Eligibility and Feasibility
Kroninger, Chief of Medical Operations
#VR-18-01, effective 10/10/16
purpose of this policy is to ensure that referrals and determinations for eligibility
and feasibility are processed and determined consistently and appropriately.
policy applies to:
care organization (MCO) staff; and
rehabilitation case managers (VRCMs) assigned by the MCO.
“Vocational Rehabilitation Definitions” in Chapter 4 of the MCO 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 Disability Management Coordinators (DMC) to serve as resources and points
of contact for vocational rehabilitation program coordinators on vocational
1. It is the policy of BWC
to encourage and support a referral to vocational rehabilitation as soon as the
need is identified 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.
1. It is the policy of BWC
that the DMC is responsible for determining the IW’s eligibility for vocational
2. To be eligible for vocational
rehabilitation services (other than as provided in section IV.C.4 and 5), the
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
ii. Certified by a state
university or state agency; or
iii. Certified by a
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
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
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
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
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
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
5. Employees of State
Agencies and State Universities
a. An employee of a state
agency or state university shall be eligible for vocational rehabilitation
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
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
D. Initial and Continuing Feasibility
1. It is the policy of BWC
that initial and ongoing feasibility will be decided by the MCO.
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
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.
A. Referral Processing by
the MCO - Gathering Documentation, Initial Feasibility Determination and Eligibility
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
d. Recommendation pursuant
to an independent medical evaluation (IME); or
e. Contact from an
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:
a) The IW’s interest in
returning to work;
b) The IW’s past
participation in vocational rehabilitation plans or other BWC-provided
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 evaluation.
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.
d. The MCO shall request
medical documentation from the POR to establish the IW’s current restrictions
e. The MCO shall request an
eligibility determination from the DMC. The request shall include:
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
MCO shall contact the IW and POR to determine if the IW is interested and able
to participate in vocational rehabilitation services.
b. 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 sent to BWC for
an eligibility determination. The MCO shall indicate in MCO notes an
explanation of the decision regarding the referral.
c. 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
a. Referrals Received Via a
i. If a C-84 is received
and the IW has indicated an interest in vocational rehabilitation services, the
MCO shall 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 MCO shall make a note to review
the claim in the future and notify the IW.
b. Referrals for Job
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
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
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 and processed
consistent with the Claim Reactivation policy and procedure.
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.
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.
4. The DMC shall also
provide the MCO with documentation of the eligibility decision on the
information concerning compensation rates (average weekly wage, full weekly
wage, and living maintenance rates) and if applicable, relevant vocational information from any
for the injured worker.
Once completed, the DMC shall image the screening tool into the claim.