Policy and procedure Name:
|
Vocational Rehabilitation Plan Review and Decision
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Policy #:
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VR-22-02
|
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
|
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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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.
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History:
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New
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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.