OhioBWC - Basics: (Policy library) - File

Assignment of VRCM

Policy and Procedure Name:

Assignment and Reassignment of the Vocational Rehabilitation Case Manager

Policy #:

VR-01-01

Code/Rule Reference:

O.A.C. 4123-18-01

Effective Date:

09/14/18

Approved:

Deborah Kroninger, Chief of Medical Operations

Origin:

Vocational Rehabilitation Policy

Supersedes:

 Policy and Procedure VR-01-01, effective 10/10/16

History:

New 10/10/16; Rev. 09/06/18

 

I. Policy Purpose

 

The purpose of this policy is to ensure that:

·        The injured worker (IW) has a choice in the selection of a vocational rehabilitation case manager (VRCM);

·        The VRCM is promptly assigned;

·        The VRCM is provided with, or can otherwise obtain, the information necessary to fulfill his or her responsibilities; and

·        A VRCM is effectively reassigned, as appropriate.

 

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

·        VRCMs assigned by the MCO.

 

III. Definitions

 

See “Vocational Rehabilitation Definitions” in Chapter 4 of the MCO Policy Reference Guide.

 

IV. Policy

 

A.     It is the policy of BWC to ensure the IW is provided information regarding the provision of vocational rehabilitation services and has the opportunity to select a VRCM of his/her choice.

 

B.     It is the policy of BWC to ensure the prompt assignment of a VRCM and that the VRCM is provided with all relevant information necessary for vocational rehabilitation planning and service delivery to the IW.

 

C.    It is the policy of BWC that the MCO may reassign a VRCM when there are extraordinary circumstances justifying such a reassignment.

 

V. Procedure

 

A.     Assigning a VRCM

1.     Within three (3) business days of the MCO’s receipt of the eligibility verification from the DMC, the MCO shall contact the IW and verify the IW’s interest in vocational rehabilitation. If the IW’s interest was verified within 10 business days prior to the referral date, additional verification of interest is not required.

a.     If the IW or the IW’s attorney of record (AOR) has previously indicated a choice of provider, the MCO shall confirm this choice.

b.     If no previous choice has been made by the IW, the MCO shall discuss with the IW available providers and agree on a selection.

2.     The MCO may close the vocational rehabilitation case, consistent with the Vocational Rehabilitation Case Closure policy, prior to assigning a VRCM if:

a.     The IW does not respond within 10 business days of the latest documented contact attempts from the MCO; or

b.     The MCO finds the IW is clearly not feasible for services; or

c.      The IW does not wish to participate.

3.     Within three (3) business days of the verification of the IW’s interest in vocational rehabilitation and selection of a provider, the MCO shall assign the case to the VRCM.

a.     It is the responsibility of the VRCM to decline an assignment if he or she is not reasonably able to provide appropriate and timely services.

b.     The MCO shall notify the DMC by email of the VRCM assignment and provider number. The date of the email becomes the assignment date.

4.     Once a VRCM has been assigned, the MCO shall forward to the VRCM a referral packet containing the following information, as applicable:

a.     Claim demographics

i.       Claim number;

ii.      Allowed conditions (narrative and ICD code);

iii.     Date of injury (DOI);

iv.     Last date worked;

v.      Occupation;

vi.     Date of birth;

vii.   Average weekly wage;

viii.  Full weekly wage;

ix.     Temporary total rate; and

b.     Claim documents

i.       First Report of an Injury, Occupational Disease or Death (FROI);

ii.      Most recent Request for Temporary Total Compensation (C-84);

iii.     Most recent Physician’s Report of Work Ability (MEDCO-14);

iv.    Most recent Mental Health Notes Summary (Non-Psychotherapy Note) (MEDCO-16), if applicable;

v.      Most recent extent of disability independent medical examination;

vi.    A written job description(s) the IW held on the date of injury and/or the most recent job;

vii.   Vocational rehabilitation screening tool;

viii. Complexity Factors Reporting Form (an electronic blank EXCEL format);

ix.    All vocational rehabilitation initial assessments;

x.      All vocational rehabilitation closure reports; and

xi.    All vocational evaluations and functional capacity exams;

c.      Complete contact information for each of the following (e.g., cell phone, fax number, email address):

i.       IW;

ii.      AOR or other authorized representative, if applicable;

iii.     DMC;

iv.    MCO name and contact at MCO;

v.      Physician of record (POR) and contact at POR’s office;

vi.    Employer of record (EOR) name and contact at EOR; and

vii.   EOR third party administrator (TPA) name and contact at TPA if applicable.

d.     Vocational rehabilitation information

i.       The date the MCO is forwarding the referral packet to the VRCM;

ii.      The date of referral, name of the person who initiated the referral and the reason for the referral;

iii.     The basis for IW’s eligibility determination; and

iv.    The basis for IW’s initial feasibility determination.

5.     The VRCM shall promptly review the referral packet and request any missing information from the MCO.

 

B.     Reassigning a VRCM

1.     Any request for reassignment of the VRCM, from whatever source, shall be addressed by the MCO.

a.     The DMC or any other BWC staff shall forward any request for VRCM reassignment, from whatever source, to the MCO.

b.     The MCO may also initiate a VRCM reassignment.

2.     The MCO may reassign the VRCM when extraordinary circumstances exist that justify the reassignment. Examples of extraordinary circumstances may include, but are not limited to:

a.     The IW moving to a different area;

b.     The IW threatening the VRCM;

c.      The VRCM being unavailable for two or more weeks; or

d.     The VRCM failing to meet or maintain certification as required by the Credentialing Requirements of Providers of Vocational Rehabilitation Services policy and O.A.C. 4123-6-02.2.

3.     If the VRCM reassignment is initiated by the MCO and is not at the request of the IW or the VRCM, the MCO may consult with the DMC and/or the BWC Rehabilitation Policy Unit as necessary, prior to reassigning.

4.     The IW retains choice in the selection of a VRCM and the MCO shall ensure the IW is in agreement with the new VRCM assignment.

5.     The MCO shall enter a claim note describing the reason for reassignment of the VRCM.

6.     Within five (5) days of receiving notice of VRCM reassignment, the current VRCM shall prepare and provide to the MCO a transfer summary report. This report shall include:

a.     The current job goal;

b.     IW restrictions;

c.      The EOR contact information;

d.     Training and/or job placement status, as applicable; and

e.     All services that have been completed, to date.

7.     Within five (5) days of assignment to the new VRCM, the MCO shall provide the VRCM:

a.      The transfer report;

b.     An updated referral packet containing the information described in section IV.A.4, as applicable;

c.      Any vocational rehabilitation plans completed since the date of referral.

8.     The newly assigned VRCM shall review the referral packet, transfer report and any additional documentation. The VRCM shall take appropriate steps, based on where the IW is in the vocational rehabilitation process and consistent with the applicable policy and procedure.

a.     If an assessment plan or a job retention plan has been prepared and/or begun, the VRCM shall prepare an amended plan.

i.       The VRCM may amend the plan to reflect new or changed services; or

ii.      At a minimum, the VRCM shall provide an amended plan reflecting the new VRCM assignment with no change in services.

b.     If a comprehensive vocational rehabilitation plan has begun, The VRCM shall:

i.       Prepare and submit an amended plan if there is a significant change in the job goal or the VRCM identifies a significant new barrier and/or service needed; or

ii.      If there is no need to amend the plan, prepare and submit a progress report and Authorization Request for Vocational Rehabilitation Plan (RH-45).

 

C.    Managing Out-Of-State Cases:

 

1.     When the IW does not live in Ohio, the MCO shall:

a.     Assign a VRCM the IW is in agreement with and in close proximity to the IW (The IW retains choice in the selection of a VRCM); and

b.     Ensure the VRCM is BWC certified or at a minimum becomes enrolled to provide services under the direction of the Ohio MCO.

2.     The MCO shall only approve payment for services provided by the assigned out-of-state VRCM.