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Policy and Procedure Name:
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Comprehensive Vocational Rehabilitation Plan and
Progress Reports
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Policy #:
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VR-03-02
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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-03-02, effective 08/20/18
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History:
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Previous versions of this policy are available upon
request
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The purpose of this policy is to ensure that an injured
worker (IW) who is approved to participate in vocational rehabilitation
services has a plan developed that will best enable the IW to obtain employment.
II. APPLICABILITY
This policy applies to the:
·
BWC disability management coordinators (DMC);
·
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.
IV. POLICY
1. When an injured
worker (IW) is approved to participate in vocational rehabilitation services and
is feasible following the initial assessment or assessment plan, a
comprehensive plan shall be developed to outline:
a. A summary of the
relevant factors influencing the plan; and
b. The IW’s job
goal(s) and the services recommended to return to work (RTW) and become stable
on the job.
2. Comprehensive plans
shall be developed in accordance with Ohio
Administrative Code (OAC) 4123-18-05.
3. BWC shall pay
living maintenance compensation (LM) when the IW is actively participating in
comprehensive plan services in accordance with OAC
4123-18-04. For additional information regarding LM, refer to the Living
Maintenance Compensation policy and procedure.
B. Comprehensive
Plan Expectations
1. The comprehensive
plan must:
a. Reflect that the
IW’s participation in services will approximate:
i. The
IW’s pre-injury workweek; or
ii. The number
of hours the IW is medically released for participation.
b. Identify the:
i. IW’s
RTW goals;
ii. Barriers
to employment;
iii. Types of
services required;
iv. Estimated costs; and
v. Estimated
length of time required to attain the goals of the plan.
c. Explain
the specific strategies that will be employed to assist the IW in returning to
work.
2. RTW goals shall:
a. Follow the
hierarchy of RTW objectives set forth in OAC
4123-18-02; and
b. Lead to suitable
employment and comparably paying work set forth in OAC
4125-1-01, whenever possible.
C. Comprehensive
Plan Progress and Evaluation
1. Specific
services within the comprehensive plan shall be authorized throughout the
duration of the plan, just prior to their implementation.
2. All
comprehensive plan services shall be evaluated on a routine basis to facilitate
the IW’s progress toward RTW.
3. At comprehensive
plan closure, the plan’s success shall be evaluated according to the definition
of a successful return to work outcome set forth in the appendix to OAC
4123-18-09.
V. PROCEDURE
A. Comprehensive
Plan Development
1. The VRCM shall
use the Vocational Rehabilitation Comprehensive Plan
(RH-44) form to complete the comprehensive plan.
2. Prior to submitting
the RH-44 to the MCO, the VRCM shall complete the following sections of the
RH-44:
a. Plan information
at the top of the first page (except for complexity and duration);
b. The following Plan
of Service Approvals:
i. The
signature of the VRCM that prepared the RH-44 and the date; and
ii. Verification
of Verbal Approval by the IW.
a) The VRCM shall
obtain an updated verbal approval from IW anytime there is a substantive change
to the RH-44 (e.g., job goal changes, adding or removing a service).
b) The VRCM is not
required to receive an updated verbal approval from the IW if the RH-44 is
being corrected for clerical errors (e.g., date corrections).
c. Narratives:
i. Vocational
considerations: A brief summary of the vocationally relevant work and training
history, including:
a)
Job history;
b)
Transferable skills;
c)
Job analysis information;
d)
Academic history; and
e)
Military service.
ii. Medical
considerations: A brief summary of vocationally relevant medical information (i.e.,
those factors which are currently or potentially impacting a return to work)
including:
a)
Medical issues to be addressed for return to work;
b)
Co-morbidities and non-allowed conditions impacting return to work; and
c)
Surgeries and other treatment.
iii. Other
considerations: A brief summary of other vocationally relevant factors
including:
a)
Personal factors;
b)
Legal factors;
c)
Strengths upon which the comprehensive plan relies; and
d)
Barriers to employment and plans to overcome them.
iv. Justification of
return to work level and job goal: The rationale for the return to work level (a.k.a.
“return to work hierarchy”) and job goal selected as well as relevant labor
market information supporting the job goal if a change in employers is
necessary.
v. Comprehensive
plan of services with justification:
a)
A description of the services to be provided and the rationale for the
services (not simply a listing of the definition of the services);
b)
The reason the services are included specific to the IW and the specific
barriers to employment or needs to be addressed by the service; and
c)
The expectations of the IW’s participation in the services.
d. Plan of services
grid, including:
i. Vocational
rehabilitation case management for comprehensive plan implementation;
ii. Vocational
rehabilitation case management services for pre-plan time if this is the first plan
during this referral;
iii. Provisions for LM;
iv. Provider travel, wait time
and mileage as a single summary entry;
v. A minimum
of 30 days of vocational rehabilitation case management for return to work
follow-up;
vi. The service provider -
This may be a company rather than an individual, particularly if the exact
assignment is anticipated later in the comprehensive plan;
vii. The estimated number of
weeks of a particular service;
viii. Estimated cost of each service;
ix. RH-44 plan begin date and
plan end date;
x. Total days:
a) If there have
been no vocational rehabilitation plan closures, total days are calculated from
the first approved comprehensive plan begin date through the estimated end date
of the most recent comprehensive plan.
b) If there have
been comprehensive plan closures and reopenings in the current case, total days
do not include any dates the plan was closed and not reassigned. Total days are
calculated by adding up the total days of comprehensive plans that closed and
the date of reassignment through the estimated end date of the most recent
comprehensive plan.
xi. The total estimated
cost of all services and living maintenance.
3. Upon submission
of the RH-44 to the MCO, the VRCM shall:
a. Ensure that the
IW has a prescription or a medical release from the POR for vocational
rehabilitation services, as necessary. (see Appendix A to this policy and
procedure for a list of services that require a physician prescription or
release); and
b. Submit the
completed Complexity Factors Reporting Form (CFF).
4. Timeframes
a. The VRCM shall
submit the RH-44 to the MCO for review and approval:
i. Within
seven calendar days of submission of the initial assessment report (where no
assessment plan was needed); or
ii. Within seven
calendar days of completion of the services in an assessment plan.
b. If the VRCM
determines that it will not be possible to develop a comprehensive plan within
the required timeframes, they shall:
i. Submit
written justification for the extension to the MCO within the seven day time
frame; and
ii. Staff the
issue with the MCO.
c. Justifiable
reasons for an extension may include (but are not limited to):
i. Pre-plan
information is not received following a timely request (e.g., physician of
record (POR) or employer information, functional capacity or vocational
evaluations); or
ii. An
unexpected situation prevents the IW from participating in the vocational
rehabilitation process (e.g., a family emergency).
B. RH-44
Review and Approval
1. Upon receipt of
the RH-44 from the VRCM, the MCO shall review the RH-44 in accordance with the Vocational
Rehabilitation Plan Review and Decision policy and procedure.
2. When the MCO approves
the RH-44, they shall:
a. Review the CFF;
b. Enter factor
scores according to form directions; and
c. E-mail the
CFF to the DMC.
3. The DMC shall:
a. Review the
information submitted by the VRCM and MCO within one business day of receipt of
the CFF and the approved RH-44;
b. Enter the
following on the CFF:
i. Closure
code information for the plan type;
ii. Comprehensive
plan begin date; and
iii. DMC reviewer’s
name.
c. Complete a
Duration and Complexity Level Determination, using the
information submitted on the RH-44 and CFF, and send the results to the MCO;
and
d. Submit the CFF
to the Complexity Factor Mailbox.
4. Following the
DMC’s review of the RH-44 and submission of the Duration and Complexity
Level Determination, the MCO shall:
a. Update the
duration and complexity level on the approved RH-44; and
b. Send it to the
VRCM, who shall:
i. Review
the RH-44; and
ii. If willing
to accept implementation of the plan, provide a hard copy signature and date on
the RH-44.
iii. If not willing
to accept implementation of the plan, notify the MCO.
5. The MCO shall
ensure that the signed and accepted RH-44 is submitted to the claim prior to the
first date of plan services.
6. The VRCM shall
obtain and submit to the MCO a hard copy signature on the RH-44 from the IW
within 30 days of the start of plan services.
C. Amending
the Comprehensive Plan
1. The VRCM may
amend the comprehensive plan to continue or redirect vocational rehabilitation
services when:
a. There is a
significant change in the job goal; or
b. The VRCM
identifies a significant new barrier and/or service need.
2. The VRCM shall
amend a comprehensive plan using the RH-44, identifying it as amended and
providing the next sequential comprehensive plan number.
3. The VRCM shall
staff the amended comprehensive plan with the MCO.
4. If additional
assessments are needed prior to amending the comprehensive plan, the VRCM
shall:
a. Submit a
progress report and authorization request outlining the needed assessment services;
and
b. Once the needed
assessments are completed, submit the amended comprehensive plan to the MCO.
5. The VRCM shall
ensure that all sections on the RH-44 are completed with updates, as needed. The
amended RH-44 shall:
a. Outline all the
services necessary to progress an IW from the current situation through RTW;
and
b. Be submitted to
the MCO so that it is received by the DMC no later than three business days
prior to the end of the previous comprehensive plan. This will ensure there is
no interruption in the IW’s LM payment.
6. If a new
complexity factor has been identified, the VRCM must submit an updated CFF with
the amended RH-44. The VRCM does not need to remove a previously identified
complexity factor if it has been resolved through plan services.
7. Upon receipt of
the amended RH-44, the MCO and DMC shall process and review the RH-44 as
described in Sections V.A-B of this procedure.
D. Reopened
Comprehensive Plans
1. When a
comprehensive plan is reopened (e.g., the IW has successfully appealed a case
closure) the VRCM shall submit an amended comprehensive plan (if needed
pursuant to Section V.C above) within 21 days from the date the case is reassigned
to the VRCM.
2. If a comprehensive
plan is reopened and there is no need to amend the comprehensive plan, the VRCM
shall continue the services that were authorized before closure.
1.
If the comprehensive plan or the amended comprehensive plan will result
in more than an aggregate of six months of LM, (including any LM paid while the
IW was in an assessment plan), the MCO shall notify the DMC.
2.
For purposes of extending LM beyond an aggregate of six months, the DMC
shall ensure the extension of vocational rehabilitation services will benefit
the injured worker and enter a claim note indicating approval of the extension
of LM.
F. Progress
Reports
1. For every IW
participating in a comprehensive plan, the VRCM shall:
a. Complete written
updates of progress using the Vocational
Rehabilitation Progress Report (RH-46), for every 30-day period
of comprehensive plan participation, or more frequently if necessary; and
b. Submit the progress
report to the MCO, no later than five business days from the end of the reporting
period.
2. The VRCM shall
ensure all the requested information on the RH-46 is provided, including:
a. Adequate
information about the current status of the IW’s progress towards return to
work or remain at work;
b. Justification
for service authorization requests and minor changes in services;
c. Requests
for any necessary assessments when a significant change in direction in the comprehensive
plan is required; and
d. The VRCM’s hard
copy signature.
3. When the RH-46
extends the duration of a service beyond the duration of service in the RH-44,
adds a service, or adds an interrupt, the VRCM shall also obtain:
a. Verification of Verbal
Approval from the IW prior to submission of the RH-46; and
b. The IW’s
hard-copy signature within 30 days of submission of the RH-46.
4. The MCO is
responsible for reviewing the progress reports as part of oversight of the comprehensive
plan.
G. Authorization
of Services
1. The VRCM shall obtain
authorization for approved RH-44 plan services using an Authorization
Request for Vocational Rehabilitation Plan (RH-45). The RH-45 shall be
submitted to the MCO with either the:
a. RH-44 to ensure that
it is received by the DMC no later than three business days prior to initiation
of services; or
b. RH-46, to
authorize the next set of services at least five business days prior to the end
of the current authorization.
2. The VRCM shall
ensure that all the information requested on the RH-45 is provided, including
the hard copy signature of the VRCM.
3. If, while
reviewing the RH-45, the MCO believes a denial of services is necessary, the MCO
shall follow the directions detailed in the Vocational
Rehabilitation Plan Review and Decision policy and procedure.
4. Upon approval or
denial of the RH-45, the MCO shall:
a. Review, hard
copy sign, and image the RH-45; and
b. Send the signed
copy of the RH-45 to the VRCM.
APPENDIX A
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Services
Requiring a POR Prescription or C-9
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Services
Requiring a POR Release Documentation from POR that IW may return to work with
restrictions MEDCO 14, or office notes, etc
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Services Not
Requiring a POR Prescription or Release
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Code
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Service
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Code
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Service
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Code
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Service
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No code
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Gradual return
to work
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No code
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Employer
Incentive Contract
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CPT codes
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Adjustment
Counseling
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CPT
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Functional
Capacity Evaluation
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W0660 W3260
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Job Placement
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W0647
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Auto Repairs
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W0750
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Nutritional
Consult
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W0659 W3259
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Job Development
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W0674
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Child Care
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CPT
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Occupational or
Physical Therapy
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No code
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Job Search
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W0644
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Ergonomic Study
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W0637
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Transitional
Work Services
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W0694
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Long term
training
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W0645
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Job Analysis
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W0648
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Physical Reconditioning Unsupervised
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No code
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On-the-job
training
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W0650
W3257
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Job Seeking
Skills
Training
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W0710
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Work Conditioning
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W0692
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Short term
training
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W0690
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Training-Books,
Supplies and Testing
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W0702 Initial 2
hr: W0703 Each add. hr:
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Work Hardening/
Occ. Rehab
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No code
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Work Trial
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W0663
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Job
Modifications
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Z0700
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Relocation
Expense
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W0672
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Job Coach
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W0635
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Situational
Work Assessment
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W0641 W3258
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Job Club
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W0665
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Tools &
Equipment
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W3000-3040 W3200-3240
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Vocational Case
Management
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W0610
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Vocational
Eval. Comprehensive
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W0631
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Vocational
Screening
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W0662
W0620
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Work Adjustment
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W0523-0524
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Career
Counseling
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