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OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Vocational Rehabilitation Case Closure

Policy #:

VR-22-01

Code/Rule Reference:

O.A.C. 4123-18-05(G)

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 vocational rehabilitation case closure 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 vocational rehabilitation cases are closed for consistent reasons in a consistent manner.

 

II. APPLICABILITY

 

This policy applies to the:

·         BWC disability management coordinators (DMCs);

·         Managed care organization (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

 

A.    It is the policy of BWC to close a vocational rehabilitation case when vocational rehabilitation services will not be provided or are no longer being provided.

 

B.    Closure of a Referral:

1.    Closure of a vocational rehabilitation referral occurs after:

a.    The injured worker (IW) has been found not eligible;

b.    The IW has been found eligible but is not feasible for services; or

c.    The IW has been found eligible and feasible but the IW does not participate in services.

 

C.   Closure After Participation in a Vocational Rehabilitation Plan - After the IW has participated in a vocational rehabilitation assessment plan, comprehensive vocational rehabilitation plan, or job retention plan (“vocational rehabilitation plan”), closure occurs when:

1.    The IW has completed an assessment plan and it is determined further vocational rehabilitation services are not needed;

2.    The IW has failed to fulfill the responsibilities outlined in the vocational rehabilitation plan;

3.    The IW is unable to attain the goals of the vocational rehabilitation plan;

4.    The IW has refused, without good cause, to accept an offer of employment within the vocational goal of the comprehensive vocational rehabilitation plan;

5.    The IW dies;

6.    The IW does not agree with the decision of the MCO or BWC to approve or deny specific vocational rehabilitation plan services;

7.    The claim is subsequently disallowed by an order of the Industrial Commission or by order of the court;

8.    The claim is settled for medical and/or indemnity;

9.    The IW has completed a comprehensive vocational rehabilitation plan;

10.  The IW has completed a job retention plan;

11.  The IW is determined to be no longer feasible for vocational rehabilitation services; or

12.  The IW has returned to work and the case follow-up period has ended.

 

V.         PROCEDURES

 

A.    The MCO shall notify the DMC by phone, fax or email of a return to work or other case closure event within one business day.

 

B.    Within ten (10) business days of case closure:

1.    For all cases in which the IW has been determined eligible, whether or not assigned to a VRCM, the MCO shall prepare and send a vocational rehabilitation closure letter to all parties to the claim, including a copy to the DMC, which includes:

a.    The specific reason for closure;

b.    The IW’s appeal rights; and

c.    The timeframes for appeal using the established closure date.

 

2.    For referrals that have been assigned to a VRCM:

a.    The VRCM shall complete and provide to the MCO a Vocational Rehabilitation Closure Report (RH-21);

b.    The MCO and VRCM shall complete the Complexity Factor form; and

c.    The MCO shall forward the report and Complexity Factor form to the DMC.

 

C.   The DMC shall assign the closure code. If the MCO believes the closure code does not correspond with the information submitted, the MCO shall contact the DMC to resolve.

1.    A closure may be rescinded during the closure appeal period if the MCO, employer and IW all agree to keep the vocational rehabilitation case open.

2.    If the employer is out of business or no longer doing business in Ohio, the employer’s agreement is not required, consistent with the Due Process policy.

3.    The MCO shall send a letter to all parties documenting the agreement to rescind a closure.

 

D.   Lump Sum Settlement (LSS) and Closure of a Case

1.    When the DMC becomes aware that a Settlement Agreement and Application for Approval of Settlement Agreement (C-240) is filed in a claim where the IW is participating in a vocational rehabilitation plan:

a.    The DMC shall ensure the MCO and VRCM are aware of the LSS application.

b.    The DMC shall communicate with the LSS CSS, monitor the status of the claim and keep the MCO and VRCM apprised.

c.    Vocational rehabilitation services may continue until the day before the claim enters “Settled-Pending” status (i.e., the day the “Approval of Settlement Agreement” letter is mailed).

d.    Services provided on or after the effective date of settlement shall not be reimbursed.

2.    If settlement is reached and no prior notice was given to the provider, a closure report shall not be completed. BWC shall reimburse authorized services provided prior to the effective date of the settlement.

3.    Refer to the Lump Sum Settlement policy and procedure for further information.

 


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