OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Special Vocational Rehabilitation Plan Types

Policy #:

VR-19-01

Code/Rule Reference:

R.C. 4121.61

Effective Date:

08/20/18

Approved:

Deborah Kroninger, Chief of Medical Operations

Origin:

Vocational Rehabilitation Policy

Supersedes:

Policy #VR-19-01, effective 10/10/16

History:

New: 10/10/16

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that vocational rehabilitation plans that contain certain special plan types are properly managed and facilitated.

 

II. APPLICABILITY

 

This policy applies to the:

·        BWC disability management coordinators (DMCs);

·        MCO staff involved in the coordination and management of the vocational rehabilitation program; 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

 

It is the policy of BWC to ensure that when the following services are contained in a vocational rehabilitation plan, they are properly managed and processed:

·        Plans that require an extension of reimbursable service guidelines;

·        Plans that include payment of services above fee schedule;

·        Plans that include service codes that have no established fees for the identified service (i.e., services paid “by report”);

·        Plans involving rehabilitation injury claims;

·        Plans requiring interpreter services;

·        Plans using return to work incentive services; and

·        Plans developed in collaboration with the Opportunities for Ohioans with Disabilities (OOD) agency.

 

V. PROCEDURE

 

A.     Extension of Reimbursable Service Limits

1.     The MCO shall ensure that service limits defined as ‘maximum’ in the Vocational Rehabilitation Provider Fee Schedule are not exceeded.

2.     Service limits defined as ‘up to’ in the Vocational Rehabilitation Provider Fee Schedule may be exceeded, with justification, as follows:

    1. When the VRCM identifies a need to extend a service which will exceed the ‘up to’ service code limit, the VRCM shall include:

i.       The justification of the service in the progress report or in the narrative of the vocational rehabilitation plan, whichever is applicable; and

ii.      The adjusted costs and weeks on the authorization request or plan grid, whichever is applicable.

    1. The MCO shall review the submitted documentation and enter a claim note titled, “Service Limit WXXX Decision”, indicating approval or denial of the extension of the service code limit. The note shall include:

i.       The service code and description of service,

ii.      The justification of the decision, and

iii.     A description of any extension approved.

 

B.     Payment of Services Above Fee Schedule for Out-of-State Providers: The MCO shall process a request for payment of out-of-state vocational rehabilitation services above fee schedule consistent with the procedures in the Pricing Override Policy and Procedure, except, rather than describing how the Miller criteria are met, the MCO shall describe the vocational necessity of the request.

 

C.    Plans with Services Paid “By Report”

1.     “By Report” codes include the following:

a.     W0647 Automobile repairs

b.     W0648 Physical reconditioning-unsupervised

c.      W0663 Job modifications

d.     W0665 Tools/equipment

e.     W0674 Child/dependent Care

f.       W0690 Training-books, supplies and testing

g.     W0691 Remedial training

h.     W0692 Short-term training-up to one year

i.       W0694 Long term training –over one year

2.     When including a “By Report” code in a vocational rehabilitation plan, the VRCM shall:

a.     Research the service that is needed and the available provider for that service;

b.     Staff the service with the MCO;

c.      Document in the vocational rehabilitation plan narrative the justification for the service and the associated costs; and

d.     Include the service and cost of the service on the plan grid.

3.     The MCO shall process these services consistent with the procedures in the Pricing Override Process policy and procedure, except, instead of including describing how Miller criteria are met, the MCO shall provide a description of why the vocational rehabilitation service is necessary.

 

D.    Rehabilitation Injury Claims:

1.     The DMC, the MCO, and the VRCM from the source claim shall staff the claim and determine if the new injury impacts the IW’s participation in vocational rehabilitation services and whether vocational rehabilitation services will:

a.     Continue as originally approved;

b.     Be interrupted temporarily using a medical interrupt; or

c.      Be closed. If the decision is to close, the DMC shall determine if a medical hold is appropriate.

2.     If, at any point after closure of the vocational rehabilitation case in the source claim, vocational rehabilitation services are requested, the DMC shall determine:

a.     Which claim (source or new) has the more significant barriers to return to work; and

b.     In which claim the vocational rehabilitation case will be addressed.

 

E.     Interpreter Services: The MCO or VRCM shall notify the DMC of any plan that will require interpreter services.

1.     The DMC shall be responsible for identifying and authorizing interpreter services consistent with the Interpreter Services policy and procedure, and communicating this information to the VRCM.

2.     The VRCM shall be responsible for scheduling the interpreter at critical junctures in the vocational rehabilitation process.

 

F.     RTW Incentive Services: The VRCM shall refer to Chapter 3 of the Provider Billing and Reimbursement Manual for information related to:

1.     Employer Incentive Contracts (EIC),

2.     Gradual RTW,

3.     Job Modifications,

4.     On the Job Training, and

5.     Tools and Equipment:

 

G.    Plans Developed in Coordination with the Opportunities for Ohioans with Disabilities (OOD) Agency

1.     When the IW will be receiving vocational rehabilitation services through BWC and OOD, the VRCM shall:

a.     Collaborate with OOD in the development of each agency’s vocational rehabilitation plan, including reaching agreement on the specific services for which each agency will be responsible;

b.     Staff the vocational rehabilitation plan with the MCO;

c.      Prepare the final BWC vocational rehabilitation plan;

d.     Submit the plan to the MCO  with a copy of OOD’s Individualized Plan for Employment (IPE), reflecting the services each agency is providing; and

e.     Once the plan is approved the MCO shall notify the DMC to update the case with joint plan status.

Throughout implementation of the vocational rehabilitation plan, the MCO shall reference OOD’s IPE to ensure coordination and appropriate payment of services.