OhioBWC - Basics: (Policy library) - File

Policy and procedure Name:

Vocational Rehabilitation Plan Review and Decision

Policy #:

VR-22-02

Code/Rule Reference:

O.A.C. 4123-18-05

Effective Date:

07/01/21

Approved:

Deborah Kroninger, Chief of Medical Operations

Origin:

Vocational Rehabilitation Policy

Supersedes:

All vocational rehabilitation policies, procedures, directives and memos regarding vocational rehabilitation plan review and decision that predate the effective date of this policy and procedure.

History:

New

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure approvals and denials of assessment plans, job retention plans or comprehensive plans are handled in a consistent, reasonable and efficient manner.

 

II. APPLICABILITY

 

This policy applies to:

·         Managed care organization (MCO) staff involved in the coordination and management of the vocational rehabilitation program; and

·         Vocational rehabilitation case managers (VRCM) assigned by the MCO.

 

III. DEFINITIONS

 

See Vocational Rehabilitation Definitions. For purposes of this policy, the following definitions also apply:

 

Vocational Rehabilitation Program Coordinator or Equivalent: A Vocational Rehabilitation Program Coordinator or an individual working for the MCO who has equivalent credentials.

 

Vocational Rehabilitation Reviewer: A Vocational Rehabilitation Program Coordinator or equivalent, or an individual working for the MCO who has at least five years of experience with BWC vocational rehabilitation.

 

Vocational Rehabilitation Staff: A Vocational Rehabilitation Reviewer or an individual working for the MCO who has fewer than five years of experience with BWC vocational rehabilitation.

 

IV. POLICY

 

It is the policy of BWC that vocational rehabilitation plans and plan amendments submitted for an injured worker’s (IW’s) participation in return to work or remain at work services be evaluated to ensure these services are appropriate to the unique needs of the IW and likely to achieve the goals of the plan.

 

V. PROCEDURE

 

A.    Staffing

1.    The VRCM and the MCO are encouraged to staff vocational rehabilitation plans and services whenever necessary to ensure both the quality and effectiveness of the services being provided to the IW.

2.    Prior to submitting the plan, the VRCM shall staff the proposed plan for services with the Vocational Rehabilitation Reviewer when:

a.    Long term training is recommended in the plan;

b.    The IW resides outside of the Ohio region;

c.     A comprehensive plan amendment is proposed that significantly changes job goal or duration; or

d.    A job retention plan is being converted to an assessment plan or comprehensive plan.

3.    A VRCM intern shall staff all proposed plans with the Vocational Rehabilitation Program Coordinator or equivalent prior to submission.

4.    The MCO shall document a summary of the staffing with the VRCM in claim notes, including:

a.    Any issues identified;

b.    The parties involved in the staffing process;

c.     Negotiation of services (if applicable); and

d.    The result of the staffing.

5.    The VRCM and MCO may also staff vocational rehabilitation plans and services with the DMC whenever necessary.

6.    For additional guidance on staffing requirements, refer to Chapter 3 of BWC’s Provider Billing and Reimbursement Manual (BRM) and the Special Vocational Rehabilitation Plan Types policy and procedure.

 

B.    Plan Review and Decision

1.    Plan Review

a.    The MCO shall:

i.      Review all plans submitted for appropriateness according to the requirements set forth in Chapter 3 of the BRM and in the following policies and procedures:

a)    Job Retention Plan Development and Implementation;

b)    Comprehensive Vocational Rehabilitation Plan and Progress Reports;

c)    Special Vocational Rehabilitation Plan Types; and

d)    Initial Assessment and Assessment Plan; and

ii.     Request modifications or corrections from the VRCM as needed.

b.    The Vocational Rehabilitation Reviewer must review the plan when:

i.      Long term training is recommended in the plan;

ii.     The IW resides outside of the Ohio region;

iii.    A comprehensive plan amendment is proposed that significantly changes a job goal or duration;

iv.   A job retention plan is being converted to an assessment plan or comprehensive plan;

v.     The plan is submitted by a newly-enrolled VRCM; or

vi.   The claim is flagged as catastrophic in the claims management system.

c.     The MCO Vocational Rehabilitation Program Coordinator or equivalent shall review all plans submitted by a VRCM intern.

d.    The MCO shall provide a response to the VRCM dismissing, pending, denying, or approving within three business days.

2.    Plan Dismissal

a.    When the MCO is unable to approve or deny the plan, and pending is not appropriate, the MCO shall dismiss the plan.

b.    It is appropriate to dismiss the plan only when:

i.      There is some defect that cannot be fixed and that would prohibit BWC from paying the provider (e.g., the provider is not enrolled and refuses to (or cannot) become enrolled); or

ii.     The plan is a duplicate of a plan that has been denied in a final administrative or judicial order and there are no new and changed circumstances.

3.    Pending

a.    If the Vocational Rehabilitation Staff is unable to approve or deny the plan, and dismissal is not appropriate, they shall make a decision to pend.

b.    A decision to pend is appropriate when the plan requires additional:

i.      Correction; or

ii.     Negotiation.

c.     The decision shall be documented in claim notes, as described below.

d.    Pending is not a final decision status; the MCO must approve or deny the plan within three business days.

4.    Plan or Service Denial

a.    Prior to denying any plan or service, the Vocational Rehabilitation Program Coordinator or equivalent shall participate in negotiation of the disputed plan or service with the VRCM.

b.    If, after negotiating, the Vocational Rehabilitation Program Coordinator or equivalent determines that a plan or service should be denied, they shall ensure that the decision is for a substantive, supportable reason and not for minor or insignificant clerical errors.

c.     If the MCO and VRCM disagree about whether a plan or service should be denied, either party may seek an opinion from the BWC Rehabilitation Policy Unit, who will then provide a recommendation.

d.    If the MCO decides that the plan or service should be denied, the entire plan shall be denied. The MCO shall then determine if:

i.      A new plan will be submitted; or

ii.     Case closure is appropriate.

5.    Documentation Requirements

a.    Upon making any decision regarding a plan (dismiss, pend, deny, approve), the MCO shall document the:

i.      Decision regarding the plan;

ii.     Reason for the decision;

iii.    The parties involved in the decision-making process; and

iv.   Details of any actions taken.

b.    Upon plan approval or denial, the MCO shall:

i.      Sign and date the appropriate section on the plan; and

ii.     Ensure the plan is imaged to the claim.