CHAPTER 4 THE ROLE OF VOCATIONAL REHABILITATION IN OHIO WORKERS COMPENSATION

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1 TABLE OF CONTENTS CHAPTER 4 THE ROLE OF VOCATIONAL REHABILITATION IN OHIO WORKERS COMPENSATION Introduction Remain at Work Programs Vocational Rehabilitation Program Coordinator Vocational Rehabilitation Laws, Rules, and Guidelines BWC, MCO and Vocational Rehabilitation Case Manager Responsibilities in Providing Vocational Rehabilitation BWC Responsibilities Customer Care Team DMC BWC Administrative MCO Responsibilities Vocational Rehabilitation Case Manager Responsibilities Job Placement Specialist Responsibilities Injured Worker Responsibilities Vocational Rehabilitation Case Management Qualifications Ethical Standards Case Management Compliance with Rehabilitation Policies Vocational Case Management Interns Intern Enrollment Process Qualifications to Provide Intern Services Rehabilitation Recommendation Process Vocational Rehabilitation Referral Process and Initial Feasibility Review Vocational Rehabilitation Screening Tool Job Retention Referral Vocational Rehabilitation Referral Process: PPI/MMI Claim Reactivation Referrals Vocational Rehabilitation Eligibility Criteria Vocational Rehabilitation Eligibility Process Initial Feasibility Review Referral Packets and Complexity Factor Forms Plan Assessment/Development: Initial Contact and Interview, Assessment and Progress Reports and Continued Feasibility Review Use of Interpreter Services during Vocational Rehabilitation Return-To-Work Hierarchy (Rule ) Plan Elements including Plan Signature Requirements (prescriptions) Amended Vocational Rehabilitation Plan January 2014 Final

2 TABLE OF CONTENTS (continued) Reports for Job Placement Services DMC Authorization of Special Vocational Rehabilitation Plan Types RSC Coordinated Plans Plans Developed by Intern Extension of Chapter 4 Reimbursable Service Guidelines Rehabilitation Injury Claims Plans Needing Interpreter Services Plans Using Return to Work Incentive Services Plans with Services Paid By Report Interruption to Vocational Rehabilitation Plan Services Non-Medical Interruptions Medical Interruption during Vocational Rehabilitation Plan MCO Responsibilities during a Medical Interruption BWC s DMC Responsibilities during a Medical Interruption Case Management Follow-Up Services4-36 Vocational Rehabilitation Closure Procedure 4-37 Vocational Case Closures Requesting Medical Hold MCO Responsibilities during a Medical Hold BWC s DMC Responsibilities during a Medical Hold Rehabilitation Services Commission/BWC Agreement Rehabilitation Injury Claims (RIC) Appeals Living Maintenance Compensation Salary Continuation in Lieu of Living Maintenance Compensation Deduction from/termination of Living Maintenance Living Maintenance Wage Loss (LMWL) Compensation Bureau Responsibilities Vocational Rehabilitation Case Manager Responsibilities with LMWL DMC Responsibilities with LMWL Injured Worker Responsibilities with LMWL Lump Sum Settlements and Vocational Rehabilitation Services BWC Compliance and Performance Monitoring Unit MIRA Information related to Rehabilitation Surplus Fund Expenditures Appropriate NOT Appropriate Payment for Services Provider Enrollment Information Provider Scope of Practice Reimbursement for Services January 2014 Final

3 TABLE OF CONTENTS (continued) Reimbursable Services Automobile Repairs Biofeedback Training Body Mechanics Education Child/Dependent Care Counseling Employer Incentive Contract Ergonomic Implementation Ergonomic Study Exercise Equipment Gradual Return to Work Injured Worker s Meals and Lodging Injured Worker s Travel Expense Injured Worker Travel, Meals and Lodging (Program Reimbursed) Interpreter Services (BWC Authorized) Job Analysis Job Club Job Coach Job Modification Job Placement and Development Job Search Job Seeking Skill Training Nutritional Consultation/Weight Control Occupational Rehabilitation Comprehensive (Work Hardening) Occupational Therapy On-The-Job Training Physical Reconditioning, Unsupervised Physical Therapy Relocation Expenses Retraining Exercise Equipment Situational Work Assessment Tools and Equipment Training Transitional Work and Work-Site PT/OT Services Unallowed Conditions Vocational Evaluation (Screening and Comprehensive) Vocational Exploration and Guidance Vocational Rehabilitation Case Management Vocational Rehabilitation Provider Travel Work Adjustment Work Conditioning Work Hardening Work Trial January 2014 Final

4 TABLE OF CONTENTS (continued) Return to Work Incentive Services Employer Incentive Contract Gradual Return to Work Job Modifications On-The-Job Training Tools and Equipment Work Trial Appendix A MCO Vocational Rehabilitation Screening Tool Appendix B Remain at Work Program Appendix C Websites for Labor Market Information Appendix D Voc Rehab By Report Template January 2014 Final

5 CHAPTER 4 THE ROLE OF VOCATIONAL REHABILITATION IN OHIO WORKERS COMPENSATION A. Introduction Vocational Rehabilitation Program Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker with a lost time claim who needs assistance in safely returning to work or in retaining employment. Vocational rehabilitation emphasizes restoring or maximizing the injured worker s abilities and minimizing long debilitating absences from work. When an injured worker quickly returns to work, feelings of self-worth stay high and ties to the job and work community stay strong. The employer may also benefit from vocational rehabilitation services when an experienced worker remains productive and the costs associated with hiring and training a new employee are reduced. If a return to work at the original employer is not possible, rehabilitation services may help the injured worker identify skills and abilities to secure a new job with another employer. Remain at Work Program BWC is committed to providing injured workers with the right services at the right time and minimizing unnecessary absences from work. The Remain at Work (RAW) Program allows an injured worker with 7 or less days off work due to the allowed conditions in a claim who is experiencing difficulty at work, related to the allowed conditions in the claim, to receive services to stay on the job. In RAW programs, vocational case management services are reimbursed using the Z codes for vocational rehabilitation services, see #37 in the Reimbursable Services section of this chapter. RAW services, including any vocational rehabilitation case management services associated with the RAW case, are charged to the employer s risk account and are not reimbursed using the 753 EOB code which reimburses from the BWC Surplus Fund. For more information on the Remain at Work program, see chapter 3 of the Managed Care Organization (MCO) Policy Reference Guide. The identical information is also located in Appendix B of this chapter. Vocational Rehabilitation Program Coordinator To provide increased accountability in the delivery of high quality vocational services and enhance communication between BWC and the MCO, each MCO must designate a vocational rehabilitation program coordinator to direct its management of vocational rehabilitation services. Program guidelines require the vocational rehabilitation program coordinator meet the qualifications for vocational/medical case managers, as set forth in Rule (38) of the Ohio Administrative Code and case manager supervisor, as identified in American Health Care Commission/URAC ( URAC ) standards. The vocational rehabilitation program coordinator must have at least one year of field vocational rehabilitation case management experience. January 2014 Final 4-1

6 Notwithstanding the preceding sentence, if immediately prior to January 1, 2008 the MCO was using a vocational rehabilitation program coordinator that did not have at least one year of field vocational rehabilitation case management experience, but that did have at least one year of experience as the MCO's vocational rehabilitation program coordinator, the MCO may continue to use that person as program coordinator. However, if the MCO subsequently selects a new vocational rehabilitation program coordinator, the new program coordinator must have at least one year of field vocational rehabilitation case management experience. The program coordinator must be proficient in the MCO Policy Reference Guide, especially chapter 4 of the guide, and attend all BWC training sessions for the program coordinators. MCOs must submit the program coordinator s name, contact information and a resume or curriculum vitae documenting adherence to credentialing and experience requirements to BWC s MCO Business Unit. MCOs are responsible for notifying the MCO Business unit by at MCOUpdates@bwc.state.us within two business days of any change in this information. B. Vocational Rehabilitation Laws, Rules, and Guidelines Sections to of the Ohio Revised Code and Rules to and applicable rules within chapter of the Ohio Administrative Code pertain to workers compensation vocational rehabilitation. According to Rule , BWC is responsible for developing policies to implement vocational rehabilitation service delivery. The MCOs are contractually obligated to adhere to the BWC policies and guidelines outlined in this chapter of the MCO Policy Reference Guide. C. BWC, MCO and Vocational Rehabilitation Case Manager Responsibilities in Providing Vocational Rehabilitation BWC Customer Care Team Responsibilities: 1. Staff potential internal rehabilitation referrals with the Disability Management Coordinator (DMC). 2. Notify the DMC of external rehabilitationreferrals. 3. Based on DMC s approval, issue compensation payments such as living maintenance, living maintenance wage loss, and return to work incentive reimbursements. 4. Send correspondence to all parties to the claim when living maintenance (LM) compensation is initiated and when LM compensation is suspended or terminated. 5. Notify Special Claims when an injured worker is injured while participating in a BWC rehabilitation plan. 6. Notify DMC whenever rehabilitation progress notes, rehabilitation plans, and rehabilitation closure reports are received. 7. Update the RTW screen under Comp, Ineligibility, Return to Work when injured workers return to work as a result of a rehabilitation plan. 8. Notify the Rehab Eligibility Unit of any appeals faxed to the claim regarding rehabilitation eligibility issues (rehabilitation services, living maintenance wage loss, living maintenance, medical hold, etc.). January 2014 Final 4-2

7 BWC Disability Management Coordinator (DMC) Responsibilities 1. Notify the MCO about referrals from an external source by forwarding the request to the MCO who will process it. If the external source is not the POR, treating physician or a party to the claim, due process may not be necessary. Please see Section F. Vocational Rehabilitation Referral Process and Initial Feasibility Review.Staff (telephonic or ) any BWC Customer Care Team generated recommendation for rehabilitation (not a referral from an external source) with the MCO prior to making an actual referral. 2. Verify the MCO s initial identification of an injured worker's eligibility/noneligibility for vocational rehabilitation services and send letters with appeal language. Add specific information regarding the reason for eligibility/noneligibility in letters and in V3 system notes. 3. Staff concerns about the injured worker s feasibility for rehabilitation with the MCO from referral through case closure. Feasibility is defined as the reasonable probability that the injured worker will benefit from services at this time and return to work as result of the services. 4. Participate in the Rehabilitation Recommendation process outlined in this chapter when the DMC and MCO are not in agreement with a feasibility decision or rehabilitation plan direction. 5. Determine eligibility for compensation payments, such as living maintenance and living maintenance wage loss and request that these compensations be issued by the Customer Care Team. 6. Monitor and regulate surplus fund use, review the appropriateness and timeliness of rehabilitation interventions/plans, and make recommendations including recommendations for case closure to the MCO, as needed. 7. Authorize via and V3 note the following vocational rehabilitation plan types: plans coordinated with the Rehabilitation Services Commission, plans developed by vocational rehabilitation case manager interns, plans exceeding Chapter 4 average duration timeframes, plans with training programs exceeding six months, employer incentive contracts (EIC), plans for rehabilitation injury claim (RIC), and plans with services paid by report. 8. Verify incentive payment calculations and notify the Claims Services Specialist (CSS). 9. Assist the MCOs in educating their internal staff, vocational rehabilitation case managers and employers about vocational rehabilitation. 10. Verify that factors identified on the Complexity Factor Form completed by the vocational rehabilitation case manager and MCO are appropriately documented. 11. Provide ongoing medical or claim related information to vocational rehabilitation case manager as appropriate; document progress and planning being accomplished toward RTW; when indicated, consider adjusting the program as necessary including skill enhancement/training. 12. Inform the injured worker about living maintenance wage loss (LMWL) before the rehabilitation file is closed. 13. Track and work with the injured worker to obtain POR restrictions every 6 months or expiration date of restrictions (whichever comes first) to justify extension of LMWL benefits. Perform review of vocational rehabilitation plan costs for reasonableness and appropriateness January 2014 Final 4-3

8 BWC Administrative Responsibilities: 1. Maintain the BWC Rehabilitation Eligibility Unit to hear disputed issues and issue administrative orders. 2. Maintain the cash transfer agreement between the Ohio Rehabilitation Services Commission and BWC. 3. Maintain the Compliance and Performance Monitoring Unit to perform audits on MCO files concerning vocational rehabilitation issues. 4. Maintain the Rehab Policy Unit to create and review standards of practice, research insurance rehabilitation policies in other states, develop evaluation standards and performance indicators and create guidelines to insure that rehabilitation services have a RTW focus. MCO Responsibilities: 1. Manage the medical and vocational rehabilitation portions of the claim, including vocational rehabilitation case management, services, costs and time frames to ensure a RTW outcome, whenever possible, on each vocational rehabilitation referral. 2. Provide rehabilitation services in accordance with chapters and of the Administrative Code and BWC guidelines derived from them. 3. Designate a vocational rehabilitation program coordinator to direct the MCO s management of vocational rehabilitation services in claims assigned to the MCO 4. Ensure that the vocational rehabilitation program coordinators are appropriately credentialed and knowledgeable of the vocational rehabilitation concepts listed below. This knowledge must result in plan approval based on vocational rehabilitation expertise and the ability to recognize ethical, efficient, return to work focused services. 5. Ensure that vocational rehabilitation case managers are appropriately credentialed and knowledgeable of the vocational rehabilitation concepts listed in Vocational Rehabilitation Case Manager (VCRM) Responsibilities below. 6. Insure that each VRCM is BWC certified. 7. Insure that all vocational rehabilitation providers included in a vocational rehabilitation plan are enrolled as BWC providers 8. Assure that vocational rehabilitation case management interns are closely supervised by credentialed case managers and knowledgeable of the vocational rehabilitation concepts listed below. 9. Attempt to obtain POR restrictions for vocational rehabilitation referrals to facilitate eligibility determination. 10. Document and follow-up on all referrals of injured workers for vocational rehabilitation. 11. Staff (telephonic or ) any MCO, BWC, or non-party to the claim generated recommendation for rehabilitation with the DMC prior to making an actual referral. (POR or treating physician referrals do not fall into this category and do not require prior staffing.) January 2014 Final 4-4

9 12. When someone not a party to the claim (who is not the POR or treating physician) recommends an injured worker for vocational rehabilitation,the MCO should follow Section F. Vocational Rehabilitation Referral Process and Initial Feasibility Review process. 13. Determine the injured worker s initial eligibility for vocational rehabilitation services if the referral is initiated by a party to the claim or POR or treating physician and notify BWC immediately via ed, password protected vocational screening tool (or send other password protected document with identical information in same order) so that BWC can verify eligibility and send due process letters as soon as possible. If the MCO feels the injured worker is ineligible, the decision must be deferred to the DMC. 14. Staff concerns about the injured worker s feasibility for rehabilitation with the DMC from referral through case closure. Feasibility is defined as the reasonable probability that the injured worker will benefit from services at this time and return to work as result of the services. 15. Participate in the Rehabilitation Recommendation process outlined in this chapter when the MCO and DMC are not in agreement with a feasibility decision or rehabilitation plan direction. 16. If consensus on the feasibility decision cannot be reached, the Rehabilitation Recommendation process outlined in this chapter will be followed. 17. Assist in educating internal staff, vocational rehabilitation case managers, and employers about vocational rehabilitation. 18. Submit a First Report of Injury (FROI) to the DMC if an injured worker sustains an injury while participating in rehabilitation. 19. Submit appeals regarding vocational rehabilitation eligibility, Medical Hold eligibility, LMWL eligibility and Rehab Recommendations to the BWC Rehabilitation Eligibility Unit if the appeals are sent directly to MCO and not BWC. 20. Maintain the ADR system at the MCO as per ADR Rule Provide case files with documentation to the Compliance and Performance Monitoring Unit for audit. 22. When submitting closure documentation to the DMC, verify that factors identified on the Complexity Factor Form completed by the vocational rehabilitation case manager are appropriately documented. However, MCO must not add complexity factors to the form. 23. After eligibility has been confirmed by BWC and the MCO has confirmed the injured worker s interest in vocational rehabilitation participation (see section I, #4), assign the vocational rehabilitation case manager within three working days. 24. Provide ongoing medical or claim related information to vocational rehabilitation case manager; ensure that vocational rehabilitation case manager has an adequate picture of the ongoing process; provide claim information in a timely manner; staff ongoing rehabilitation efforts with vocational rehabilitation case manager and DMC and document progress in V3 notes; be flexible enough to adjust the program as necessary including skills enhancement /training. January 2014 Final 4-5

10 25. Respond to an assigned vocational rehabilitation case manager s submitted vocational rehabilitation plan or plan amendment within three (3) Business Days from the MCO s Vocational Rehabilitation Plan Receipt Date or Vocational Rehabilitation Plan Amendment Receipt Date, either approving, denying, dismissing, or pending the plan or plan amendment due to insufficient information, or otherwise acting in accordance with the provisions of Rule of the Ohio Administrative Code and the MCO Policy Reference Guide. 26. Submit approved vocational rehabilitation plans to the DMC at least three working days prior to the start of the plan or amendment. 27. Require and forward activity logs from vocational rehabilitation providers to BWC. Vocational Rehabilitation Case Manager Responsibilities: Understand the skills and competencies associated with vocational rehabilitation case management. At a minimum, these skills must include the ability to: 1. integrate vocational, educational, physical, and psychological data, 2. understand testing and measurement concepts, 3. analyze and document an injured worker s transferable skills and write transferable skill analysis reports, 4. conduct labor market surveys and write these reports, 5. conduct and write job analyses, 6. identify the essential functions of a job, 7. establish realistic vocational goals based upon the injured worker s skill, abilities, labor market and the BWC vocational hierarchy, 8. evaluate at referral the injured worker s ability to participate in vocational services and assess on an ongoing basis the continued need for these services for return-to-work outcomes, 9. develop, write, and sign sound vocational rehabilitation plans and reports, 10. monitor an injured worker s progress and be able to recognize when current interventions are not effective and appropriately intercede, 11. provide accurate estimates of costs of services, 12. effectively communicate with the injured worker, employer, physician and others, 13. staff plan and case direction with the MCO and DMC, 14. submit original plans and plan amendments to the MCO in a timely manner (so that the plan can be reviewed and forwarded to DMC three working days prior to dates on grid services), so that living maintenance payments are not disrupted for injured worker, 15. write reports that indicate joint agreement with plan services by the MCO, DMC, and injured worker, 16. foster relationships among MCO, DMC and injured worker so that plan services for the injured worker are provided smoothly, 17. identify appropriate job accommodations for an injured worker and develop job modifications, 18. understand disability management concepts, including BWC s early return-towork initiatives such as transitional work, January 2014 Final 4-6

11 19. understand and apply the most current version of chapter 4 of the MCO Policy Reference Guide. 20. be familiar with job availability and employment resources in the injured worker s geographic area, 21. establish realistic vocational goals based upon the injured worker s restrictions from the POR, 22. effectively communicate with the injured worker, employer, physician, and others to insure continuity and consistency, 23. identify barriers to return to work and strategize solutions, 24. know the appropriate time to refer an injured worker for skill enhancement, job placement and job development services. 25. provide all necessary information to other vocational rehabilitation providers (if involved in the case) including, all pertinent medical and any other information affecting the RTW process, 26. detail injured worker and provider expectations in the vocational rehabilitation plan and, when indicated, consider adjusting the program as necessary, including skill enhancement/training, 27. identify RTW incentive opportunities and, if a job placement or job development specialist is involved, indicate who is responsible for negotiating details after discussing and obtaining approval from the MCO and DMC before presenting to injured worker and employer, 28. be knowledgeable of wage loss benefits, determine whether return to work follow up is done by the job placement specialist or field case manager. Job Placement and Job Development Specialist Responsibilities Possess the skills and competencies associated with job placement and job development. At a minimum, these skills must include the ability to: 1. demonstrate familiarity with employers, employment websites, employment agencies and other resources (i.e., job fairs) in the targeted geographic area; 2. utilize the Ohio Department of Job and Family Services (ODJFS) resources to facilitate labor market research, identify potential employers, and assist injured workers with their job search. Injured workers are required to register with ODJFS full service offices for Ohio Workforce Systems (formerly SCOTI) program; 3. provide leads regarding job openings and assist with getting job interviews with employers and placement agencies; 4. develop and make contacts with employers in the local job market specific to the injured worker s return to work goal; 5. provide written weekly progress reports that detail job placement and job development activities, injured worker participation, and follow up on activities and recommendations for changes to job goal or rehabilitation plan; 6. be able to match the injured worker to a job based on the injured worker s unique abilities and the demands of the job; 7. maintain timely contact with the vocational rehabilitation case manager; 8. provide necessary documentation to justify any plan extension, change in vocational direction, or closure of the vocational rehabilitation case; January 2014 Final 4-7

12 9. review the injured worker s record of Job Search and Contacts (RH10); 10. regularly evaluate the need for skills enhancement or training programs 11. encourage and facilitate injured worker independence with the job search process (finding jobs/leads/interviews on their own); 12. continuously evaluate feasibility; 13. identify RTW incentive opportunities and staff with field case manager 14. be knowledgeable of living maintenance wage loss benefits; 15. provide information about billing activity and units of service for each date of service. No bundling of services by week. Injured Worker Responsibilities: A minimal level of active participation is demonstrated by the injured worker s adherence to the following: 1. informing the vocational rehabilitation case manager of changes in health status, RTW barriers, physical abilities, transportation, child care, other claims, legal problems, lump sum settlement application, or other issues that may impact participation; 2. signing the rehabilitation agreement (RH-1), authorization to release medical information (C101), rehabilitation plan (RH-2), and living maintenance wage loss form (RH-18); 3. attending appointments, program activities, classes or evaluations related to the vocational rehabilitation plan; 4. documenting the number of job contacts agreed to in the plan on RH-10 forms and follow up on job leads provided; 5. being accessible as needed phone, meetings, interviews, etc.; 6. following up on advice given to improve employability and appearance; 7. work with the vocational rehabilitation case manager to establish a realistic job goal, wage expectations and job search area (geographic). D. The Provision of Vocational Rehabilitation Case Management Credentialing/Enrollment: To provide and receive payment for vocational rehabilitation case management, including the services provided by an intern, the service provider must be BWC certified and enrolled. For information on out-of-state case management see guidelines of managing out-of-state cases under service #37 Vocational Rehabilitation Case Management in the Reimbursable Service section in this chapter. Rule (C) (38) identifies the type of credentials a vocational/medical case manager must maintain. A nationally recognized accreditation committee must have credentialed the provider in one of the following: Certified Rehabilitation Counselor (CRC); Certified Disability Management Specialist (CDMS); Certified Rehabilitation Registered Nurse (CRRN); Certified Vocational Evaluator (CVE); Certified Occupational Health Nurse (COHN); Certified Case Manager (CCM) January 2014 Final 4-8

13 American Board of Vocational Experts (ABVE). Ethical Standards for Vocational Rehabilitation Case Managers: The national associations of the seven credentialing organizations require adherence to ethical standards of professional behavior. These ethical codes oblige responsibility in serving clients, good behavior towards colleagues, and honesty in professional matters. The role of vocational rehabilitation case management professionals in workers compensation is to counsel and encourage injured workers and serve as their advocate, while providing timely, goal oriented services. Vocational Rehabilitation Case Manager Compliance with Rehabilitation Policies Case management services provided to an injured worker in a vocational rehabilitation plan must be in accordance with the Ohio Revised Code, the Ohio Administrative Code, and this chapter 4 of the MCO Policy Reference Guide. A vocational rehabilitation case manager shall not accept a rehabilitation assignment if it is not reasonably possible to provide appropriate and timely services. Initial vocational rehabilitation plan submission timeframes and monthly progress reporting requirements are included as part of chapter 4. If timely services and reports are not provided, or other chapter 4 guidelines not followed, the MCO will shall: contact the vocational rehabilitation case manager regarding the specific problems and provide a written timeframe to the vocational case manager for resolution of the issues; inform the injured worker by letter that vocational services are not being provided in a timely manner or are otherwise not being provided in accordance with BWC law, rules and chapter 4 policies. As a result, future services may not be authorized; discuss with the injured worker possible ways to continue plan services. Vocational Rehabilitation Case Management Intern Services: Vocational case management intern services must be provided by a BWC enrolled and/or certified intern. The provider enrollment number must be received prior to the provision of any services. Plans developed by an intern are authorized by the MCO in the same manner as plans from a credentialed vocational case manager. Plans developed by an intern are reviewed and authorized by the BWC DMC as outlined in section Q of this chapter, DMC Authorization of Special Plan Types. Enrolled BWC certified interns use the vocational rehabilitation case management W and Z codes for professional time, mileage, travel, and wait time. The intern fees are paid by BWC at 85% of the rate associated with those codes except for mileage, which is paid at the regular rate. January 2014 Final 4-9

14 Intern Enrollment Process: To enroll or become certified as a BWC vocational rehabilitation case management intern, the applicant must complete a MEDCO-13 form, Application for Provider Enrollment and Certification. This form is available from the BWC Web site Once BWC receives the completed MEDCO-13, the applicant is mailed an intern addendum form which must be signed and returned to BWC Rehab Policy along with any other required documentation as instructed in the form. The internship period provides 48 months from the date of enrollment for the intern to gain any necessary employment experience and to successfully complete one of the seven vocational rehabilitation case management credentialing examinations. At the end of this 48 month period, no re-enrollment as an intern is permitted. Interns who successfully attain case management credentials must re-enroll with BWC as a case manager. Those interns not attaining one of the seven qualifying credentials will have their provider number terminated. Qualifications to provide intern services: Rule (C) (39) identifies the criteria for BWC certification. To enroll as a vocational rehabilitation case manager intern, the applicant must submit documentation proving that all academic courses needed to take a credentialing examination for one of the seven certifications listed below have been completed: Certified Rehabilitation Counselor (CRC) Certified Disability Management Specialist (CDMS) Certified Case Manager (CCM) Certified Vocational Evaluator (CVE) Certified Rehabilitation Registered Nurse (CRRN) Certified Occupational Health Nurse (COHN) American Board of Vocational Experts (ABVE) The applicant must obtain information regarding the educational and experience requirements to take an examination from the associated credentialing organization. Depending on the credential pursued, the documentation submitted to BWC must include one or more of the following: a letter from one of the credentialing organizations stating that the applicant is qualified to take a credentialing exam an official transcript with required courses highlighted and a course description or syllabus a copy of the applicant s diploma a state license with number and expiration date verification of continuing education experience E. Rehab Recommendation Process 1. The DMC is responsible for monitoring surplus fund usage, discussing feasibility concerns, and reviewing the appropriateness of and timeliness of rehabilitation interventions on all vocational rehabilitation cases, as needed. January 2014 Final 4-10

15 When issues arise, the DMC will staff the issues with the Customer Care Team (CCT) Leader and other CCT members as needed and then contact the MCO to attempt to resolve the issues. The MCO Vocational Coordinator and BWC Rehab Policy may also be involved in these discussions. If the issue is not resolved, the issue must then be staffed with the Service Office Manager (SOM). The SOM should attempt to resolve any professional differences with the MCO at the administrative level. In most cases, these staffings will help resolve the issue and eliminate the need for the Service Office to submit written Rehab Recommendations to the MCO. However, if no mutual resolution is achieved at the conclusion of the Rehab Recommendation process, BWC may begin vocational management of the claim and levy a financial set-off on the MCO pursuant to Rule Written Rehab Recommendations must be ed to the MCO from the SOM and include the information listed in section 4 below. If the MCO does not agree with the Rehab Recommendations, the MCO may appeal them by to the Rehab Administrative Designee box within 5 working days from receipt of the Recommendations. 2. The Rehab Administrative designee will make a determination and send the decision to the MCO. The MCO has five working days to implement the decision or respond via to the designee that they desire a review by BWC Administration. If a further appeal is requested, BWC Administration will review the case within five working days. BWC Administration will notify the MCO, Service Office Manager and DMC of the results of the review. 3. If BWC Administration upholds the Rehab Recommendations, the BWC Customer Care Team may be requested to begin management of the vocational portion of the claim and a financial set-off will be imposed on the MCO. 4. Information to be included in the Rehab Recommendation Rehab Recommendation from Service Office Injured Worker Name; Claim #; Age; Date of Injury; ICD 9 Codes; Rehab Eligibility Status; Medical Stability Status; Job at Time of Injury; Summary of Case; Potential Vocational Barriers; Coordination Efforts; Suggested Recommendation and Intervention. Include the following appeal language: If you do not agree with these recommendations you have 5 working days from the receipt of this to appeal. F. Vocational Rehabilitation Referral Process and Initial Feasibility Review 1. Anyone can refer an injured worker for vocational rehabilitation. Information or statements received about the injured worker s need for vocational rehabilitation services, other than pre-referral staffing between the BWC DMC and the MCO, are considered referrals for vocational rehabilitation. The first documented date of receipt of a vocational rehabilitation referral by BWC or the MCO becomes the official referral date. January 2014 Final 4-11

16 It is the MCO s obligation to follow through on all referrals to case resolution (including those referrals found on C-9s and C-84s, suggested by Independent Medical Evaluations (IME) or via a phone call from an interested party). 2. Whenever the MCO receives a vocational rehabilitation referral from a party to the claim, the POR, or treating physician, eligibility must be verified by BWC so that the bureau can provide due process rights. Before the MCO sends this type of referral to BWC, attempts should be made by the MCO to secure POR restrictions to facilitate the vocational rehabilitation eligibility decision if there are no current restrictions related to the allowances in the claim on file. 3. However, if a referral is received from any other source,it will be given due process only when the IW or POR agree to participation in services. In the case of non-party to the claim referral the MCO and the DMC should staff the case with each other and discuss feasibility and eligibility. If not eligible, MCO and DMC should discuss what is needed to find the injured worker eligible. The MCO should then contact the POR and injured worker about services. 4. If the POR or injured worker states that the injured worker is unable or not interested in participating at this time, the case should not be referred and no due process is required. A note must be entered into the claim by the MCO explaining the decision regarding the referral. 5. If the POR or injured worker agrees that rehab would be beneficial, due process described in Section I of this chapter should be given. If injured worker or POR is interested, but injured worker does not appear eligible, the MCO should explain what the injured worker should do to meet eligibility requirements (i.e., obtain POR restrictions, apply for non-working wage loss, etc.). 6. An injured worker may be determined eligible for services but may not be feasible to participate. At this stage of the referral process, feasibility for services is determined from a file review perspective. Some issues that may suggest a need for additional research include the presence of other medical conditions, documentation of severe pain, upcoming surgery, and/or medication use and its effect on driving abilities or job tasks such as equipment operation. These feasibility issues may also need to be explored during initial interviews with the injured worker, EOR and POR. If the MCO knows at the time of referral that an injured worker is not eligible and/or feasible for vocational rehab, an explanation of the circumstances must be included in the referral to the DMC, see Eligibility Verification Process section of this chapter. If a referral or case is closed, the associated referral date is no longer valid. A new referral date is issued with each referral. January 2014 Final 4-12

17 7. When a source who is not a party to the claim and is not the POR believes an injured worker could benefit from rehabilitation, the MCO and the BWC DMC should staff the case with each other and determine eligibility. If not eligible, MCO and DMC should discuss what is needed to find the injured worker eligible. The MCO should then contact the POR and injured worker about services. If the POR or injured worker states that the injured worker is unable or not interested in participating at this time, the case should not be referred and no due process is required. A note must be entered into the claim by the MCO explaining the outcome of the referral. If the POR or injured worker agrees that rehab would be beneficial, due process described in Section I of this chapter should be given. If injured worker or POR is interested, but injured worker does not appear eligible, the MCO should explain what the injured worker should do to meet eligibility requirements (i.e., obtain POR restrictions, apply for non-working wage loss, etc.). 8. Vocational Rehabilitation Screening Tool The Vocational Rehabilitation Screening Tool (see Appendix A) assists the MCO in identifying more appropriate referrals. It is not designed to replace DMC/MCO staffings. Once a determination has been made to refer an injured worker, the MCO must complete the screening tool and it with the eligibility verification request. The actual screening tool form does not have to be used. When another password protected document is used in place of the form, it must provide all of the information in the same order as the Screening Tool form. 9. Special Categories of Referrals: a. Job Retention Job retention is a special category of vocational rehabilitation requiring a specific process for referral and eligibility. A job retention may be needed when a currently working employee who has received temporary total compensation or salary continuation compensation from the previous lost time claim (missed 8 or more days off work) due to the allowed injury experiences a significant work-related problem. This problem must be a direct result of the allowed conditions in the claim. The physician of record must provide a written statement, in office notes or correspondence, indicating that the injured worker has work limitations related to the allowed conditions in the claim that negatively impact the injured worker s ability to maintain the injured worker s employment. The injured worker s employer must describe the specific job task problems the injured worker is experiencing to the MCO and the MCO must document these problems in the claim. The MCO shall include a statement describing why the injured worker needs job retention services to maintain employment. b. Percentage of Permanent Partial Impairment Award (%PP) or determination of Maximum Medical Improvement (MMI) January 2014 Final 4-13

18 An injured worker with a claim with 8 or more days off work due to the allowed injury) and a %PP award or an MMI determination may be eligible for vocational rehabilitation services. As indicated in Rule , the injured worker must continue to have job restrictions from the allowed claim. In both cases, the job restrictions (dated not more than one hundred eighty days prior to the date of referral) must be documented by the physician of record. Job restrictions are the injured worker s physical restrictions. It is necessary that the referral information identifies the injured worker s physical restrictions and that the restrictions create a significant impediment to return to work. c. Claim reactivation referrals. Rule (B) (6) states that a referral for vocational rehabilitation in an inactive claim is processed in accordance with Rule (A). The MCO will review the referral for vocational rehabilitation in an inactive claim to see if it is accompanied by medical evidence dated not more than sixty days prior to the date of the request, or when such evidence is subsequently provided to the MCO upon request (e.g. C-9-A request). If the referral for vocational rehabilitation does not have medical evidence dated within sixty days prior to the date of the request, and after the MCO requests medical evidence, the MCO will dismiss the vocational rehabilitation referral. The MCO will not refer to the BWC. There is no appeal to this dismissal and the dismissal should not contain appeal language. A new referral for vocational rehabilitation with medical evidence may be submitted at any time for consideration later. MCO dismissals, which will be faxed to the service office after MCO processing, must have attached the C9-A used to communicate with the provider. These two documents will be imaged into the system by BWC and will be part of the claim file. If medical evidence dated within sixty days prior to the date of the request is on file, the MCO will send a password protected document in accordance with the Sensitive Data Policy to the assigned CSS and copy the DMC with the standard title Request for Reactivation Review. The MCO will provide the CSS with the following information: Request, Referred by, and Referral date. The CSS will contact the DMC with the referral. When the DMC receives notice of a referral for vocational rehabilitation on an inactive claim, the DMC January 2014 Final 4-14

19 will contact Rehab Policy for further instructions. The DMC will coordinate and work with the MCO and CSS to resolve and the CSS will issue a decision on the vocational rehabilitation referral. The DMC and the MCO will not issue correspondence on the referral for vocational rehabilitation for eligibility and feasibility when the claim is inactive. This process requires BWC and the MCO to work in partnership using the most efficient and effective communication method to discuss outstanding issues in an attempt to reach consensus and to try to resolve all conflicts prior to issuing a decision on the referral. Communication will be in accordance with the Sensitive Data Policy. G. Vocational Rehabilitation Eligibility Criteria To be eligible for rehabilitation services, the injured worker must meet the following criteria: (1) Referred claim that is: a. a claim allowed by an order of the bureau of workers compensation or the industrial commission or of its hearing officers with 8 or more days of lost time due a work related injury); or, b. a claim certified by a state university or state agency; or c. a claim certified by a self-insuring employer and, (2) The injured worker must have a significant impediment to employment or the maintenance of employment as a direct result of the allowed conditions in the referred claim. and, (3) The injured worker must also have at least one of the following present in the referred claim: a. The injured worker is receiving or has been awarded temporary total, nonworking wage loss, or permanent total compensation for a period of time that must include the date of referral (the first date the BWC or MCO receives a request for vocational rehabilitation services from anyone which is verified by a date stamp or note in the claim file). For purposes of this section, payments made in lieu of temporary total compensation (e.g. salary continuation) shall be treated the same as temporary total compensation; or, January 2014 Final 4-15

20 b. The injured worker was granted a scheduled loss award (PP) under division (B) of section of the Revised Code; or, c. The injured worker received, or was awarded, a permanent partial award (%PP) under division (A) of section of the Revised Code and has documented job restrictions as a result of that award documented by the physician of record and dated not more than one hundred eighty days prior to the date of referral; or, d. The injured worker was determined to have reached maximum medical improvement in the claim (with eight or more days of lost time due to a work related injury) by an order of the bureau or the industrial commission, or the injured worker's physician of record has documented in writing that the injured worker has reached maximum medical improvement in the claim, and the injured worker is not currently receiving compensation and has job restrictions in the claim as documented by the physician of record which are dated not more than one hundred eighty days prior to the date of referral; or, e. The injured worker is currently receiving Job Retention services to maintain employment or satisfies the criteria set forth in paragraph # 5 (below) of this chapter on the date of referral; or, f. The injured worker sustained a catastrophic injury claim and a vocational goal can be established; or, g. The injured worker was receiving living maintenance wage loss not more than ninety days prior to the date of referral, has continuing job restrictions documented by the physician of record as a result of the allowed conditions in the claim, and has lost his or her job through no fault of his or her own. (4) An injured worker employed by a state agency or state university may be eligible for vocational rehabilitation services when the state agency or state university has accepted or certified the claim and the employee and employer agree upon a program of rehabilitation services, even if the injured worker does not meet any of the eligibility criteria in heading G. 3. (a) through (g) above. January 2014 Final 4-16