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OhioBWC - Basics: (Policy library) - File

Interruption to Plan

Policy and procedure Name:

Interruptions to Assessment or Comprehensive Plan and Medical Hold

Policy #:

VR-09-02

Code/Rule Reference:

OAC 4123-18-04

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 interruptions to assessment or comprehensive plans and medical hold 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 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” in Chapter 4 of the MCO Policy Reference Guide.

 

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. PROCEDURES

 

A.    Non-Medical Interruption: The VRCM shall notify the DMC within 24 hours of becoming aware that an IW will not be participating in the assessment plan or the comprehensive plan for one or more days. Notification to the DMC shall be by phone, fax, or email.

1.    If the interruption is expected to be five (5) working days or less, the DMC shall consider the circumstances and determine if living maintenance compensation (LM) will continue.

2.    If the interruption is expected to be more than five (5) working days, the VRCM, MCO and DMC shall staff the plan to consider if closure is appropriate.

3.    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.    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 RH-43 and a request for the medical interrupt with continuation of LM if appropriate.

2.    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.

3.    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.

4.    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.

5.    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.

6.    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.

7.    At the end of the medical interruption, the VRCM shall submit an amended plan, as appropriate, consistent with the Initial Assessment and Initial Assessment Plan policy or the Comprehensive Vocational Rehabilitation Plan and Progress Reports policy, as applicable.  

8.    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 review the IW’s feasibility for vocational rehabilitation services and advise the DMC.

10.  If the MCO finds the IW is currently feasible for vocational rehabilitation services, the IW shall resume participating in plan services as soon as possible.

 

 

 


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