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

Effective Date:

07/01/21

Approved:

Deborah Kroninger, Chief of Medical Operations

Origin:

Vocational Rehabilitation Policy

Supersedes:

Policy # VR-22-01, effective 10/07/19

History:

Previous versions of this policy are available upon request

 

 

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.