Skip Navigation Links.
Online Support available
Monday through Friday
7:30 a.m. - 5:30 p.m.
Click here to get help!
OhioBWC - Basics: (Policy library) - File

Referrals, eligibility, feasibility Policy

Policy and Procedure Name:

Referrals, Eligibility and Feasibility

Policy #:

VR-18-01

Code/Rule Reference:

O.A.C. 4123-18-03

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 referrals, eligibility and feasibility 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 referrals and determinations for eligibility and feasibility are processed and determined consistently and appropriately.

 

II. APPLICABILITY

 

This policy applies to:

·         BWC staff;

·         Managed care organization (MCO) staff; and

·         Vocational rehabilitation case managers (VRCMs) assigned by the MCO.

 

III. DEFINITIONS

 

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

 

IV. POLICY

 

A.    MCO and BWC Roles

1.    It is the policy of BWC that the MCO shall designate a vocational rehabilitation program coordinator to direct the MCO’s management of vocational rehabilitation services. The vocational rehabilitation program coordinator’s role is to:

a.    Increase accountability in the delivery of high quality vocational services; and

b.    Enhance communication between BWC and the MCO.

2.    It is the policy of BWC to assign a Disability Management Coordinator (DMC) to serve as the point of contact for the vocational rehabilitation program coordinator on case-specific vocational rehabilitation issues.

 

B.    Referral

1.    It is the policy of BWC to encourage and support a referral to vocational rehabilitation as soon as the need is indentified and viable services may be delivered.

2.    It is the policy of BWC that anyone may refer an injured worker (IW) for vocational rehabilitation services, including referrals for job retention services.

3.    BWC and the MCO shall consider any information or statements received indicating the IW’s need for vocational rehabilitation services, other than pre-referral staffing, as a referral for vocational rehabilitation services.

4.    The first documented date of receipt of a vocational rehabilitation referral by BWC or the MCO becomes the official referral date.

 

C.   Eligibility:

1.    It is the policy of BWC that the DMC is responsible for determining the IW’s eligibility for vocational rehabilitation services.

2.    To be eligible for vocational rehabilitation services (other than as provided in section IV.C.4 and 5), the IW must:

a.    Have a claim:

i.      Allowed by BWC or the Industrial Commission (IC), with eight or more days of lost time due to a work related injury; or

ii.     Certified by a state university or state agency; or

iii.    Certified by a self-insuring employer.

b.    Be experiencing a significant impediment to employment or the maintenance of employment as a direct result of the allowed conditions in the referred claim; and

c.    Have at least one of the following present in the referred claim:

i.      The IW is receiving or has been awarded temporary total, payments made in lieu of temporary total compensation (e.g., salary continuation), non-working wage loss, or permanent total compensation for a period of time that includes the date of referral; or

ii.     The IW was granted a scheduled loss award under R.C. 4123.57(B) (e.g., loss of use of a finger or limb); or

iii.    The IW received or was awarded a permanent partial award under R.C. 4123.57(A) and has job restrictions as a result of the allowed conditions in the claim for which that award was granted, documented and dated by the physician of record (POR) not more than 180 days prior to the date of referral; or

iv.   The IW:

a)    Has reached maximum medical improvement in the claim, as determined by an order of BWC or the IC, or documented in writing by the POR;

b)    Is not currently receiving compensation; and

c)    Has job restrictions in the claim, documented and dated by the POR not more than 180 days prior to the date of the referral; or

v.    The IW is receiving job retention services to maintain employment, or satisfies the criteria for job retention services pursuant to section IV.C.4 of this policy, on the date of referral; or

vi.   The IW sustained a catastrophic injury claim and a vocational goal can be established; or

vii.  The IW was receiving living maintenance wage loss not more than ninety (90) days prior to the date of referral and:

a)    Has continuing job restrictions documented by the POR as a result of the allowed conditions in the claim, and

b)    Has lost his or her job through no fault of his or her own.

3.    The IW must not be working on the date of referral, with the exception of a referral for job retention services.

4.    Job Retention Services - An IW shall be eligible for job retention services when:

a.    The IW is working and experiences a significant work-related problem as a direct result of the allowed condition(s) in the claim;

b.    The IW has received temporary total compensation or salary continuation in an allowed claim with eight or more days of lost time due to a work related injury;

c.    The POR provides a written statement in office notes or correspondence indicating that the IW has work limitations related to the allowed conditions in the claim that negatively impact the IW’s ability to maintain employment; and

d.    The IW’s employer describes the specific job task problems the IW is experiencing to the MCO and the MCO documents these problems in the claim. The MCO shall include a statement describing why the IW needs job retention services to maintain employment.

5.    Employees of State Agencies and State Universities

a.    An employee of a state agency or state university shall be eligible for vocational rehabilitation services when:

i.      The IW has a significant impediment to employment or the maintenance of employment as a direct result of the allowed conditions in the referred claim;

ii.     The state agency or state university certifies the claim; and

iii.    The employee and employer agree upon a program of vocational rehabilitation services.

b.    Employees of a state agency or state university are not required to meet the eligibility criteria stated in section IV.C.2.c.

6.    An IW is not eligible for vocational rehabilitation services when:

a.    The IW enters into a lump sum settlement (medical and/or indemnity; or

b.    When the IC or a court order subsequently disallows the claim.

7.    BWC will document the facts supporting an eligibility determination in its decision letter.

8.    A party may appeal an eligibility determination to the BWC Rehab Eligibility Appeal Unit (address provided on the determination letter) within fourteen days of receipt of BWC’s decision.

 

D.   Initial and Continuing Feasibility

1.    It is the policy of BWC that initial and ongoing feasibility will be decided by the MCO with input from BWC.

2.    An IW is feasible for vocational rehabilitation services when a review of all available information demonstrates that the provision of vocational rehabilitation services is likely to result in the IW’s returning to work.

3.    The MCO will assess feasibility throughout the vocational rehabilitation process as further information becomes available and the IW’s circumstances change.

4.    Appeals of feasibility determinations shall be governed by the alternative dispute resolution process provided for in O.A.C. 4123-6-16 and the Alternative Dispute Resolution policy.

 

E.    Immigration Status

1.    The IW’s immigration status, including status as an undocumented worker, is not a factor in determining eligibility and feasibility for vocational rehabilitation.

2.    The VRCM shall not provide job development or job placement services if the IW does not have legal permission to work in the United States.

 

V.   Procedures

A.    Referral Processing by the MCO - Gathering Documentation, Initial Feasibility Determination and Eligibility Recommendation

1.    The MCO shall be responsible for management of all referrals through case resolution, including those referrals submitted via a:

a.    Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9);

b.    Physician’s Report of Work Ability (MEDCO-14);

c.    Request for Temporary Total Compensation (C-84);

d.    Recommendation pursuant to an independent medical evaluation (IME); or

e.    Contact from an interested party.

2.    Processing Referrals from Parties to the Claim, a POR, or Treating Physician

a.    When the MCO receives a vocational rehabilitation referral from a party to the claim, the POR, or the treating physician, the MCO will begin the initial feasibility determination and eligibility verification process by:

i.      Obtaining any needed medical documentation from the POR describing the IW’s restrictions related to the allowed conditions;

ii.     Providing a cursory review of whether the IW meets the eligibility criteria; and

iii.    Evaluating any documented factors that may impact initial feasibility such as:

a)    The IW’s interest in returning to work;

b)    The IW’s past participation in vocational rehabilitation plans or other BWC-provided services;

c)    Documentation of events that could impact the IW’s ability to participate in vocational rehabilitation services (e.g., scheduled surgery, vacation, incarceration);

d)    Documentation of medical and psychological issues, including pain issues, and medication or substance abuse issues , both related and unrelated to the allowed conditions in the referred claim;

e)    Diagnostic evaluations.

b.    If the IW clearly does not appear eligible based on the current circumstances or information available, the MCO shall communicate to the IW what additional information the IW may submit or what steps the IW may take to become eligible (e.g., obtain current physical restrictions from physician).

c.    The MCO shall use the Vocational Rehabilitation Screening Tool or an equivalent tool to assist in collating and documenting referral information.

i.      When a screening tool other than the Vocational Rehabilitation Screening Tool is used, it must provide all the same information, in the same order, as the Vocational Rehabilitation Screening Tool.

ii.     Screening tool information shall be password protected, consistent with the BWC Sensitive Data Transmission policy.

d.    The MCO shall request medical documentation from the POR to establish the IW’s current restrictions as needed.

i.      If the requested medical documentation is not received within seven (7) days, the MCO shall send the request for eligibility determination to the DMC.

ii.     The MCO shall note the request for medical documentation from the POR and the outcome on the vocational screening tool.

e.    The MCO request for eligibility determination to the DMC shall include:

i.      The vocational rehabilitation screening information;

ii.     A written initial feasibility determination (if reasonably able to determine from the available information) which includes identification of the information utilized in making the determination; and

iii.    An eligibility recommendation.

3.    Processing BWC or MCO Initiated Referrals and Referrals from Other Sources

a.    If the MCO receives a vocational rehabilitation referral from a source not a party to the claim, or the MCO or BWC determines that an IW may benefit from vocational rehabilitation services, the MCO and DMC shall staff the case, as necessary, to discuss eligibility and initial feasibility.

b.    The MCO shall contact the IW and POR to determine if the IW is interested and able to participate in vocational rehabilitation services.

c.    If the IW and POR indicate that the IW is not interested or is unable to participate in vocational rehabilitation services at this time, the referral shall not be referred to BWC. The MCO shall indicate in MCO notes an explanation of the decision regarding the referral.

d.    If the IW or POR indicate the IW is interested and able to participate in vocational rehabilitation services, the referral shall continue to be processed consistent with section V.A.2.

4.    Special Categories of Referrals

a.    Referrals Received Via a C-84

i.      If a C-84 is received and the IW has indicated an interest in vocational rehabilitation services, the MCO and DMC shall consult to determine if a referral is appropriate at this time.

ii.     If a referral is appropriate at this time, the C-84 shall be treated as a referral and processed consistent with section V.A.2.

iii.    If it does not appear to be an appropriate time for a referral, the DMC and the MCO shall make a note to review the claim in the future and the MCO shall notify the IW.

b.    Referrals for Job Retention

i.      The MCO shall process a referral for job retention services consistent with section V.A., including obtaining, if not received with the referral:

a)    A written statement from the POR, either in office notes or correspondence, indicating that the IW has work limitations related to the allowed conditions in the claim that negatively impact the IW’s ability to maintain employment; and

b)    A written or verbal statement from the employer describing the specific job task problems the IW is experiencing.

ii.     The MCO shall include in the request for eligibility determination a description of why the IW needs job retention services to maintain employment.

c.    Referrals When a Claim is Inactive

i.      When a referral for vocational rehabilitation services is received by BWC or the MCO in an inactive claim, the referral shall be considered a request for claim reactivation.

ii.     The DMC and MCO shall make the eligibility and feasibility determinations, and notify the assigned claims service specialist (CSS) of the determinations.

a)    If the IW is determined to be eligible and feasible for vocational rehabilitation services, the CSS shall issue an order allowing reactivation of the claim, including the eligibility and feasibility determination and supporting justification.

b)    If the IW is determined to not be eligible and/or feasible for vocational rehabilitation services, and there is no other justification for reactivating the claim, the CSS shall issue an order denying reactivation with the supporting justification.

d.    Referrals When a Claim has Pending Issues Before the IC

i.      If a claim has any issues pending before the IC that could affect vocational rehabilitation feasibility or eligibility, the DMC shall not take action on the referral until such matters have been resolved.

ii.     Once the DMC is notified of resolution of all issues, provided the claim is still active, the DMC shall process the referral as described in this procedure.

 

B.    Eligibility Verification/Determination by the DMC

1.    The DMC shall review the information provided by the MCO and other related documentation to determine if the IW meets the criteria for eligibility.

2.    The DMC shall request documentation of the IW’s restrictions from the MCO or the IW’s POR if the documentation is not already in the claim or included with the referral.

3.    Within two (2) business days of receipt of the request for eligibility determination, the DMC shall communicate the eligibility decision:

a.    To the MCO via email. If the DMC requested the MCO to seek additional medical documentation from the POR, the eligibility decision shall be emailed to the MCO within:

i.      Two (2) business days of receipt of the documentation; or

ii.     Within seven (7) business days from the date of the request to the POR, whichever is earlier.

b.    To the parties via letter. The letter shall contain language instructing the parties of their rights and the process for appealing the decision.

 

 


 

MCO Vocational Rehabilitation

Screening Tool

 

MCO Name                                                       MCO Number___________________

 

MCO Vocational Rehabilitation Coordinator_____________     

Phone Number_____________

 

MCO Contact:                                                   Phone Number:                                               

 

Injured Worker Name                                       Claim #                                               

 

Referral:           ¨ Internal        ¨ External   

 

Referral Source:                                              

 

Is injured worker medically stable to actively participate in vocational rehabilitation services geared toward return to work? (FROM A FILE REVIEW PERSPECTIVE)

 

 

Are there opportunities for transitional work or does alternative work exist at the injured worker’s employer?

 

 

What is this injured worker’s significant impediment for return to work?

 

 

Is this a re-referral for vocational rehabilitation? (Yes/No)  If yes, what are the new or changed circumstances now making the injured worker feasible for vocational rehabilitation services geared toward return to work?

 

 

Other relevant information including:

 

·         Has the injured worker’s current (or previous) MCO ever denied physical restorative or vocational services in this claim? (specify)

 

 

 

·         Has the Industrial Commission or BWC ever denied any related services?

 

 

 

·         Are there specific independent medical examination recommendations given for the related services?

 

 

 

·         Briefly list any physical or vocational services provided in previous referrals:

 

 

 

Does it appear this injured worker is eligible for vocational rehabilitation. Yes/No

Please verify eligibility or ineligibility.

 

 

NOTE:  Upon completion of initial feasibility review and receipt of positive eligibility verification, the MCO must contact the injured worker to determine interest in vocational rehabilitation.  An email will then be sent to the DMC outlining the results of the contact and/or case manager assignment or closure.

 


Resources