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OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Comprehensive Vocational Rehabilitation Plan and Progress Reports

Policy #:

VR-03-02

Code/Rule Reference:

O.A.C. 4123-18-05

Effective Date:

10/10/16

Approved:

Deborah Kroninger, Chief of Medical Operations (Signature on file)

Origin:

Vocational Rehabilitation Policy

Supersedes:

All vocational rehabilitation policies, procedures, directives and memos regarding comprehensive vocational rehabilitation plan and progress reports that predate the effective date of this policy and procedure.

History:

New

Review date:

10/10/19

 

I. Policy Purpose

 

The purpose of this policy is to ensure that an injured worker (IW) who is eligible and feasible for vocational rehabilitation services has a plan of services developed that will best enable the IW to obtain employment. 

 

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” in Chapter 4 of the MCO Policy Reference Guide.

 

IV. Policy

 

It is the policy of BWC that when an IW is eligible and feasible for vocational rehabilitation services, the vocational rehabilitation case manager (VRCM) will develop a comprehensive plan and collaborate with the MCO and DMC to assist the IW in obtaining employment.

 

V. Comprehensive Plan Development and Expectations

 

A.    Timeframes

1.    The VRCM shall submit the comprehensive plan to the MCO for review and approval:

a.    Within seven (7) calendar days of submission of the initial assessment report (where no assessment plan was needed); or

b.    Within ten (10) days of completion of the services in an assessment plan.

2.    If the VRCM determines that it will not be possible to develop a comprehensive plan within the required timeframes, he or she shall:

a.    Submit written justification for the extension to the MCO within the seven (7) or ten (10) day time frame (whichever is applicable); and

b.    Staff the issue with the MCO and DMC.

3.    Justifiable reasons for an extension may include (but are not limited to):

a.    Pre-plan information is not received following a timely request (e.g., physician of record (POR) or employer information, functional capacity or vocational evaluations); or

b.    An unexpected situation prevents the IW from participating in the vocational rehabilitation process (e.g., a family emergency).

 

B.    Comprehensive Plan Components and Expectations

1.    The VRCM shall use the Vocational Rehabilitation Comprehensive Plan (RH-44) to complete the comprehensive plan.

2.    The comprehensive plan must reflect that the IW’s participation in services will approximate the IW’s pre-injury workweek or, if applicable, the number of hours the IW is medically released for participation.

3.    The VRCM shall ensure all the requested information on the RH-44 is provided, including:

a.    Plan of Service Approvals:

i.      Verification of verbal approval by the IW, initials of person verifying the verbal approval (typically the VRCM) and the date;

ii.     MCO authorization or denial, with a signature and date (a denial shall only be generated following reasonable negotiation and clarification);

iii.    Signature of the VRCM that prepared the comprehensive plan and date;

iv.   Signature of IW indicating acceptance of the comprehensive plan and date (a hard copy signature must be received within 30 days of the first date of plan service); and

v.    Printed name and signature of VRCM accepting the comprehensive plan for implementation of services.

b.    Narratives:

i.      Vocational considerations – A brief summary of the vocationally relevant work and training history, including:

a)    Job history;

b)    Transferable skills;

c)    Job analysis information;

d)    Academic history; and

e)    Military service.

ii.     Medical considerations: A brief summary of vocationally relevant medical information (i.e., those factors which are currently or potentially impacting a return to work) including:

a)    Medical issues to be addressed for return to work;

b)    Co-morbidities and non-allowed conditions impacting return to work; and

c)    Surgeries and other treatment.

iii.    Other considerations: A brief summary of other vocationally relevant factors including:

a)    Personal factors;

b)    Legal factors;

c)    Strengths upon which the comprehensive plan relies; and

d)    Barriers to employment and plans to overcome them.

iv.   Justification of return to work level and job goal: The rationale for the return to work level (a.k.a. “return to work hierarchy”) and job goal selected as well as relevant labor market information supporting the job goal if a change in employers is necessary.

v.    Comprehensive plan of services with justification:

a)    A description of the services to be provided and the rationale for the services (not simply a listing of the definition of the services);

b)    The reason the services are included specific to the IW and the specific barriers to employment or needs to be addressed by the service; and

c)    The expectations of the IW’s participation in the services.

c.    Plan of services grid, including:

i.      Vocational rehabilitation case management for comprehensive plan implementation;

ii.     Provisions for living maintenance compensation;

iii.    Provider travel, wait time and mileage as a single summary entry;

iv.   A minimum of 30 days of vocational rehabilitation case management for return to work follow-up;

v.    The service provider - This may be a company rather than an individual, particularly if the exact assignment is anticipated later in the comprehensive plan;

vi.   The estimated number of weeks of a particular service;

vii.  Estimated service dates (from and to);

a)    Services shall overlap and run concurrently, when possible.

b)    Estimated service dates may vary as the comprehensive plan progresses.

viii. Estimated cost of each service;

ix.   Total weeks - Calculated from the first approved comprehensive plan with a begin date on or after 2-1-2015 for this vocational referral through the estimated end date of the most recent comprehensive plan; and

x.    The total estimated cost of all services and living maintenance.

4.    The VRCM shall ensure that the IW has a prescription or a medical release from the POR for vocational rehabilitation services, as necessary. See Appendix A to this policy and procedure for a list of services that require a physician prescription or release.

5.    The DMC is responsible for authorizing comprehensive plans that qualify as special plan types prior to implementation. See the Special Vocational Plan Types policy and procedure for further information.

 

VI. Amending the Comprehensive Plan

 

A.    The VRCM may amend the comprehensive plan to continue or redirect vocational rehabilitation services when:

1.    There is a significant change in the job goal; or

2.    The VRCM identifies a significant new barrier and/or service need.

 

B.    The VRCM shall amend a comprehensive plan using the RH-44, identifying it as amended and providing a plan identification number. 

 

C.   The VRCM shall staff the amended comprehensive plan with the MCO and the DMC.

 

D.   If additional assessments are needed prior to amending the comprehensive plan, the VRCM shall:

1.    Submit a progress report and authorization request outlining the needed assessment services; and

2.    Once the needed assessments are completed, submit the amended comprehensive plan to the MCO.

 

E.    The VRCM shall ensure that all sections on the RH-44 are completed with updates, as needed.

1.    The amended comprehensive plan shall outline all the services necessary to progress an IW from the current situation through return to work.

2.    An updated complexity factor form may also be submitted with the amended comprehensive plan, if needed.

 

F.    To ensure there is no interruption in the IW’s living maintenance payment, the VRCM shall submit the amended comprehensive plan to the MCO so that it is received by the DMC no later than three (3) business days prior to the end of the previous comprehensive plan.

 

VII. Reopened Comprehensive Plans

 

A.    When a comprehensive plan is reopened (e.g., the IW has successfully appealed a case closure) the VRCM shall submit an amended comprehensive plan (if needed pursuant to section VI.A, above) within twenty-one (21) days from the date the case is reassigned to the VRCM.

 

B.    If a comprehensive plan is reopened and there is no need to amend the comprehensive plan, the VRCM shall continue the services that were authorized before closure.

 

 

VIII. Progress Reports

 

A.    For every IW participating in a comprehensive plan, the VRCM shall:

1.    Complete written updates of progress using the Vocational Rehabilitation Progress Report (RH-46), for every 30 day period of comprehensive plan participation, or more frequently if necessary; and

2.    Submit the progress report to the MCO and DMC, no later than five (5) business days from the end of the reporting period.

 

B.    The VRCM shall ensure all the requested information on the RH-46 is provided including:

1.    Adequate information about the current status of the IW’s progress towards return to work or remain at work;

2.    Justification for service authorization requests and minor changes in services; and

3.    Requests for any necessary assessments when a significant change in direction in the comprehensive plan is required.

 

C.   The MCO and DMC are responsible for reviewing the progress reports as part of oversight of the comprehensive plan.

 

IX. Authorization of Services

 

A.    The VRCM shall use an Authorization Request for Vocational Rehabilitation Plan (RH-45) for services on the comprehensive plan or an amended comprehensive plan. The RH-45 shall be submitted:

1.    With the comprehensive plan or amended comprehensive plan to ensure the first period of services are authorized at least three (3) business days prior to initiation of services; or

2.    With a progress report, to authorize the next set of services at least five (5) business days prior to the end of the current authorization.

 

B.    The VRCM shall ensure that all the information requested on the RH-45 is provided.

 

C.   The MCO shall not deny any service on an RH-45 prior to staffing with the VRCM. Denial of comprehensive plan services may result in a closure of the comprehensive plan. See the Vocational Rehabilitation Plan Closure policy and procedure for more information.

 

X. Signature Requirements

 

A.    On an RH-44 (both the original comprehensive plan and an amended comprehensive plan), the MCO shall require a hard copy signature from the:

1.    VRCM;

2.    MCO; and

3.    The IW (within 30 days pursuant to Section X. B., below).

 

B.    When the VRCM initially receives verbal approval from the IW, the VRCM shall:

1.    Initial and date the comprehensive plan in the appropriate “Plan of service approval” section, which serves to attest the VRCM has discussed the comprehensive plan services with the IW and the IW agrees with the services; and

2.    Within 30 days of the comprehensive plan start date, obtain and submit the IW’s hard copy signature to the MCO and DMC.

 

C.   On an RH-46 the MCO shall require:

1.    A hard copy signature from the VRCM; and

2.    If the progress report reflects changes to the types or overall duration of services, a hard copy signature or verbal approval from the IW.

a.    The VRCM may submit a verbal signature from the IW.

b.    The VRCM shall submit a hard copy signature of the IW no later than 30 days after submission of the progress report.

 

D.   The MCO shall not accept an email- generated (i.e., typed) signature as a hard copy signature. The MCO shall accept a scanned document sent via fax or email which reflects a hard copy signature.

 

 

 

 

 

 

 

 

 

 

APPENDIX A

 

Services Requiring a POR Prescription or C-9

Services Requiring a POR Release                      Documentation from POR that IW may return to work with restrictions MEDCO 14, or office notes, etc

Services Not Requiring a POR Prescription or Release

Code

Service

Code

Service

Code

Service

No code

Gradual return to work

No code

Employer Incentive Contract

CPT codes

Adjustment Counseling

CPT

Functional Capacity Evaluation

W0660 W3260

Job Placement

W0647

Auto Repairs

W0750

Nutritional Consult

W0659 W3259

Job Development

W0674

Child Care

CPT

Occupational  or Physical Therapy

No code

Job Search

W0644

Ergonomic Study

W0637

Transitional Work Services

W0694

Long term training

W0645

Job Analysis

W0648

Physical Reconditioning Unsupervised

No code

On-the-job training

W0650

W3257

Job Seeking Skills

Training

W0710

Work Conditioning

W0692

Short term training

W0690

Training-Books, Supplies and Testing

W0702 Initial 2 hr: W0703 Each add. hr:

Work Hardening/

Occ. Rehab

No code

Work Trial

W0663

Job Modifications

 

 

 

 

Z0700

Relocation Expense

 

 

W0672

Job Coach

W0635

Situational Work Assessment

 

 

W0641 W3258

Job Club

W0665

Tools & Equipment

 

 

 

 

W3000-3040   W3200-3240

Vocational Case Management

 

 

 

 

W0610

Vocational Eval. Comprehensive

 

 

 

 

W0631

Vocational Screening

 

 

 

 

W0662

W0620

Work Adjustment

 

 

 

 

W0523-0524

Career Counseling

 


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