Policy and Procedure Name:
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Vocational Rehabilitation Case Closure
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Policy #:
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VR-22-01
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Code/Rule Reference:
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O.A.C.
4123-18-05
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Effective Date:
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07/01/21
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Approved:
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Deborah Kroninger, Chief of Medical Operations
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Origin:
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Vocational Rehabilitation Policy
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Supersedes:
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Policy # VR-22-01, effective 10/07/19
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History:
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Previous versions of this policy are available upon
request
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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.
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 vocational rehabilitation referral occurs after:
1. The
injured worker’s (IW) participation in vocational rehabilitation has been
denied by BWC order; or
2. The IW has
been approved to participate in vocational rehabilitation and has been assigned
a VRCM, but does not ultimately participate in vocational rehabilitation
services.
C. Closure of a
vocational rehabilitation plan 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. PROCEDURE
A. Once an IW
is assigned a VRCM and begins participation in a vocational rehabilitation
plan, the MCO shall, on an ongoing basis:
1. Assess an
IW’s feasibility for vocational rehabilitation services; and
2. Monitor an
IW’s vocational rehabilitation case for any other case closure event listed in
section IV.C above.
B. Upon the
IW’s return to work:
1. The VRCM
shall notify the MCO and DMC within the same day that they become aware of the
IW’s return to work; and
2. The DMC
shall work with the CSS to take appropriate action regarding living maintenance
compensation (LM).
C. Upon a case
closure event:
1. The MCO
shall notify the DMC within one business day;
2. The VRCM
shall complete and provide to the MCO a Vocational
Rehabilitation Closure Report (RH-21);
3. The MCO
and VRCM shall complete the Complexity Factors Reporting Form (CFF).
4. Within 10
business days of case closure, the MCO shall:
a. Prepare
and send a vocational rehabilitation closure letter to all parties to the
claim, which includes:
i. The
specific reason for closure;
ii. Appeal
language; and
iii. The
timeframes for appeal using the established closure date.
b. Ensure
that the RH-21 and closure letter are imaged into the claim; and
c. Submit
the CFF to the DMC.
5. The DMC
shall:
a. Review the
closure documents; and
b. Close the
case by assigning the appropriate case closure status and status reason.
6. If the MCO
believes the closure code does not correspond with the information submitted,
the MCO shall contact the DMC to resolve.
D. Rescinding Case
Closures After Assignment of VRCM
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. The MCO
shall send a letter to all parties documenting the agreement to rescind a
closure and including appeal language.
3. 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.
E. 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:
i. Ensure
the MCO and VRCM are aware of the LSS application;
ii. Remain
in contact with the LSS CSS to stay up to date on the status of the C-240;
iii. Monitor
the status of the claim; and
iv. Keep the MCO and
VRCM apprised.
b. 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).
2. When the
DMC becomes aware of a court settlement, the DMC shall:
a. Ensure the
MCO and VRCM are aware of the settlement and that no further services are
provided; and
b. Wait to
close the case until BWC receives documentation from the Attorney General’s
Office that the settlement is final.
3. 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.
4. Services
provided on or after the effective date of settlement shall not be reimbursed.
5. Refer to
the Lump
Sum Settlement policy and procedure for further information.