
medical interruption (regardless of the approved duration of the medical
interruption) is limited to 30 calendar days per vocational rehabilitation case.
See the Living
Maintenance Compensation policy and procedure for further information.
8. At the end of
the medical interruption, the VRCM shall submit an amended plan, as appropriate,
consistent with the Initial
Assessment and Assessment Plan policy or the Comprehensive
Vocational Rehabilitation Plan and Progress Reports policy, as
applicable.
9. The VRCM shall
require a medical release for participation in a scheduled service as needed.
C. Plan
Closure
1. If at any point
it appears likely the IW’s medical condition or other circumstances will prohibit
a return to active plan participation within a reasonable time, the MCO shall
close the case.
2. Any closure due
to interruption, whether medical or non-medical, shall be completed consistent
with the Vocational
Rehabilitation Case Closure policy.
D. Medical
Hold Closure
1. The IW, POR or
any party to the claim may make a request to the MCO for a medical hold.
2. If the medical
condition for which the hold is being requested is not an allowed condition,
the MCO shall ensure that:
a. The IW has
signed a consent form permitting the MCO and DMC to communicate with the
relevant treating physician about the stability of the medical condition as it
relates to a return to active rehabilitation; and
b. The claim file
contains documentation of the diagnosis and prognosis of the medical condition.
3. Upon receipt of
the request for a medical hold, the MCO shall forward the request along with
any necessary information to the DMC.
4. The DMC shall
determine if a medical hold status is appropriate.
5. The DMC may deny
a request for medical hold for the following reasons:
a. The IW was not
participating in a plan at the time of case closure;
b. The request for
medical hold was not made at the time of case closure;
c. The IW did
not sign a consent form for both the DMC and the MCO to communicate with the
treating physician (if the medical condition for which the hold is being
requested is not an allowed condition);
d. There is no
documentation of diagnosis or prognosis of the medical condition;
e. The treating
physician did not indicate the IW’s medical condition would interfere with
participation in a plan; or
f. The
medical evidence indicates the medical treatment the IW is considering is
cosmetic and/or recovery is short-term only.
6. The DMC shall
communicate to the MCO, IW and other parties to the claim the decision to allow
or disallow a medical hold using the “Medical Hold - Eligible” or “Medical Hold
– Not Eligible” letter available on COR.
7. The MCO shall
monitor the IW’s medical status and communicate that status to the DMC on a
monthly basis for the first six months of the medical hold and bi-monthly
thereafter, up to two years.
8. Whenever the MCO
or DMC receives information that the IW’s medical condition has stabilized, the
MCO or DMC shall notify the other.
9. Following the
medical hold, the MCO shall assign a VRCM, according to the Assignment
and Reassignment of the Vocational Rehabilitation Case Manager policy
and procedure, to review the IW’s continuing feasibility for vocational
rehabilitation services and advise the DMC.
10. If the IW is currently
feasible for vocational rehabilitation services, the IW shall resume
participating in plan services as soon as possible.