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:

10/07/19

Approved:

Deborah Kroninger, Chief of Medical Operations

Origin:

Vocational Rehabilitation Policy

Supersedes:

Policy # VR-18-01, effective 08/20/18

History:

Rev. 10/07/19, 08/20/18; New 10/10/16

 

 

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.

 

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 Disability Management Coordinators (DMC) to serve as resources and points of contact for vocational rehabilitation program coordinators on 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 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.

 

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 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 is not currently receiving compensation and has job restrictions in the claim, documented by the physician of record (POR) and dated not more than 180 days prior to the date of referral; or

iv.   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

v.     The IW sustained a catastrophic injury claim and a vocational goal can be established.

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.    The IC or a court order subsequently disallows the claim; or

c.     The IW, after successfully completing a comprehensive vocational rehabilitation plan, subsequently resigns from employment or is terminated for cause and the resignation or termination is not due to the allowed conditions in the claim.

 

D.   Initial Feasibility

1.    It is the policy of BWC that an IW’s initial feasibility to participate in vocational rehabilitation services will be decided by the MCO.

2.    An IW is feasible for vocational rehabilitation services when all available information demonstrates that:

a.    The IW is willing to participate in vocational rehabilitation services;

b.    The IW is able to participate in vocational rehabilitation services; and

c.     There is a reasonable probability that the IW will benefit from vocational rehabilitation services and return to work as a result of the services.

 

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.

 

F.    Decision

1.    It is the policy of BWC that a decision approving or denying the IW’s participation in a vocational rehabilitation program shall be documented in a BWC order, which shall address:

a.    Eligibility;

b.    Feasibility; and

c.     Living Maintenance (LM) compensation.

2.    Approval of an IW to participate in a vocational rehabilitation program renders the IW eligible to receive LM according to the criteria set forth in 4123-18-04.

3.    Denial of an IW to participate in vocational rehabilitation services shall not affect an IW’s right to compensation for which the IW otherwise qualifies.

 

V.   PROCEDURES

 

A.    Referral Processing

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.     Verifying with the IW their willingness to participate in vocational rehabilitation by contacting the IW.

i)      If the IW is willing to participate, the MCO shall:

a.    Ask if the IW has a preferred vocational rehabilitation provider; or

b.    If the IW or attorney of record (AOR) have previously indicated a preferred provider, confirm this choice with the IW; or

c.     If neither the IW nor the AOR have a preferred provider, the MCO shall select a provider, and discuss and confirm this choice with the IW.

ii)     If the MCO is unable to speak with the IW:

a.    The MCO shall send a letter to the IW requesting that the IW contact the MCO; and

b.    If the IW does not respond to the MCO within 10 calendar days from the date the letter was mailed, the MCO can proceed with the request for a determination noting they were not able to contact the IW

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); and

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.

b.    The MCO shall use the appropriate vocational rehabilitation screening tool (Appendix A or B) or an equivalent tool to assist in collating and documenting referral information.

i.      When a screening tool other than the Return to Work Screening Tool or the Job Retention Screening Tool is used, it must provide all the same information, in the same order, as the Return to Work Screening Tool or the Job Retention Screening Tool and be provided to the DMC in an MS WORD document.

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

c.     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 ten calendar 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.

d.    The MCO shall request an eligibility determination from the DMC.

i.      The request shall include:

a)    The vocational rehabilitation screening information; and

b)    A written initial feasibility determination which includes identification of the information utilized in making the determination.

ii.     The request shall be sent to the DMC within 18 calendar days of receipt of the referral by the MCO. If the MCO is unable to meet this requirement, the MCO must document why more time is needed in an e-mail notice to BWC (see Appendix C for template) and in a claim note.

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 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 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 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 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 using the Job Retention Screening Tool.

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 and processed consistent with the Claim Reactivation policy and procedure and the directions outlined immediately below.

ii.     The MCO shall send a feasibility recommendation to the DMC, who shall then assess the IW’s eligibility, as outlined in this policy. The DMC shall then notify the assigned claims service specialist (CSS) of the participation decision.

a)    If the IW is approved to participate in a vocational rehabilitation program, the CSS shall issue an order allowing reactivation of the claim, including approval language regarding the IW’s ability to participate in a vocational rehabilitation program, which includes eligibility, feasibility, and payment of LM.

b)    If the DMC did not find the IW able to participate in vocational rehabilitation, the CSS shall issue an order denying reactivation and participation in vocational rehabilitation with the supporting justification.

c)    If there is other justification to reactivate the claim (e.g., request for chiropractic treatment and vocational rehabilitation on one C-9), but the DMC did not find the IW able to participate in vocational rehabilitation, the CSS shall issue an order allowing reactivation of the claim but denying the IW’s participation in vocational rehabilitation.

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

i.      When the DMC receives a request for determination for vocational rehabilitation and theclaim 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 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.    If the documentation is not already in the claim or has not yet been requested by the MCO, the DMC shall request documentation of the IW’s restrictions from the MCO.

3.    Within two business days of receipt of the request for eligibility determination, the DMC shall:

a.    Ensure the screening tool is imaged into the claim;

b.    Decide whether to approve or deny the IW’s participation in vocational rehabilitation, or, if the DMC requires additional information, to pend the decision for a specific period of time; and

c.     Communicate the decision:

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

a)    Two business days of receipt of the documentation; or

b)    Within ten calendar days from the date of the request to the POR, whichever is earlier.

ii.     To the parties via order. The order shall address the IW’s participation in vocational rehabilitation, which includes eligibility, feasibility, and payment of LM.

iii.    The DMC shall also provide the MCO with documentation of the eligibility decision on the appropriate vocational rehabilitation screening tool (Appendix A or B), as well as information concerning compensation rates (average weekly wage, full weekly wage, and living maintenance rates) and if applicable, relevant vocational information from any other claims for the injured worker. Once completed, the DMC shall image the screening tool into the claim.

4.    If the order approves the IW’s participation in vocational rehabilitation, the DMC or the MCO may:

a.    Discuss with all parties their right to waive the appeal period; or

b.    Allow the appeal period to run prior to assigning the vocational rehabilitation case manager (VRCM).

 

 


 

APPENDIX A: Return to Work Screening Tool

 

MCO Feasibility Determination

 

Claim Number

Injured Worker

MCO Name & Number

Choose an item.

MCO Voc Rehab Coord

Phone Number

MCO Contact

Phone Number

Referral Source

Choose an item.

Referral Date

 

(FROM A FILE REVIEW PERSPECTIVE)

     

1.       Is the injured worker willing to participate in vocational rehabilitation services? Yes / No Click or tap here to explain why.

 

 

2.       Is the IW able to participate in vocational rehabilitation services? Yes / No Click or tap here to explain why.

 

 

3.       Is there a reasonable probability that the injured worker will benefit from vocational rehabilitation services and return to work as a result of the services? Yes / No Click or tap here to explain why.

 

 

4.       Do you recommend the IW to be feasible for vocational rehabilitation services? Yes / No Click or tap here to explain why.

 

Note: Upon completion of the MCO feasibility review, this form must be submitted via email to the assigned DMC for eligibility determination. Upon receipt of BWC order approving IW participation, the MCO must complete the Voc rehab case manager assignment and notify the DMC via email of the contact and/or case manager assignment or closure.

 

 


 

BWC Eligibility Determination

 

Claim Number

DMC Name

Choose an item.

Date of Determination

 

ELIGIBILITY INFORMATION:

 

A significant impediment to employment as a direct result of the allowed conditions in the claim?

 

Temp Total Disability compensation for date of referral?

Salary Continuation in lieu of TT for date of referral?

Permanent Total Compensation for date of referral?

Receiving or awarded non-working wage loss for the date of referral?

Awarded Scheduled Loss award?

Catastrophic injury claim?

·         Vocational goal able to be established?  (REQUIRED)

Employee of state agency or university?

·         Employer of Record agrees with rehabilitation?  (REQUIRED)

IW not currently receiving compensation and POR documented work restrictions/barriers within 180 days?  

INELIGIBILITY INFORMATION:

Is this claim disallowed, denied or in hearing status?

Are there 7 or fewer days of lost time allowed in this claim?

Is this a settled claim (medical and/or indemnity)?

Is the Injured Worker working on the date of referral?

Did the IW RTW after successfully completing a vocational rehabilitation rehab plan but subsequently resign and/or was terminated for cause and the resignation or termination was not due to the allowed conditions in the claim?

PARTICIPATION DETERMINATION

Is the IW approved to participate in return to work services?

The above claim has been reviewed by the Disability Management Coordinator.  The above criteria for participation in return to work service was outlined according to the Ohio Administrative Code OAC 4123-18-03

 


 

Additional Referral Information

 

Claim Number

 

 

MCO Provided

 

1.       Did you ensure updated restrictions are documented within 180 days of referral? Yes / No Click or tap here to explain why.

 

 

2.       Is this a re-referral for vocational rehabilitation? Yes / No

If yes, what are the new or changed circumstances now making the IW feasible for vocational rehabilitation services geared toward RTW? Click or tap here to explain why.

 

 

3.       Other relevant information including:

(5)    Has the Industrial Commission or Bureau ever denied any related services? Yes / No Click or tap here to explain why.

 

 

4.       Are there specific Independent Medical Examination (IME) recommendations given for the related services? Yes / No Click or tap here to explain why.

 

DMC Provided

 

Weekly TT Rate

AWW

FWW

 

Other claim information

1.       Does the IW have other BWC claims? Yes / No

a.       If yes, how many? 

b.       How many active lost time claims?  

c.       How many have had prior vocational rehabilitation referrals? 

d.       What was the outcome of those cases?

 

Claim Number

Case Number

Referral Date

Case Completion Date

Case State

Case Status

Case Status Reason

 

Click here to enter vocational case history from DMC query




.

Note: When the MCO does not manage the other claim(s), the DMC should send the MCO closure reports for cases assigned to vocational rehabilitation case managers, if the closure occurred within the past 5 years. Upon completion of this form, the DMC shall issue an order determining the IW’s ability to participate, image this document to the claim, and email the completed screening tool notifying the MCO of your decision.


 

APPENDIX B: Job Retention Screening Tool

 

MCO Feasibility Determination

 

Claim Number

Injured Worker

MCO Name & Number

Choose an item.

MCO Voc Rehab Coord

Phone Number

MCO Contact

Phone Number

Referral Source

Choose an item.

Referral Date

 

(FROM A FILE REVIEW PERSPECTIVE)

     

1.       Is the injured worker willing to participate in job retention services? Yes / No Click or tap here to explain why.

 

 

2.       Is the IW able to participate in job retention services? Yes / No Click or tap here to explain why.

 

 

3.       Is there a reasonable probability that the injured worker will benefit from job retention services and remain at work as a result of the services? Yes / No Click or tap here to explain why.

 

 

4.       Do you recommend the IW to be feasible for job retention services? Yes / No Click or tap here to explain why.

 

 

Note: Upon completion of the MCO feasibility review, this form must be submitted via email to the assigned DMC for eligibility determination. Upon receipt of BWC order approving IW participation, the MCO must complete the Voc rehab case manager assignment and notify the DMC via email of the contact and/or case manager assignment or closure.

 


 

BWC Eligibility Determination

 

Claim Number

DMC Name

Choose an item.

Date of Determination

 

ELIGIBILITY INFORMATION:

Has the injured worker returned to work (RTW)?

Date of RTW:  Click here to enter text.

Received temporary total compensation or salary continuation in the past in this claim?

Physician of record documented work limitations related to the allowed conditions that negatively impact the injured worker’s ability to maintain their employment?

Employer described the specific job tasks / problems the injured worker is experiencing and explained the reason job retention services are needed to maintain employment as provided in writing or documented by the MCO in claim notes?

INELIGIBILITY INFORMATION:

Is this claim disallowed, denied or in hearing status?

Is this a settled claim (medical and/or indemnity)?

Did the IW RTW after successfully completing a vocational rehabilitation plan but subsequently resign and/or was terminated for cause and it was not due to the allowed conditions in the claim?

PARTICIPATION DETERMINATION

Is the IW approved to participate in job retention services?

The above claim has been reviewed by the Disability Management Coordinator.  The above criteria for participation in return to work service was outlined according to the Ohio Administrative Code OAC 4123-18-03

 

 


 

Additional Referral Information

 

Claim Number

 

 

MCO Provided

 

1.       Did the employer describe the specific job task problems the injured worker is experiencing to justify their request for job retention? Yes / No If yes, click here to describe the problems.

 

 

2.       Did you obtain documentation from the POR office notes or correspondence that indicates the IW has limitations related to the allowed conditions that impacts IW’s ability to maintain employment. (This could be documented in office notes, prescription, correspondence, or a MEDCO-14.) ? Yes / No Click or tap here to explain why.

 

 

3.       Other relevant information including:

(6)    Has the Industrial Commission or Bureau ever denied any related services? Yes / No Click or tap here to explain why.

 

 

4.       Are there specific Independent Medical Examination (IME) recommendations given for the related services? Yes / No Click or tap here to explain why.

 

 

DMC Provided

 

Weekly TT Rate

AWW

FWW

 

Other claim information

1.       Does the IW have other BWC claims? Yes / No

a.       If yes, how many? 

b.       How many active lost time claims?  

c.       How many have had prior vocational rehabilitation referrals? 

d.       What was the outcome of those cases?

 

Claim Number

Case Number

Referral Date

Case Completion Date

Case State

Case Status

Case Status Reason

 

Click here to enter vocational case history from DMC query




.

Note: When the MCO does not manage the other claim(s), the DMC should send the MCO closure reports for cases assigned to vocational rehabilitation case managers, if the closure occurred within the past 5 years. Upon completion of this form, the DMC shall issue an order approving or denying  participation, image this document to the claim, and email the completed screening tool notifying the MCO of the decision.

 


 

APPENDIX C: Timeframe Waiver

 

 

Upon receipt of a vocational rehabilitation referral, the MCO has 18 calendar days to submit their initial feasibility determination to the DMC. If the MCO determines that they cannot submit their request within 18 calendar days, they must submit a request for timeframe waiver.

 

The MCO shall not request a timeframe waiver and shall process the request for eligibility determination without additional delay when:

 

  1. The physician or treating provider did not respond to a request for restrictions within 10 calendar days
  2. The IW or their representative did not respond to a written request for contact within 10 calendar days
  3. The EOR did not respond to a written request for information within 10 calendardays

 

The MCO shall request a timeframe waiver when the MCO:

 

  1. Is waiting for a response to a written request for:
    1. Medical documentation from the POR; or
    2. Willingness to participate from the IW, or their representative AOR; or
    3. Eligibility information from the EOR, or their representative.
  2. Contacted the POR, who indicated they would provide information at the next medical appointment that is less than one month in the future.
  3. Has not addressed the initial referral in a timely manner.

 

The MCO will send a timeframe waiver to to the BWC Rehabilitation Policy Unit at Policy.R.1@bwc.state.oh.us. The email must include the following information:

 

Email Title: “NN-XXXXNN Voc Timeframe Waiver”

 

Email Body:

 

Injured Worker Name: Jane Doe

Claim Number: XX-XXXXXX

Referral Date: XX/XX/XXXX

Justification for Request:

 

Outline the steps taken to document the IW’s willingness and ability to participate and the reasonable probability the IW will benefit from services and return to work.

 

Include the dates and types of attempts made to obtain the needed information.

 

Provide the next steps and timeframes to obtain the necessary information to complete the appropriate MCO Vocational Rehabilitation Screening Tool.