OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Rehabilitation Injury Claims

Policy #:

CP-18-02

Code/Rule Reference:

O.R.C. 4121.68, O.A.C. 4123-18-14

Effective Date:

10/27/2020

Approved:

Ann M. Shannon, Chief of Claims Policy and Support

Origin:

Claims Policy

Supersedes:

All claims policies, directives or memos regarding rehabilitation injury claims that predate the effective date of this policy.

History:

New

 

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).

 

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

 

A.     General Claim Note and Documentation Requirements

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.

 

C.    Rehabilitation Injury Claim Assignment

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.

 

D.    BWC Claims Services Staff Responsibilities

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 notice is provided to the source claim employer on any written communication in the rehabilitation injury claim, when applicable. 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.

b.     PES, the employer is 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.