and procedure Name:
to Assessment or Comprehensive Plan and Medical Hold
Kroninger, Chief of Medical Operations (Signature on file)
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.
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.
policy applies to the:
disability management coordinators (DMC);
care organization (MCO) staff involved in the coordination and management of
the vocational rehabilitation program; and
rehabilitation case managers (VRCM) assigned by the MCO.
“Vocational Rehabilitation Definitions” in Chapter 4 of the MCO Policy
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.
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
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.