CHAPTER 4 THE ROLE OF VOCATIONAL REHABILITATION IN OHIO WORKERS COMPENSATION

Transcription

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 [email protected] 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

21 (5) An injured worker is eligible for vocational rehabilitation services in a Job Retention Status when currently working and experiencing a significant work related problem as a direct result of the allowed conditions of the claim, and, a. The injured worker has received temporary total compensation or salary continuation from an allowed claim (8 or more days off work due to work related injury) and, b. 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. and, c. The injured worker s employer describes the specific problem(s) the injured worker is experiencing to the MCO and the MCO documents these problems in the claim. The MCO shall include a statement describing why the injured worker needs job retention services to maintain employment. (6) Non-eligibility for vocational rehabilitation services. The injured worker is not eligible for vocational rehabilitation services and such services shall be terminated: a. After the effective date of a lump sum settlement; or b. If the claim is subsequently disallowed on appeal by an order of the industrial commission, its district or staff hearing officers, or by an order of the court. According to Rule (E) (8), there can be no vocational rehabilitation in settled claims, whether settled for medical or indemnity or both. (7) The injured worker must not be working on the date of referral, with the exception of referral for job retention services. (8) Diagnostic evaluations. Prior to rehabilitation plan implementation by the MCO, diagnostic evaluations may be used in determining feasibility for vocational rehabilitation services. Payment for such examination(s) and the vocational rehabilitation case management occurring during this period may be charged to the surplus fund January 2014 Final 4-17

22 Note: Rehabilitation services for an injured worker who is employed by a self-insuring employer who does not contribute to the BWC surplus fund are not reimbursed through the BWC surplus fund. These employers pay directly for rehabilitation services H. Vocational Rehabilitation Eligibility Verification Process 1. The DMC is responsible for determining eligibility for vocational rehabilitation. See Vocational Rehabilitation Eligibility Criteria section of this chapter. 2. The eligibility verification process begins when the MCO receives a referral for vocational rehabilitation (see section F, Vocational Rehabilitation Referral). The MCO completes the Vocational Rehabilitation Screening Tool (see Appendix A) and forwards the referral on to the DMC via . If the injured worker is obviously not feasible (e.g. surgery is scheduled) the MCO can ask the referral source (i.e. POR) to rescind a referral. 3. The DMC verifies the injured worker s eligibility or non-eligibility status by return to the MCO within two working days. BWC makes the final determination on all issues regarding eligibility. BWC notifies all parties to the claim and copies the MCO of the eligibility determination by letter. Due process language in the letter directs the parties to file any objection within fourteen (14) days with the BWC Rehabilitation Eligibility Unit, 30 W. Spring St., level 20, Columbus, Ohio , fax # (614) Upon receipt of the eligibility verification from the DMC, the MCO contacts the injured worker and verifies interest in vocational rehabilitation and then assigns the case to a vocational rehabilitation case manager within three working days. If the MCO has verified the injured worker's interest in vocational services within 14 calendar days prior to the referral date, they may proceed with vocational rehabilitation case manager assignment directly following eligibility verification by the DMC. The MCO must notify the DMC by of the vocational rehabilitation case manager assignment and indicate if the case manager is an intern. The date of that becomes the official assignment date. If the injured worker is clearly not feasible for services upon eligibility verification, the MCO must close the case and not assign a rehabilitation case manager. If the injured worker does not respond after multiple contact attempts within 14 calendar days, the MCO will close the rehabilitation case. Documentation of the attempted contact must be provided. Facts supporting a decision concerning either the acceptance or denial of an injured worker into vocational rehabilitation due to feasibility shall be documented in the MCO's decision. Appeals of feasibility determinations shall be governed by the alternative dispute resolution process provided for in Rule of the Administrative Code. January 2014 Final 4-18

23 I. Initial Feasibility Review for Vocational Rehabilitation Services. 1. Per Rule (H), feasibility for vocational services means there is a reasonable probability that the injured worker will benefit from services at this time and return to work as a result of the services. Feasibility is initially determined at the time of referral and is continually assessed throughout the rehabilitation process. Determination of an injured worker s feasibility for vocational rehabilitation services shall include, but not be limited to, review of the following information and factors: a. An injured worker is feasible for vocational rehabilitation services when a review of all available information demonstrates that it is likely the provision of such services will result in the injured worker returning to work. b. An injured worker is not feasible for vocational rehabilitation services when a review of all available information demonstrates that, in spite of the provision of such services, it is likely the injured worker will not return to work. c. "All available information" means records, documents, written and oral statements, and any and all medical, psychological, vocational, social, and historical data, of any kind whatsoever, developed in the claim through which vocational rehabilitation is sought or otherwise, that is relevant to the determination of an injured worker's feasibility for vocational rehabilitation services. Some examples of feasibility issues are: The injured worker s interest in returning to work; The injured worker s past participation in vocational rehabilitation plans or other bureau provided services; Documentation of events that could impact the injured worker s ability to participate in vocational rehabilitation services at this time (including, but not limited to hospitalization, scheduled surgery, vacation, incarceration, etc.); Documentation of medical and psychological issues, including pain issues, medication or substance abuse issues, both related and unrelated to the allowed conditions in the referred claim. 2. A determination of feasibility shall be written and shall enumerate all available information utilized in making the determination. Facts supporting a decision concerning either the acceptance or denial of an injured worker into vocational rehabilitation due to feasibility shall be documented in the MCO's decision. BWC provides oversight of MCO s feasibility decision. Appeals of feasibility determinations shall be governed by the alternative dispute resolution process provided for in rule of the Administrative Code. January 2014 Final 4-19

24 J. Referral Packets and Complexity Factor Forms Once an injured worker is deemed eligible and feasible for vocational rehabilitation services, the MCO must forward the following information to the assigned vocational rehabilitation case manager. Claim number; Allowed ICD codes, date of injury, last date worked, occupation, date of birth, MCO referral date; Date of referral and name of person who initiated referral and the reason for referral; Basis for injured worker s eligibility and feasibility for vocational rehabilitation services; Contact information for the following: injured worker, BWC DMC, MCO Nurse Case Manager, physician of record, contact at POR s office, contact at employer of record, attorney of record, assigned vocational rehabilitation case manager. This information must include: name, address, and phone number. Whenever possible, cell phone and fax numbers should be included; Electronic blank Excel complexity factor form. MCO should send the following documents to the assigned vocational rehabilitation case manager: All imaged past vocational rehabilitation initial assessments and closure reports, All prior vocational evaluations and functional capacity evaluations, Most recent independent medical examination, Most recent C84 and MEDCO 14, First Report of Injury (FROI) form. As soon as the vocational rehabilitation case manager receives the assignment he/she should review the referral packet and request any missing information from the MCO. From the beginning, the vocational rehabilitation case manager must begin identifying the barriers and issues that create complexity in the case and noting those issues in the initial assessment and on the Complexity Factor Form. It is important to remember that any identified complexities must be reported somewhere in the rehabilitation documentation that the vocational rehabilitation case manager submits to the MCO and BWC. The location and date of such documentation is noted on the Complexity Factor Form for each factor identified. Many, if not most, of these factors will be identified by the time the initial assessment is completed. However, the Complexity Factor Form should be updated throughout the rehabilitation process with careful attention to where the factors identified after the initial assessment are documented (plans, progress notes, closure report). January 2014 Final 4-20

25 K. Plan Assessment/Development: Initial Contact and Interview, Assessment and Progress Reports and Continued Feasibility Review 1. Contact with Injured Worker and Initial Interview: To begin the plan assessment/development phase, the vocational rehabilitation case manager contacts the injured worker within 5 calendar days after case assignment to further research feasibility issues. The case manager conducts a face-to-face initial interview with the injured worker which establishes a working relationship and serves as a source of important information concerning the injured worker s individual situation. Useful topics generally covered at the initial interview include the injured worker s: Demographic information: Age Marital status, number/age of any dependants Education, year graduated or last grade completed Employment information: Employment history, salary, job description, and reasons for leaving previous jobs Union affiliation and union representative contact information; Apprenticeships Military service Hobbies/interests Length of time off work Transportation resources/valid driver s license; Local labor market Willing to relocate if necessary? Understanding of BWC s return to work hierarchy Realistic job goals? Ability to speak, read, write in English/other languages Legal information: Arrests/convictions Legal problems Medical information: Abilities and limitations; Physical tasks at most recent job, ability to currently perform job tasks Unrelated medical/psychological conditions including hearing or visual limitations Medication usage (see #4 below Medication Usage as a Feasibility Factor) Medical Insurance BWC information: Previous claim and rehabilitation history Pending hearings, appeals or settlements January 2014 Final 4-21

26 Vocational rehabilitation participation information: Financial incentives and disincentives for return to work Financial incentives and disincentives for rehabilitation participation Motivation (behavioral based) Involvement with other agencies i.e. Bureau of Vocational Rehabilitation, Human Services, Social Security, Ohio Department of Job and Family Services. 2. Contact with the Employer of Record: During the vocational rehabilitation plan assessment/development phase the vocational rehabilitation case manager must contact the employer of record (EOR), whenever possible, to determine if return to work opportunities exist with that employer, in accordance with BWC's hierarchy of vocational placement. The vocational rehabilitation case manager must communicate with the individual representing the EOR who is responsible for decisions regarding the injured worker s return to work status. It is essential that the VRCM discuss BWC return-to-work services with this EOR representative and how these opportunities may help the employer bring the injured worker back to work. If the VRCM is convinced after meeting with the EOR representative that no return to work possibilities exist with that employer, this situation must be thoroughly documented by the VRCM for BWC and MCO review. Documentation must include all circumstances of the contact such as the name and position of the person representing the employer, when and how the contact was made and other information received. 3. Contact with the Physician of Record The vocational rehabilitation case manager must contact the POR and review the targeted job goal using the job description or job analysis, if available. The use of transitional work or other early return to work services should be discussed along with the injured worker s ability to participate in various plan services. Medication use, including the injured worker s ability to drive while medicated and perform specific work tasks such as machine operation and tool usage should be reviewed. (See #4 above). The POR should provide documentation of current physical restrictions related to the allowed conditions, current medications, and a prescription for plan services. Note: Medical release (C101) has to be signed before VRCM contacts the POR. 4. Medication Usage as a Feasibility Factor: During the initial interview, the vocational case manager must request specific information from the injured worker concerning medication usage- both prescribed and over-the-counter- including frequency, dose and prescription source. The vocational case manager must discuss the injured worker s medication usage with the physician of record to help determine feasibility. There should be special emphasis on the injured worker s ability to drive or operate equipment while using the medication. January 2014 Final 4-22

27 The physician of record should provide written documentation of any restrictions limiting participation in vocational treatment services or affecting the job goal. 5. Initial Assessment Report: MCO should ensure that the initial assessment report is based on the injured worker s self-report at the initial interview, contacts with the EOR and POR and file information. MCO should also confirm that a medical release (C101) was signed by injured worker before the VRCM contacted the POR and that the VRCM submits the initial assessment to the MCO and DMC before any plan services are delivered. Note: All written correspondence submitted by BWC providers may be viewed by the injured worker. Any subjective inferences in a report must be substantiated with objective behavioral descriptions of the situation. 6. Progress reports: The progress report provides information about the current status of the injured worker, any barriers that have developed and specific strategies to overcome the barriers. The progress report includes the next steps that will be taken to move the injured worker toward the goal of return to work. The vocational rehabilitation case manager must submit to the MCO and DMC written progress reports at a minimum thirty calendar day interval after case assignment. These reports must be submitted even if a vocational plan or amended plan has been submitted. The first progress report may either be the initial assessment report or a progress report. All progress reports must be signed by the VRCM. Initial Assessment Report, Plan, and Progress Reports Timeframes (Example of maximum submission timeframes) MONTHS Tasks Start Date July August September Duration (cumulative days) Case Manager Assignment 7/1 X 1 Initial Assessment (IA) Report or Progress Report 7/ X 30 Initial /Original Plan Submission (due within 45 days of case manager assignment)* 8/ X 45 Subsequent Progress Report - 1st 8/ X 60 Subsequent Progress Report - 2nd 9/ X 90 * or documentation of just cause (see #8 below) January 2014 Final 4-23

28 Note: Vocational Rehabilitation Providers must fax all vocational rehabilitation information (plans, reports, etc.) to the MCO s toll free fax number only. MCOs must submit the signed plans to BWC via the specific BWC Service Office imaging/terminating fax numbers. 7. Evaluations to Help Determine Feasibility or Case Direction: In conjunction with the initial interview, the rehabilitation case manager may schedule the following evaluations, as necessary, to further evaluate the appropriateness of vocational rehabilitation interventions and/or establish case direction. These evaluations must be authorized by the MCO. Reimbursable vocational rehabilitation plan development evaluations may include: Vocational evaluation; Evaluation of physical capacity; Multi-disciplinary evaluation; Evaluation by a physical medicine and rehabilitation physician; Psychological evaluation; Other vocational rehabilitation evaluative services as authorized by the MCO. 8. Integrating Information and Recommendations for Plan Participation: The vocational rehabilitation case manager assesses and integrates all of the information gathered and makes a recommendation as to whether the injured worker is a viable candidate for participation in vocational rehabilitation at this time. If the vocational rehabilitation case manager determines that the injured worker is not a viable candidate for participation in rehabilitation at this time, the MCO must follow standard rehabilitation case closure procedures. Cases closed during or after the vocational rehabilitation plan assessment/ development phase may only be reopened with justification of significant changes in the injured worker s circumstances. If the MCO decides to close the case during the vocational rehabilitation plan assessment/ development phase, the MCO must issue letters of notification to all parties to the claim. These letters must specifically state why the injured worker is not feasible for services. Due process language in the letter directs the parties to file any objection with the MCO according to the identified ADR process. If the injured worker is deemed a viable candidate for participation in vocational rehabilitation, the vocational rehabilitation case manager develops the initial individual written vocational rehabilitation plan with the injured worker and submits it to the MCO for review and authorization. The initial rehabilitation plan must be received by the DMC within 45 calendar days of case manager assignment. If the vocational rehabilitation case manager determines that it will not be possible to develop a plan within 45 days of case manager assignment, they January 2014 Final 4-24

29 must provide written justification and staff the issue with the MCO and DMC as soon as possible but within 45 days of case assignment. Extensions of the preplan time frame for any exception to this 45 day target date will be considered on a case-by-case basis by the MCO and the DMC. These exceptions, also called just cause, include but are not limited to: (a) situations in which pre-plan information (such as physician of record or employer information, results of functional capacity or vocational evaluations) has not been received following a timely request: (b) Unexpected injured worker delays: (c) Other documented justification as deemed sufficient by BWC. Additional Note: If a rehabilitation plan is reopened within 2 months of closure, due to a rescinded closure or claim transfer, another initial assessment is not necessary and the vocational rehabilitation case manager should develop a plan within 21 days from the date the case is reassigned to a VRCM or continue the services that were offered before closure, if appropriate. 9. Vocational Rehabilitation Case Manager Transfer: For a variety of reasons, a vocational rehabilitation case may be transferred from one BWC enrolled case manager to another. When this occurs, the current vocational rehabilitation case manager must submit a transfer summary report to the MCO. This report must identify the current job goal, hierarchy level, physician of record approval for job goal, restrictions, employer of record contact information, training and/or job placement status, as applicable, and all services that have been completed to date. L. Use of Interpreter Services during Vocational Rehabilitation The Americans with Disability Act (ADA) guarantees a legal right to interpreter services for hearing impaired clients of public entities. Although a limited English proficiency is not considered a disability, BWC also assists these injured workers in obtaining necessary return-to-work services. In many situations, the injured worker has already been using a non-enrolled family member, community member, or BWC staff as an interpreter prior to referral to rehabilitation and these services should continue, if possible. Confidentiality issues or other individual issues may preclude the use of a nonenrolled interpreter in certain situations. Interpreter services during rehabilitation, either foreign language or sign language, are arranged and managed on an individualized case-by-case basis by the DMC, not the MCO. During rehabilitation, the MCO, vocational rehabilitation case manager, and DMC must work closely together to assist the injured worker in obtaining interpreter services at certain critical junctures in the rehabilitation process. These critical junctures will be determined by the DMC with on-going assistance from the vocational case manager. Critical junctures may include these meetings: the case manager s initial assessment; January 2014 Final 4-25

30 the discussion and signing of the vocational rehabilitation agreement; when plan expectations are discussed; if case direction changes. Sign language interpreter services for deaf or hearing impaired injured workers will be approved, when requested, for POR, Physical or Occupational Therapy appointments occurring during rehabilitation programming. The vocational rehabilitation case manager will note the use of interpreter services in the rehabilitation plan (grid and narrative) for informational purposes. Although interpreter services are arranged and managed by BWC, plans with interpreter services will be considered a Special Plan Type and follow special plan guidelines described in Section Q. of this chapter. To select an interpreter, the DMC should go to COR, Interpreter Services, Tips and Tools, Interpreters for a list of enrolled providers, and look for an interpreter in injured worker s geographic area. The DMC will then contact the interpreter and arrange for services for the injured worker and advise the interpreter of these guidelines. DMC will then contact the Vocational Rehabilitation Case Manager and approve the services at critical junctures during pre-plan and during an authorized plan. Services should be listed on the appropriate plan grid with an estimated cost within the Professional Provider Medical Services fee schedule, which can be located on The DMC will approve or deny requests for interpreter services in vocational rehabilitation by using the Interpreter Services Approval/Denial Letter. If a bi-lingual case manager is used, the case manager will not be reimbursed for both case management and interpreter services. Bi-lingual case managers will follow the regular travel guidelines currently in place for case management. An appeal to the use of interpreter services during vocational rehabilitation will not follow the usual appeal route for vocational rehabilitation service disputes. Appeals will be initiated by the injured worker or authorized representative filing a motion with BWC (form C-86). The DMC will enter a note into V3 labeled Interpreter Services and indicate approval or denial of services and the estimated costs of these services listed in the plan grid. Bills for interpreter services requested by BWC shall be sent to the DMC who requested interpreter services. Bills submitted directly to BWC Medical Billing and Adjustments will be re-routed to the DMC. The DMC shall review the bill to verify the billed services are the same as those that were requested, and then will submit the bill to BWC Medical Billing and Adjustments for payment. M. Return-To-Work Hierarchy Research demonstrates that the use of the return-to-work hierarchy minimizes disruption in the injured worker life and ensures the most cost effective, efficient and permanent reemployment for that injured worker. The rehabilitation case manager must consider and address each step of this hierarchy sequentially and document why any step can be ruled out in the vocational rehabilitation plan narrative. Training may be provided at any level January 2014 Final 4-26

31 of the hierarchy, when appropriate, to aid injured workers in successfully returning to work. The return-to-work hierarchy is outlined in Rule (B) which states that the goals of vocational rehabilitation are to return the injured worker to: 1. Same job, same employer: The first goal is to return the injured worker to the original employer in the original job. (Original employer and same employer refer to the employer of record or EOR. The EOR is the employer with whom the injured worker was employed at the time of the injury.) 2. Different job, same employer: To encourage the employer to modify the original job or to provide employment in a different job at that employer. 3. Same job, different employer: To assist the injured worker in finding employment with a different employer in a related industry. 4. Different job, different employer: To assist the injured worker in finding a job in another industry. N. Vocational Rehabilitation Plan Elements The outcome of the plan development phase is an individualized written vocational rehabilitation plan. The initial plan integrates the information obtained during the assessment phase, identifies the strategies to overcome any barriers to return to work, and outlines a comprehensive plan to progress the injured worker from the current point through to the return to work for the job goal identified. The initial plan also details the services from the comprehensive plan for which the vocational rehabilitation case manager is currently requesting authorization. Subsequent plans will only include the comprehensive outline if there has been a change in the job goal or an unforeseen barrier is identified that requires a change in the planned services to achieve the job goal. The injured worker, vocational rehabilitation case manager, employer (when required) and the MCO must agree to the rehabilitation plan. DMCs must document approval for each plan amendment in V3 notes. BWC may authorize a rehabilitation plan for a maximum 6 month period. However, more than one rehabilitation plan may be provided per referral for rehabilitation services. Vocational rehabilitation plans must reflect that the injured worker will approximate a 40 hour work week if they are released to full time work and approximate the number hours a week they are released to work by POR if limited to only part time work. With justification, the very minimum an injured worker must participate should be at least 3 days per week in plan activites. The vocational rehabilitation case manager must instruct the injured worker and treatment provider at the initiation of plan services to immediately notify the case manager of injured worker absences. The vocational rehabilitation case manager must immediately notify the DMC and the MCO. Plans should not repeat information from past plans unless it is directly relevant to the current plan. January 2014 Final 4-27

32 Plan services begin after the initial plan has been approved by the MCO and DMC. Injured workers must receive signed copies of their plans. Prescriptions for specific vocational rehabilitation plan services from the POR are necessary for some vocational rehabilitation services. (See chart next page). Note: Vocational Rehabilitation Providers must fax all vocational rehabilitation information (plans, reports, etc.) to the MCO s toll free fax number only. MCOs must submit the signed plans to BWC via the specific BWC Service Office imaging/terminating fax numbers. January 2014 Final 4-28

33 Services Requiring a POR Prescription or C9 Services Requiring a POR Release (Documentation from POR that IW may RTW with restrictions (MEDCO 14, C84 or office notes, etc) Services not Requiring a POR Prescription or Release Code Service Code Service Code Service CPT Biofeed-back No Employer CPT Adjustment codes Training code Incentive Contract codes /Career W0638 W0695 W0750 CPT Codes W0637 W0648 W0710 Initial 2 hr : W0702 Each add. hr: W0703 CPT codes Body Mechanics Education Exercise Equipment Nutritional Consult OT and Physical Therapy Transitional Work Services Unsupervised Conditioning Work Conditioning Work Hardening/Occ. Rehab Functional Capacity Evaluation Counseling W0660 Job Placement W0647 Auto Repairs W0659 Job Development W0674 Child Care No Job Search W0644 Ergonomic code Study W0694 Long term training W0645 Job Analysis No code On-the-job training W0641 Job Club W0692 Short term training W0672 Job Coach No code W0650 Work Trial W0663 Job Modifications Job Seeking Skill Z0700 Relocation Training Expense W0635 Situational Work Assessment No code Gradual RTW W0665 Tools & Equipment (unless DME) W W0610 W0631 W0662 Vocational Case Management Vocational Eval. Comprehensive Vocational Screening Work Adjustment (facility) January 2014 Final 4-29

34 Include the following information in a vocational rehabilitation plan: Demographics section: Injured worker s name; Claim number; Date of referral for vocational rehabilitation; RTW goal; Allowed injury; Job goal. Narrative section: For the original plan, the vocational case history and the vocationally relevant medical information, including issues to be addressed for return to work. Only changes to original plan information should be included in later plan amendments; The BWC return-to-work hierarchy level with rationale; The return-to-work goal and a comprehensive outline of the services to achieve that specific job goal and the services for which authorization is currently requested; The clearly defined expectations of the injured worker, the provider, and employer (as applicable) when participating in vocational rehabilitation plan services (i.e. specific responsibilities during incentive plans, Job Search plans, number of contacts and methods required for job search, required documentation, etc.); The barriers to successful vocational resolution, such as unallowed conditions, and plans to address these barriers as needed; The vocational services needed based primarily on limitations caused by the allowed condition; An explanation of how the plan will help bring the claim to vocational resolution; An explanation of any change in the direction or additional services. Other agency involvement Consequences of lack of participation. Grid section: List separately on the grid the pre-plan services and current vocational rehabilitation plan services. Each plan grid must include the hourly rate, number of hours and weeks of each service that have been completed, and how many more are requested. Provide full information: type of service including case management, individual provider name and contact information, costs or estimated costs as appropriate, dates including frequency of service per week, estimated length of service and codes for each service. (Estimated costs must be monitored closely by the vocational rehabilitation case manager). January 2014 Final 4-30

35 Signature section : Initial plan- A "hard copy" signature on a plan means the actual signed plan or a replication of the actual signed plan by scanning or fax. A hard copy signature from vocational rehabilitation case manager, employer (when appropriate), and the MCO must be on the initial plan when the plan is received by the DMC. A plan sent via with an signature is not acceptable, unless the contains the scanned document. A verbal signature may be obtained from the injured worker by the vocational case manager for the initial plan when it is submitted to the DMC. A verbal signature indicates that the vocational rehabilitation case manager has discussed plan services with the injured worker and is legally assuring BWC that the injured worker agrees with these services. A verbal signature is provided when the vocational rehabilitation case manager prints the injured worker s name on the plan signature section with the vocational case manager s initials above. The verbal signature from the injured worker must be followed-up within 30 calendar days of plan start date by a hard copy signature. The hard copy signature must be submitted to the DMC before any new amended plans can be approved (unless there is justification). Examples of justification: unusual life circumstances death in family, illness of case manager; medical interrupt, case management follow-up to RTW, voc guidance plans. A hard copy signature from the injured worker must be obtained on the BWC RH-1 form, Rehabilitation Agreement form, before the provision of plan services. The vocational case manager s provider enrollment number must be ed in a password protected document to the DMC at the time of assignment and not included on the plan (RH-2). Both initial and amended plan- The employer s signature must be on the plan when services occur at the employer s work site: Employer Incentive Contract, Gradual Return to Work, Job Modifications, On-the-Job Training, Work Trial, Transitional Work and Ergonomic Study. January 2014 Final 4-31

36 Amended plan A hard copy signature is required from the vocational case manager when the amended plan is submitted to the DMC. A hard copy signature from the injured worker must be submitted to the DMC by the 30 th date after plan start date. The hard copy signature must be submitted to the DMC before any new amended plans can be approved (unless there is justification). The rehabilitation case manager is required to obtain, at a minimum, a verbal signature from the MCO representative authorizing the amended plan. The verbal signature from the MCO must be followed-up by a hard copy signature. O. Amended Vocational Rehabilitation Plan If the initial rehabilitation plan does not result in employment and/or the vocational rehabilitation case manager identifies a new barrier prior to the completion of the current plan, the case manager may write a plan amendment to continue or redirect rehabilitation services. To ensure there is no interruption in the injured worker s payments, the amended plan must be submitted to the MCO so that it is received by DMC within three working days prior to the end of the previous plan. If there is a change to a plan it must be identified as a new amendment not as an addendum to the previous plan. P. Reports for Job Placement and Job Development services: A comprehensive narrative report for job placement and / or job development services is required weekly. The report must include the injured worker s experience in job search and constructive advice provided by the provider. The following features must be evidenced by the report: barriers to job search and strategy proposed to overcome them changes to job search being made timeframes of meetings, contacts dates and location of services and session length with injured worker should be noted legible RH-10s all job leads provided to the injured worker, including the source, and verification that the leads were for claim specific injured worker (If searches are conducted for multiple injured workers, time should be prorated across claims, terms like good faith should be backed up with specific examples homework assignments must be clear and results documented results of follow ups on RH-10 must be specific next steps and future needs must be outlined as each week progresses content should be factual and professional and be specific to the particular stage of job search, not repeated information from the past consequences to injured workers not completing assignments or contacts injured worker s success as well as need for remediation January 2014 Final 4-32

37 If the job placement and job development services are supplied by the same provider, the provider shall submit a single weekly report that identifies the activities in both areas using separate headings for the unique activities. The provider shall record the specific units of activity on their activity log (whether that is incorporated in the report or submitted on a separate sheet is up to the provider and the MCO). The following activities are considered job placement and will be recorded to W0660 Job Placement: 1. Internet job search 2. Newspaper job search 3. ODJFS search for posted jobs 4. Other advertised jobs 5. Direct meeting with the injured worker to review leads and activities 6. Direct contact with employers about jobs identified in activities 1 through 5 of this section The following activities are considered job development and will be recorded to W0659 Job Development 7. Cold calling employers who do not have advertised positions 8. Contacting known employers in a particular field 9. Searching for employers specific to a field 10. ODJFS search for hidden job market 11. Meeting with employers to develop a position specific to an injured worker 12. Developing and OJT 13. Contacting the injured worker regarding leads developed in activities 7 through 12 above. Note: All job placement and job development providers must be enrolled and bill under their individual provider number, not the company they work for. They should provide information about billing activity and units of service for each date of service. No bundling of services by week. Q. DMC Authorization of Special Vocational Rehabilitation Plan Types The DMC authorizes the following special plan types within three working days prior to plan implementation via Rehabilitation Services Commission (RSC) coordinated plans, including Bureau of Vocational Rehabilitation (BVR) and Bureau of Services to the Visually Impaired (BSVI). 2. Plans developed by Vocational Rehabilitation Case Management Interns (CMI) 3. Plans exceeding Chapter 4 Reimbursable Services guidelines (RIS) 4. Rehab Injury Claims (RIC) requiring a vocational rehabilitation plan. 5. Plans requiring interpreter services due to the injured worker s limited English proficiency or due to deafness/hearing impairments (INT). January 2014 Final 4-33

38 6. Return to Work Incentive service plans for Employer Incentive Contract (EIC), Gradual Return to Work, Work Trial, Job Modifications, On the Job Training (OJT), and Tools and Equipment. 7. Plans with services paid By Report (BR) Note: Any dispute concerning the DMC authorization of these special vocational rehabilitation plan types will follow the current DMC Rehab Recommendation process (see section E). Special considerations for the individual plan types: 1. Rehabilitation Services Commission (RSC) Coordinated plans: Initial staffing includes: DMC, the vocational rehabilitation case manager and the MCO Designee Review the vocational evaluation, labor market analysis information, specific needs of the injured worker (i.e. assessment of transferable skill, aptitudes) The vocational goal must be consistent with physical capacities The DMC will determine if hierarchy is addressed. The joint RSC/BWC plan is presented with the actual copy of RSC plan with documentation of consensus of all parties. Case manager prepares final plan, obtains signatures and submits to the DMC. 2. Plans Developed by Vocational Rehabilitation Case Management Intern (CMI): The DMC will be notified of the intern status at the time of assignment or transfer. Prior to submitting the final signed plan, the intern must staff each case plan with DMC via prior to actual plan submission. Any required justification must be included. 3. Extension of Chapter 4 Reimbursable Service guidelines: The initial staffing must include: DMC, vocational rehabilitation case manager and MCO Designee The vocational rehabilitation case manager prepares the final plan, obtains necessary signatures and submits to the DMC. 4. Rehab injury claims (RIC): The initial staffing must include the DMC and the MCO Designee. Once assigned, the vocational rehabilitation case manager will staff the case with the DMC prior to developing the plan and all amendments. 5. Plans Requiring Interpreter Services: The initial staffing regarding need for interpreter services must include the DMC, vocational rehabilitation case manager, and the MCO Designee. The DMC is responsible for arranging and authorizing interpreter services at critical junctures in the rehabilitation case, as necessary, based on on-going January 2014 Final 4-34

39 communication with the MCO and assigned vocational case manager (see Use of Interpreter Services During Rehabilitation, section L of this chapter) Once assigned, the vocational rehabilitation case manager will staff the case with the DMC prior to developing the plan and all amendments. 6. Plans Using Return to Work Incentive Services: Employer Incentive Contract (EIC), Gradual Return to Work, Work Trial, Job Modifications, On the Job Training (OJT), and Tools and Equipment. The DMC must verify that negotiated services comply with Incentive Services policy as outlined in section II of this chapter. 7. Plans with services paid By Report (effective with Rule ) By Report codes are service codes that have no established fees for the identified service. The services include the following: o W0647 Automobile Repairs o W0648 Physical Reconditioning Unsupervised o W0663 Job Modifications o W0665 Tools/Equipment o W0674 Child/Dependent Care o W0690 Training Books, Supplies and Testing o W0691 Remedial Training o W0692 Short Term Training up to 1 year o W0694 Long Term Training over 1 year, includes supplies o W0695 Retraining exercise equipment When including a by report code in a vocational rehabilitation plan, the VRCM will research the service that is needed and the available providers for that service. They will document in the vocational rehabilitation plan narrative the justification for the service and the associated costs. The service and cost of the service will be included on the plan grid. The VRCM will staff the proposed service and costs with the DMC and document DMC support in the narrative of the rehabilitation plan. The DMC will enter a note in V3 summarizing the staffing with the VRCM and indicating DMC support or lack of support for the service. When the DMC receives an MCO approved plan or amendment with a by report code from the MCO, the DMC will enter a rehabilitation note titled BR code Wxxx approval. The note will indicate that the service code listed on the plan is correct, the dates range for the services from the plan grid, the DMC s authorization of the code and fee, and indicate that the code will be payable when the MCO receives all required reports and billing documents showing services were completed. January 2014 Final 4-35

40 When the service is delivered and the billing documents are received by the MCO, the MCO will request the claim be placed on review by copying MBA SUPV in a password protected document that includes the details of the code, dates of service and date of V3 note of approval to pay as requested. If the MCO is not able to locate the DMC s note in V3, or if a change is needed to the existing note, the MCO should send a request to the Rehab Policy box including the information on the vocational rehabilitation by report request template prior to requesting the claim be placed on review. (See Appendix D) ** Note this same process is used to request units of service above the fee schedule. R. Interruptions to Vocational Rehabilitation Plan Services 1. Non-Medical Plan Interruptions If the injured worker cannot participate for a period of five working days or less per referral, due to circumstances beyond the injured worker s control, living maintenance can continue. When this occurs, the case manager must notify the DMC within 24 hours by fax, phone, or . If non-participation is expected to last beyond five working days, the MCO must contact the DMC immediately for consideration of vocational rehabilitation plan closure. If the injured worker is participating in a training plan and no courses are available for a one-term period, through no fault of the injured worker, the plan may be interrupted for the term without payment of living maintenance compensation. The vocational rehabilitation case manager must notify the DMC when this occurs. The CCT must facilitate the reinstatement of any other form of compensation when LM is stopped, if the injured worker is otherwise eligible. 2. Medical Interruption During Vocational Rehabilitation Plan Rule (B) allows a vocational rehabilitation plan in progress to be interrupted due to the injured worker s medical instability. The medical condition causing the instability does not have to be related to the allowed condition. A Medical Interruption period assists in maintaining rehabilitation case continuity while the medical condition resolves or further information about the condition is gathered. The interruption cannot exceed thirty calendar days payment of living maintenance compensation per rehabilitation case. In some unusual cases, a vocational rehabilitation case may need to stay open in a Medical Interrupt status for up to 30 additional calendar days. Living maintenance payments cannot be paid during this second 30-day period. After receiving a request for a Medical Interruption from the vocational case manager, the DMC is responsible for determining if it is appropriate to continue January 2014 Final 4-36

41 the injured worker s living maintenance compensation for the initial 30 day period based on diagnosis and prognosis. Depending on the specific circumstances, the DMC may discuss vocational rehabilitation plan closure as a possible appropriate step at the time of the request for Medical Interruption. The CCT facilitates the reinstatement of any other compensation if living maintenance is suspended or terminated, if the injured worker is otherwise eligible. a. MCO Responsibilities During a Medical Interruption: Notify the DMC within 24 hours by phone, fax, or when it is necessary to consider interruption. Confer with the DMC on the medical condition s expected impact on return to active vocational services. Submit a vocational rehabilitation plan amendment, if appropriate, for the period of Medical Interruption after discussion with the DMC. The vocational rehabilitation plan narrative section must provide justification for this interruption. This amended vocational rehabilitation plan must start the day after the last date of active plan participation and include the case management professional time and living maintenance compensation. Submit another amendment to restart active rehabilitation plan services. Written justification concerning resolution of the medical condition and the new plan activities must be included in the plan narrative. A release from the injured worker s POR for active participation in vocational rehabilitation and the planned activities is necessary. OR, close the case following usual closure procedures (see Closure Procedures, section T of this chapter) if the condition prohibits a return to active plan participation. b. BWC s DMC Responsibilities During a Medical Interruption: Determine if a Medical Interruption is appropriate, in conjunction with the MCO and the rehabilitation case manager s case information. Send letter notifying all parties to the claim of the Medical Interruption and describing appeal rights if LM is suspended or terminated. Facilitate the reinstatement of any other form of compensation when LM is stopped if the injured worker is otherwise eligible. S. Case Management Follow-up Services Follow-up services are provided prior to the closure of the rehabilitation case after the injured worker has returned to work and vocational rehabilitation treatment services have terminated. These services ensure the stability of the return to work and are provided by the rehabilitation case manager or, in some cases, the Job Placement specialist. Follow-up services are only reimbursed when the injured worker returns to work as the result of a vocational rehabilitation plan, or returns during a vocational rehabilitation plan. Follow- January 2014 Final 4-37

42 up services are separate and distinct from case management closure report services which are provided after case closure. Vocational rehabilitation case follow-up must be provided at a minimum of 10 calendar days after return to work up to maximum of 30 days, depending on need, unless the employment stability has already been established because the final vocational rehabilitation plan occurred on the work site, such as a Gradual Return to Work plan, Transitional Work plan, On-the-Job Training plan, Work Trial, etc. Upon return to work, the injured worker must be instructed by the vocational case manager to phone the case manager immediately concerning any problems that might affect work stability. The case manager must investigate and resolve the issues prior to case closure. If employment is not maintained during this follow-up period, through no fault of the injured worker, the case manager may need to change the direction of the rehabilitation plan. Justification for follow-up services must be included in the vocational rehabilitation plan narrative. Up to five hours of follow-up services may be provided by the VRCM and/or Job Placement/Job Development Specialist. Note: According to Rule , an injured worker cannot receive LMWL until the vocational rehabilitation case is closed, thus LMWL benefits cannot be paid during the follow-up period. Except in the case of a Gradual RTW incentive program, LMWL compensation may be paid retroactively to the return to work date after closure as explained in the LMWL section of this chapter, see section (BB)(2)(e)(4)). An eligible injured worker experiencing a wage loss during the follow-up period may be eligible for Working Wage Loss in accordance with Rule , except when the services are provided in Gradual RTW incentive program. T. Vocational Rehabilitation Closure Procedure 1. Closure of a vocational rehabilitation referral occurs after: a. The injured worker has been found eligible but is not feasible for services. b. The injured worker has been found eligible and feasible but does not participate in pre-plan services. 2. After the injured worker has participated in a vocational rehabilitation plan, closure occurs after: a. The injured worker has completed a vocational rehabilitation plan; b. The injured worker has failed to fulfill the responsibilities outlined in the vocational rehabilitation plan; c. The injured worker is unable to attain the goals of the vocational rehabilitation plan; d. The injured worker has refused, without good cause, to accept an offer of employment within the vocational goal of the rehabilitation plan; January 2014 Final 4-38

43 e. The injured worker is no longer living; f. The injured worker does not agree with the MCO's or bureau's decision to approve or deny specific vocational rehabilitation plan services; or g. The claim is subsequently disallowed by an order of the industrial commission, its district or staff hearing officers, or by an order of the court. h. The claim is settled (medical and/or indemnity). i. The injured worker has been provided all necessary services, goals have been obtained, the injured worker is employed, and the case follow-up period has ended. 3. The MCO must follow bureau closure procedures outlined in this section. It is important to follow the closure process as described or the injured worker s future awards may be adversely affected. The case closure date is the day following the injured worker s last day of vocational rehabilitation plan service. If the injured worker did not enter a plan, the closure date is the day BWC is in agreement with closure. Note: Both date of case closure and plan closure date have equivalent meanings indicating that rehabilitation services are no longer being provided to the injured worker. Case management follow-up services, (as described in section S. Case Management Follow-Up Services) are not to be provided past these dates. Follow-up services must be written into a vocational rehabilitation plan prior to the date of vocational rehabilitation case closure. Only the time spent in case management closure report writing duties and phone calls may be reimbursed within 10 business days after the vocational rehabilitation case closure date. 4. The MCO will notify the DMC of a return to work or other case closure within 24 hours by phone, fax or . The rehabilitation case closure date is the day following the injured worker s last day of vocational rehabilitation plan service. If the injured worker did not enter a plan, the closure date is the day BWC is in agreement with closure. If no case management follow-up period has been written in the plan, the MCO must assure that the injured worker has actually returned to work and that no further services are needed. 5. Within ten business days of rehabilitation case closure, the MCO must prepare and send a vocational rehabilitation closure letter to all parties to the claim, including a copy to the DMC, detailing the specific reason for closure, appeal rights and the timeframes for appeal using the above established date. All cases that have been determined eligible for rehabilitation require a closure letter (including cases that are not assigned to a vocational rehabilitation case manager). 6. Within 10 business days of rehabilitation case closure, the MCO must review and forward the vocational rehabilitation case manager s completed vocational rehabilitation closure report, BWC s RH-21 form, or an equivalent containing the same information, on all cases that have been assigned to a vocational rehabilitation case manager. The closure report must be submitted to the DMC. January 2014 Final 4-39

44 7. All closure reports should include the following elements, if applicable: a) Injured worker s name; b) Claim number; c) Total length of service (including plan development phase and followup); d) Total case costs: e) Living maintenance costs; f) Case management and services costs (including plan development phase and follow-up); g) Copy of the Physician of Record (POR) release; h) Case closure explanation with return-to-work hierarchy level; i) Job at time of injury; j) Description of the job injured worker returned to including salary and hours scheduled; k) New employer; l) Plan closure date; m) Vocational rehabilitation case manager and case management company. Note: The closure report must be accompanied by the Complexity Factor Form completed by both the rehabilitation case manager and the MCO. 8. The MCO will describe the reason for the closure in the closure letter and in the closure report, but the bureau s DMC assigns the closure code. If the MCO discovers that the closure code does not correspond with the information submitted, the MCO must contact the assigned DMC to discuss. 9. A closure may be rescinded during the closure appeal period if the MCO, employer, and injured worker all agree to keep the vocational rehabilitation case open. The MCO will notify the DMC of the decision to rescind the closure. U. Vocational Rehabilitation Case Closure with a Request for a Medical Hold 1. Medical Hold is a BWC term for holding an eligible injured worker s vocational rehabilitation eligibility status open, in an inactive status, for up to two years maximum from the date of vocational rehabilitation plan file closure due to an unexpected medical event for either an allowed or unallowed condition requiring case closure. At the time of the vocational rehabilitation case closure, the injured worker must currently be participating in plan services and the MCO must request a Medical Hold closure status from the DMC. 2. The DMC determines Medical Hold based on a request with adequate documentation from the MCO. Medical Hold request may come to the MCO through the POR, treating physician, or any party to the claim at the time of the case s closure. The injured worker January 2014 Final 4-40

45 must sign a consent form for the bureau s DMC and/or MCO and treating physician to communicate if the medical event is for an unrelated medical condition. In these cases, it is the responsibility of the party requesting the Medical Hold to obtain and submit the signed consent to the MCO and the DMC. The consent is limited to communication about the stability of the medical condition as related to a return to active rehabilitation. 3. MCO Responsibilities During a Medical Hold: a. Close case as medically unstable according to BWC closure procedures. b. Request the Medical Hold status from the DMC. c. If an un-allowed condition, MCO must submit the following to the DMC: documentation of diagnosis/prognosis of the medical condition along with a signed copy of the exchange of information consent form allowing the treating physician to communicate with the DMC. d. Notify the DMC when information is received indicating the injured worker s medical condition has stabilized. The POR must sign the actual release to return to vocational rehabilitation plan services. e. Monitor the injured worker s medical status with the attending physician with DMC on a monthly basis for the first six months and on a bimonthly basis thereafter up to two years. f. Submit an appropriate vocational rehabilitation plan as soon as vocational rehabilitation can be resumed. 4. BWC s DMC Responsibilities During a Medical Hold: a. Determine if Medical Hold status is appropriate in cases closed medically unstable and Medical Hold has been requested with medical documentation. b. Issue a decision on the request for Medical Hold status by letter to the MCO and all parties to the claim. c. Provide written notification to all parties of the claim of the eligibility/noneligibility determination for Medical Hold giving appeal rights. d. Monitor the injured worker s medical status with the attending physician with MCO on a monthly basis for the first six months and on a bimonthly basis thereafter up to two years. e. Notify the MCO if information is received indicating the injured worker s medical condition has stabilized. f. When the bureau becomes aware of the restabilization of the injured worker's medical condition, the injured worker's vocational rehabilitation plan shall be reactivated and, absent any extenuating circumstances, appropriate rehabilitation services shall begin as soon as possible. 5. At the conclusion of the Medical Hold, it is not necessary to re-determine the injured worker s eligibility status; however, it will be necessary to re-assess the injured worker s feasibility for vocational rehabilitation services. 6. Vocational rehabilitation case management hours are not reimbursable through the surplus fund in closed cases, including those closed with a Medical Hold closure code. January 2014 Final 4-41

46 7. Appeals by a party to the claim on the decision must be sent to the BWC Rehabilitation Eligibility Unit, Level 20, 30 W. Spring St., Columbus, OH within 14 calendar days of the receipt of the determination. V. Rehabilitation Services Commission/BWC Agreement BWC and the Rehabilitation Services Commission (RSC) have a cash transfer agreement/contract for providing vocational rehabilitation services to injured workers found eligible by both agencies. The injured workers served through this joint agreement usually have sustained severe or catastrophic injuries or are seeking a retraining program. When an injured worker is identified as a potential referral to RSC, the Rehabilitation Services Commission Referral is completed by contacting the RSC office in the injured worker s community. Written consent from the injured worker must be obtained by the person making the referral to permit full exchange of vocational rehabilitation case information exchange between BVR/BSVI s counselors, BWC s DMC, and the MCO case manager. The BVR/BSVI counselor and the MCO s case manager must discuss any plan that requires living maintenance payments. W. Rehabilitation Injury Claims (RIC) According to R.C , injured workers who sustain a new injury or occupational disease while participating in an approved vocational rehabilitation plan can file a claim as if the injured worker s employer was BWC. These claims must be filed only for new injuries or occupational diseases. While the direction of the RIC is being determined, MCO should consider placing the vocational rehabilitation case of the original claim (known as the source claim) in a medical hold, to maintain the injured worker s eligibility for vocational rehabilitation. The source claim MCO must notify DMC when these injuries occur and submit a FROI to BWC and BWC s MCO. The source claim MCO s case manager must also submit documentation, such as medical treatment notes from the new injury and the incident report from the facility, and a copy of the rehabilitation plan. Claims filed as a result of an injury sustained while participating in a rehabilitation plan will follow usual claims processing procedures. BWC s MCO becomes the MCO for the new allowed claim resulting from an injury sustained while participating in a reimbursable rehabilitation plan. Self-insuring employers not participating in the rehabilitation reimbursement fund (opted-out) at the time of the original claim are not eligible for reimbursement from the Surplus Fund for injuries occurring during vocational rehabilitation plans. X. Appeals 1. Appeals to an MCO Vocational Rehabilitation Decision January 2014 Final 4-42

47 If any party to the claim or provider disputes an MCO s vocational rehabilitation decision, the ADR guidelines derived from Administrative Rule are followed. These guidelines are outlined in Chapter 5 of this guide. Decisions made by the MCO, such as the type of rehabilitation services offered or the closure of a vocational rehabilitation case, are appealed to the MCO. When a dispute regarding vocational rehabilitation issues is filed, the MCO is responsible for informing the DMC. 2. Appeals to a BWC Vocational Rehabilitation Decision Decisions made by BWC are appealed to BWC. BWC makes vocational rehabilitation decisions concerning: Eligibility for vocational rehabilitation; Medical Hold closure; Eligibility for Living Maintenance, Living Maintenance Wage Loss, and Injured Worker Travel; Rehab Recommendations on any vocational rehabilitation issue as described in section E,1, of this chapter (appealed only by the MCO to BWC); Appeals to BWC decisions related to vocational rehabilitation, except Rehab Recommendations (as described in section E of this chapter), must be sent to the BWC Rehabilitation Appeals Unit, Level 20, 30 W. Spring St., Columbus, Ohio within 14 calendar days of receipt of the BWC decision. January 2014 Final 4-43

48 3. Appeals and the Rehabilitation Case Flow If, at the time of referral to rehabilitation, an injured worker s claim is appealed and the decision could jeopardize the rehabilitation eligibility status, as outlined in Rule , eligibility cannot be determined. The DMC will notify the MCO of this delay in determining eligibility. Once the appeal has been decided, the process of determining eligibility continues. If an injured worker is already participating in a vocational rehabilitation plan and the claim is appealed and the decision could jeopardize the vocational rehabilitation eligibility status as outlined in Rule , rehabilitation plan services continue until the appeal is decided. BWC must immediately notify the MCO of an appeal outcome that affects the continuation of vocational rehabilitation services. If the appeal decision removes the basis for the injured worker s positive determination of eligibility, i.e. temporary total compensation is vacated on the referral date and no other basis for eligibility exists, rehabilitation services are terminated. Y. Living Maintenance Compensation When an injured worker is actively participating in a vocational rehabilitation plan, he or she shall receive living maintenance payments in place of temporary total compensation (Rule ). Additionally, R.C states that BWC will issue this compensation for a period not to exceed six months in the aggregate, unless BWC s review reveals the injured worker will benefit by an extension. The CCT can issue living maintenance upon receipt of notification of vocational rehabilitation plan services. Living maintenance payments shall begin on the date that the injured worker actually begins to participate in an approved vocational rehabilitation plan as defined in rule of the Administrative Code, not the date of referral for vocational rehabilitation services not the date the injured worker signed the rehabilitation agreement. Activities performed prior to the injured worker's active participation in the approved vocational rehabilitation plan are considered pre-plan activities for which living maintenance is not paid. Note: If an injured worker is paid wages for activities (not salary continuation in lieu of living maintenance) while participating in a vocational rehabilitation plan service, such as work adjustment activity at Goodwill, the injured worker must endorse that paycheck over to BWC. The checks must be sent to State Insurance Fund, Bureau of Workers Compensation, Corporate Processing Department, Columbus Oh A note with a brief explanation must accompany the check so it may be deposited in the correct account. January 2014 Final 4-44

49 Z. Salary Continuation in Lieu of Living Maintenance Compensation If salary continuation is offered by the employer of record, an injured worker with a lost time claim (8 or more days of lost time from work due to the allowed injury) may choose to receive either salary continuation or living maintenance during vocational rehabilitation. However, if temporary total or living maintenance has been paid in the claim, the injured worker must receive living maintenance when participating in vocational rehabilitation. Whenever the employer pays salary continuation, it must be paid at the injured worker s regular (full) salary level. A lost time claim with salary continuation in lieu of LM cannot be reported as a medical only claim at a later date. Vocational rehabilitation plans with salary continuation are developed and managed in the same manner as plans in which LM is provided. The injured worker is provided the same quality of services and agrees to the same level of cooperation. After the plan is completed, an injured worker who has received salary continuation maintains the right to any future benefits, if otherwise eligible, such as Living Maintenance Wage Loss (LMWL) compensation. AA. Deduction from/termination of Living Maintenance The MCO informs the DMC of changes in case status that may affect the injured worker s receipt of living maintenance. This information must be communicated within 24 hours so that BWC can suspend or terminate compensation. The deduction from, or termination of, living maintenance is made in accordance with Rule The decision to deduct from or terminate living maintenance does not affect the injured workers rights to compensation or benefits for which they may be otherwise qualified. The CCT facilitates the reinstatement of any other compensation if living maintenance is suspended or terminated. If living maintenance is suspended or terminated, the CCT must send a letter of notification to all parties to the claim. This letter will describe appeal rights and identify the Rehabilitation Eligibility Unit on Level 20, 30 W. Spring St., Columbus, Ohio as the appropriate recipient of a dispute on the issue. The bureau may order deduction from any living maintenance payment an amount equal to: a) One-seventh of the weekly payment to which an injured worker is entitled for each full day during which the injured worker fails, without good cause, to participate in their approved vocational rehabilitation plan. b) Any wages or other remuneration received by the injured worker while participating in an approved vocational rehabilitation plan and receiving living maintenance must either be endorsed over to the bureau or will be deducted from the injured workers living maintenance payments or from future awards of compensation. The bureau shall order termination of living maintenance payments at such time as upon the earlier of: a) The injured worker s return to work other than as part of a gradual return to work plan; or January 2014 Final 4-45

50 b) Closure of the injured worker's vocational rehabilitation plan pursuant to Section T. Vocational Rehabilitation Closure Procedure of this chapter. BB. Living Maintenance Wage Loss (LMWL) Compensation 1. Application and Eligibility for Living Maintenance Wage Loss: A. In claims with a date of injury on or after August 22, 1986, the bureau shall make living maintenance wage loss payments to injured workers who complete an approved vocational rehabilitation plan, successfully return to work, and experience a wage loss while employed. (1) The wage loss must be as a consequence of the physical and/or psychiatric limitations caused by the impairments resulting from the allowed conditions in the claim as documented by the injured worker s physician of record on form MEDCO-14 or equivalent. (2) Injured workers requesting living maintenance wage loss payments shall be required to submit an application for living maintenance wage loss (on form RH-18 or equivalent) and medical documentation of the physical and/or psychiatric limitations as documented by the injured worker's physician of record on form MEDCO-14 or equivalent. Subsequent applications for living maintenance wage loss payments must be submitted by the injured worker before the specified end date of the restrictions provided by the injured worker's physician of record or every six months, whichever occurs first. (3) Injured workers requesting living maintenance wage loss payments shall not voluntarily limit their income by choosing to work fewer hours or at wages below reasonable expectations, if more appropriate jobs are reasonably available within their labor market. If the injured worker voluntarily limits his or her income by choosing to work fewer hours or by accepting a job which does not constitute suitable employment which is comparably paying work, the injured worker's living maintenance wage loss benefits shall be calculated as sixty-six and two-thirds per cent of the difference between the greater of the injured worker's full weekly wage or average weekly wage on the claim for which the injured worker underwent a rehabilitation plan and the weekly wage the injured worker would have earned had the injured worker not voluntarily limited his or her income. January 2014 Final 4-46

51 (a) In determining whether an injured worker has voluntarily limited his or her income, the bureau may review all relevant factors listed in Rule , as necessary, in determining whether the injured worker has returned to suitable employment which is comparably paying work, including: injured worker s search for suitable employment; injured worker s failure to accept a good faith offer of suitable employment; other actions of injured worker that constitute voluntary limitation of income from employment (including, but not limited to, discharges for just cause which result in a wage loss not causally related to the allowed conditions in the claim, retirement and voluntary separation from employment); whether the injured worker received a full release to return to his or her former position of employment. (b) An injured worker who wishes to change jobs after the initial receipt of living maintenance wage loss payments must notify the assigned bureau customer service team. The customer service team shall review the criteria set forth above to ensure that no voluntary limitation of income will occur in the job the injured worker wishes to change to and that the job constitutes suitable employment which is comparably paying work. (4) In the event the injured worker accepts employment that is below the reasonable expectations of the return to work goals of the vocational rehabilitation plan, or if the injured worker can reasonably be expected to obtain different employment for which earnings are more comparable to those prior to the injury, the injured worker may be required to make a good faith effort to search for suitable employment which is comparably paying work. In determining whether a good faith effort to search for suitable employment is required, the bureau shall consider factors such as the goals of the vocational rehabilitation plan, the labor market, the skills and work history of the injured worker, and any other factors that would assist in determining whether a good faith job search should be required. (5) To receive living maintenance wage loss payments under this rule after approval of these benefits by the bureau, an injured worker must provide proof of earnings at least every four weeks in the form of pay stubs, payroll reports from the injured worker's current employer, or a wage statement on form C-94(A) or equivalent. If the injured worker submits a C-94(A) completed by the injured worker, the form must be notarized. If the C-94(A) is signed by the employer, the form does not need to be notarized. If self employed, the injured worker must submit a notarized C- 94-A. January 2014 Final 4-47

52 (6) If the CSS or DMC has any questions about the validity of the pay stubs, the CSS and DMC will staff the situation and the DMC shall contact the injured worker. The DMC can explain that living maintenance wage loss cannot be paid until the questionable pay stubs are verified by a C-94-A which must be notarized and signed by the injured worker. 2. Bureau Responsibilities: The bureau shall be responsible for calculating living maintenance wage loss payment amounts based upon the injured worker's wage statement or other information on the subject submitted by the injured worker. Payments shall be sixty-six and two-thirds per cent of the difference between the greater of the injured worker's full weekly wage or average weekly wage on the claim for which the injured worker underwent a rehabilitation plan and the weekly wage received while employed up to a maximum per week equal to the statewide average weekly wage. a. Such living maintenance wage loss payments shall be issued on a biweekly basis or on a quarterly basis if the injured worker is self-employed or has a substantial variation in income and reports income to the bureau on a quarterly basis. If the injured worker has a substantial variation in income or is self employed, the wage documentation may be submitted on a quarterly basis with pay stubs, and a copy of his or her quarterly Federal Estimated Tax for Individuals to the DMC. Living maintenance wage loss payments shall be charged to the surplus fund established by section of the Revised Code. b. Payments may continue for up to a maximum of two hundred weeks but shall be reduced by the corresponding number of weeks in which an injured worker receives payments pursuant to division (B) of section of the Revised Code. c. The DMC on the assigned Customer Care Team determines eligibility for LMWL at six-month intervals or when injured worker s restrictions expire, based on BWC rule and policy guidelines. (1) The DMC must receive the necessary information from the injured worker and/or vocational rehabilitation case manager to aid in the initial authorization of LMWL. ( Closure means that the MCO has sent a Closure Letter to the injured worker and all parties to the claim giving an official closure date). (2) The vocational rehabilitation plan must be closed as a Plan Complete (PC) or Job Retention (JR), if otherwise eligible. January 2014 Final 4-48

53 (3) The injured worker must return to work at the time of vocational rehabilitation plan closure or within 60 calendar days of the plan closure for LMWL to be authorized. (4) An injured worker may receive LMWL retroactively during the period that the injured worker participated in Transitional Work, On-the-Job Training, Employer Incentive, case-management follow up period and post return to work unsupervised reconditioning plan periods (health club maintenance memberships), if he did not receive WWL during these periods. LMWL must not be paid when the injured worker is participating in a Gradual Return to Work (GRTW) program, even if no LM is paid during the GRTW. d. The following definitions shall apply to the adjudication of applications for living maintenance wage loss payments: (1) Successful return to work" as a result of an approved vocational rehabilitation plan means that the injured worker has obtained employment within sixty days of closure of the injured worker's approved vocational rehabilitation plan and the employment: (2) Is within the physical and/or psychiatric limitations caused by the impairments resulting from the allowed conditions in the claim in which the injured worker completed the vocational rehabilitation plan, as documented by the injured worker's physician of record; and (3) Is reasonable in comparison with the return to work goals of the vocational rehabilitation plan completed by the injured worker. BWC does not support speculative business ventures. Suitable employment means work which is within the claimant s physical capabilities and which may be performed by the injured worker subject to all physical, psychiatric, mental and vocational limitations to which the injured worker is subject at the time of injury which resulted in the allowed conditions in the claim or, in occupation disease claims, on the date of the disability which resulted from the allowed conditions in the claim. (4) Comparably paying work means suitable employment in which the injured worker s weekly rate of pay is equal to, or greater than, the average weekly wage received by the claimant in his or her former position of employment. 3. Vocational Rehabilitation Case Manager Responsibilities with LMWL: a. Provide general information about the availability of these benefits to injured workers who appear eligible and refer questions regarding specific benefit amounts and eligibility to the assigned DMC. January 2014 Final 4-49

54 b. Provide the DMC with thorough case management documentation especially any changes in the job goal. c. Assist the injured worker with the initial six-month LMWL authorization if needed (obtain information about the new position from the injured worker, not the new employer, unless the injured worker indicates that this employer may be contacted). 4. DMC Responsibilities with LMWL: a. provide information of possible LMWL eligibility to injured workers whose job goal is not the original job at the original employer by sending appropriate letters on COR. One letter explains eligibility for LMWL when injured worker reaches hierarchy level of different job/same employer. The other letter explains LMWL eligibility before completion of the vocational rehabilitation plan in the event the injured worker obtains a job (within the restrictions in the claim) that pays less than the job of injury within 60 days of vocational rehabilitation closure. b. fax an RH-18 to the vocational rehabilitation case manager as soon as it is clear that injured worker has obtained a job through a rehabilitation plan and will be making less than injured worker s job of injury. Vocational rehabilitation case manager will have the injured worker complete the form and will submit it to the MCO and DMC with the follow up or closure report. If the vocational rehabilitation case manager cannot complete this form with the injured worker, DMC will contact the injured worker, explain the benefit and send a letter to the injured worker with an RH-18 to complete. c. review the completed RH-18, the POR restrictions and determine eligibility in a due process letter to the injured worker and all parties to claim. Due process language in the letter informs the parties to file any dispute within 14 calendar days with the BWC Rehabilitation Appeals Unit, Wm. Green Bldg., Level 20, 30 W. Spring St, Columbus, OH d. create a diary to contact injured worker prior to expiration of LMWL to discuss whether they are still experiencing a wage loss. If so, DMC must send an RH-18 to the injured worker once RTW and wage loss has been verified. DMC must sign the completed RH-18 form once received from injured worker to authorize payments when injured worker s restrictions from POR expire or every six-month LMWL authorization period (whichever comes first) and for any job change upon determining eligibility for LMWL. Signing the RH-18 alerts the team Claim Service Specialist (CSS) to pay this benefit when the wage documentation is received. e. review wage documentation if the injured worker has a substantial variation in income or has changed jobs since the last authorization, to verify that the injured worker is not voluntarily limiting income. January 2014 Final 4-50

55 f. create a diary to contact injured workers who had not returned to work but had completed a rehabilitation plan to see if they have obtained a job within 60 days of rehabilitation closure. If they have obtained a job, send an RH-18 for them to complete. 5. Injured Worker Responsibilities with LMWL: a. provide the DMC on the assigned Customer Care Team the POR s release to return to work at the initial authorization for LMWL and documentation of current physical limitations from the POR at each six-month LMWL authorization or when restrictions expire (whichever comes first). b. work collaboratively with the vocational rehabilitation case manager to provide the DMC with information to initially authorize LMWL within 60 calendar days of the vocational rehabilitation plan closure. c. complete the RH-18 that is sent by DMC at the time of RTW d. complete new RH-18 when POR restrictions expire or every six months for renewal of LMWL and submit to DMC along with updated POR restrictions. e. request renewal, of LMWL by contacting the DMC on the CCT within thirty (30) days prior to the expiration date of the current restrictions or authorization for LMWL (whichever comes first). The injured worker is provided the expiration date on a copy of the RH-18 form, Authorization for LMWL. f. notify the DMC if planning to make a change in employment after receipt of LMWL as explained in section 2. of these guidelines. g. if a regularly salaried injured worker: submit on at least a monthly basis a wage statement (C-94A) and/or pay stubs signed by the current employer or a signed notarized wage statement (C-94A) and pay stubs to the Customer Care Team. h. if reemployed with a substantial variation in income, including selfemployment, the injured worker must generate revenue that is reasonably equivalent to the earnings that individuals with similar skill, abilities and physical capacities would earn within their local labor market. LMWL compensation is not intended to subsidize speculative business ventures or reduced income life-style choices. If his/her income is not reasonably equivalent, injured worker may have to conduct a job search. If better paying jobs are available in the injured worker s geographic area, and he/she has the skills for those jobs but does not conduct a job search, his LMWL will be computed on what he could have made, not the income he reports. i. if the injured worker has a substantial variation in income, such as commissioned sales, seasonal work, or is self-employed: submit on a quarterly basis (every 13 weeks) a signed notarized wage statement (C-94A) or pay stubs and a copy of his or her quarterly Federal Estimated Tax for Individuals to the DMC. j. if employed at the time of injury by a Self-Insured employer: submit all LMWL documentation to the Self-Insured employer. January 2014 Final 4-51

56 CC. Lump Sum Settlement (LSS) and Vocational Rehabilitation If a LSS application (C240) has been received, and there is an original or amended plan in progress, that particular plan can continue to completion. After the completion of that plan, the rehabilitation file should be closed and a closure report should be written. However, if an original or amended plan was not in progress when the C-240, Application of Settlement Agreement, was received, the rehabilitation plan cannot be implemented and the rehabilitation file should be closed and a closure report should be written. The vocational rehabilitation file in both cases above will be closed using a closure code, PI 31, Plan Interrupt Settlement. In the event that a settlement is not reached, vocational services can be reactivated. The vocational rehabilitation eligibility status does not expire until the effective date of settlement. Vocational rehabilitation services provided on or after the effective date of settlement cannot be reimbursed. So, if settlement has been reached, and no prior notice was given to the provider, no closure report should be written. Authorized services provided prior to that date will be reimbursed, even after settlement. BWC providers who have billed within the last two years in that claim and vocational rehabilitation case managers are notified by letter of the injured worker s intent for final settlement. DD. BWC s Compliance and Performance Monitoring Unit The Compliance and Performance Monitoring Unit s mission is to ensure that appropriate, timely and quality vocational rehabilitation services are provided to all interested eligible and feasible injured workers. The unit utilizes the current MCO Contract with the bureau, BWC s MCO Policy Reference Guide, applicable rules in Ohio Administrative Code Chapters and and professional standards of conduct as the basis for vocational rehabilitation audits. Tasks performed by the Compliance and Performance Monitoring Unit include: Perform periodic audits; Educate and facilitate the MCOs use of rehabilitation; Provide feedback and specific recommendations for improving the delivery of rehabilitation services. EE. Micro Insurance Reserve Analysis System (MIRA) and Vocational Rehabilitation January 2014 Final 4-52

57 MIRA is an individual case reserving system used for workers compensation claims. MIRA II is the next generation of the MIRA reserving system that was implemented in July, 2008 for private employers and January, 2009 for the public employers. With MIRA, individual claims characteristics are the determining factor in setting reserves. The algorithm for MIRA uses 180 different claims characteristics to set reserves, these include things like type of injury, gender of the injured worker, age of the injured worker, and whether an attorney has been retained, to name just a few. MIRA II was designed to react to good claims management, which for the purposes of this explanation would be prompt return to work. The quicker someone returns to work the quicker the reserve can be reduced. Once an injured worker returns to work and is receiving no services, then the reserve will often disappear. Beginning July 2010, claims with Living Maintenance or Living Maintenance Wage Loss as the last paid compensation no longer had the reserve reduced by 50% automatically. First, Living Maintenance and any associated costs for a vocational rehabilitation program are paid out of the surplus fund just as they have been. The key to MIRA II is that it reacts to good claims management so, since vocational rehabilitation is often the next step in getting an injured worker back to work, it s possible that the MIRA reserve may actually be reduced by more than 50%. FF. Surplus Fund Expenditures 1. The following are appropriate Surplus Fund expenditures: Vocational rehabilitation case management professional time is reimbursable: after the eligible rehabilitation case is assigned to the vocational rehabilitation case manager; through the progression of the rehabilitation program and through vocational rehabilitation case closure. During the 10 business days after case closure, only the time spent in case management report writing duties and phone calls may be reimbursed. Compensation to the injured worker and employer reimbursements. Vocational rehabilitation plan services. These services must directly relate to the specific vocational goal identified in the plan and be developed in accordance with the return to work hierarchy outlined in Rule The costs of treatment of unallowed conditions. (See Unallowed Conditions in section HH (34) Reimbursable Services of this chapter). 2. The following are NOT appropriate Surplus Fund charges: The injured worker has been determined not eligible for rehabilitation according to Rule The service or program has no strong vocational component and is primarily medically focused, such as passive therapy, transcutaneous electrical nerve stimulation (TENS) units, ultrasound treatment, massage and chiropractic January 2014 Final 4-53

58 manipulation and medically invasive procedures including nerve block injections. The physical or occupational therapy or treatments are primarily passive modalities or they are aimed at maintaining current level of functioning, instead of increasing overall physical capacities for return to work. The service or program is provided while the injured worker is not medically stable, or is still in the acute or post-operative phase of recovery. The active physical or occupational therapy in the plan is not provided in conjunction with services that simulate the injured worker s job or job goal. The service is a drug detoxification program for prescription or nonprescription drugs. The service is provided to increase quality of life or independent living rather than returning the injured worker to work. The service is a pain management program. Job retention services are not reimbursable when provided to the injured worker only to maintain levels of function achieved in a previous rehabilitation program or the current problems do not appear to represent a significant impediment to maintaining employment as outlined in Rule (E), eligibility for job retention services. Note: A significant impediment to maintaining employment means that the functional problems would cause the worker to lose the current job without receipt of services. Ongoing chiropractic manipulations are medically directed and are not considered appropriate for job retention services. GG. Payment for Services 1. Provider Enrollment Information Surplus monies are to be paid to BWC enrolled providers only. If a service is required from a provider who is not BWC enrolled, a one-time enrollment must be secured. The provider completes a provider enrollment application noting that this is a one-time enrollment. The rehabilitation plan grid is attached to the application and faxed to BWC Provider Enrollment at (614) Further explanation of the provider enrollment process can be found in Chapter 6 of the MCO Policy Reference Guide. Note: Occasionally, while participating in approved vocational rehabilitation plan services, an injured worker may purchase an item or service on a one-time basis. In these cases, the provider of the service is enrolled via the one-time enrollment process, that provider number is put on the C-19 form and the pay to injured worker box is checked. 2. Provider Scope of Practice Providers are ethically bound by their professional licensure boards and accreditation commissions to provide services that are within their professional January 2014 Final 4-54

59 scope of practice. It is the responsibility of each professional to be aware of these limitations and provide services accordingly. 3. Reimbursement for Services When the injured worker participates in an approved vocational rehabilitation plan or in plan development activities, BWC reimburses for vocational rehabilitation services from its surplus fund. Vocational rehabilitation service providers may bill on a UB-92, HCFA-1500 or C-19 form. Hospital based outpatient providers with separate provider numbers may use a HCFA BWC s Billing and Reimbursement Manual (BRM) provides detailed instructions for submitting billing invoices and indicates that each actual date of service must be identified on the invoice. The service provider submits invoices to the MCO and then the MCO sends it to BWC. BWC pays the MCO from the surplus fund, and in turn the MCO pays the provider. On submission of bills for reimbursement from the surplus fund, the MCO must designate 753 EOB (Explanation of Benefits) per line item. Reimbursement for these services occurs when the services are delivered within an MCO-approved vocational rehabilitation plan or they have been approved as a plan development phase activity. Some of the services listed below require that the MCO provide BWC with specific information. Note: To receive reimbursement, a provider must submit a detailed report of the services rendered and, when appropriate, the results of those services. HH. Reimbursable Services PLEASE NOTE the fees and timeframes for the services described in this section may be found on the appropriate provider fee schedule. Note: BWC fee schedules can be viewed by using the web address: and clicking on the link with the following statement at the bottom of the webpage. I accept the terms of above agreement and want to view, download and print a copy of the fee schedule. BWC s previous, current, and proposed fee schedules may be accessed in this manner. For services governed by the Vocational Rehabilitation Provider Fee Schedule, the following definitions apply: By Report These are service codes that have no established fees for the identified service, and that are jointly approved for inclusion in a plan by BWC and the MCO. The vocational provider must submit a detailed report of the service to the MCO, which shall determine the appropriate rate of reimbursement and follow standard bill reimbursement protocols for payment of vocational rehabilitation services. January 2014 Final 4-55

60 Note: Plans with services paid by report are considered Special Plan types according to Section Q of this chapter and require review and authorization by the DMC. Please see Section Q, #7 for handling instructions for plans with services paid by report. Service Code Limits Services listed as maximum will be capped at the fee of units of service listed. When service caps or units of services are listed as up to, the cap may be exceeded with prior authorization by the BWC DMC upon presentation of the appropriate justification following special plan type guidelines. The MCO must provide a review and justification for the additional service and place it in the MCO case file. The justification must include: case factors influencing the need; rationale for length of service; past motivation/cooperation of the injured worker. It is also appropriate for the justification to be documented in the vocational rehabilitation plan amendment. The DMC will contact the MCO if justification is not present or if further clarification of the justification is needed. Service maximums are in effect during the current vocational rehabilitation referral period, not for the life of the claim. A previously provided service should only be repeated when necessary, using a case-by-case decision making process. For example, if an injured worker received job seeking skill training (JSST) two years ago, it may be necessary to provide the injured worker with additional JSST services if referred again for vocational rehabilitation. Rounding: For all services with a fifteen minute unit of service, providers shall round time spend providing the service to the nearest whole unit when billing. January 2014 Final 4-56

61 1. Automobile Repairs (W0647) This service provides payment for necessary repairs to an injured worker s vehicle incurred during participation in a rehabilitation program and made for the sole purpose of allowing participation in the rehabilitation program. Total cost of the repairs cannot exceed the trade in value of the vehicle as reported in nationally recognized data, i.e. Kelley Bluebook value at Estimates on repairs must also include a statement from the mechanic regarding the overall condition of the car. Note: Providers must be enrolled with BWC. This service is provided on an individual basis as determined by need with DMC approval only. 2. Biofeedback Training (See CPT codes in CPT manual for psycho physiological therapy incorporating biofeedback training) Biofeedback training develops the injured worker s ability to control the autonomic (involuntary) nervous system and aids in pain management. 3. Body Mechanics Education (W0638) Beginning August 1, 2011, this local code will no longer be available for use. Services may be billed using existing CPT codes for physical therapy as applicable. 4. Child/Dependent Care (W0674) This service provides reimbursement to an enrolled provider for care for a child or dependent of an injured worker with the sole purpose of allowing the injured worker to participate in their vocational rehabilitation program. The maximum hourly and weekly reimbursement rates shall be equal to the ODJFS rates set forth in the appendix to Rule 5101: , 41_PH_FF_A_APP1_ _1334.pdf Services are provided on an individual basis as determined by need with DMC approval only. 4. Child/Dependent Care (W0674) This service provides reimbursement to an enrolled provider for care for a child or dependent of an injured worker with the sole purpose of allowing the injured worker to participate in their vocational rehabilitation program. The maximum hourly and weekly reimbursement rates shall be equal to the ODJFS rates set forth in the appendix to Rule 5101: Services are provided on an individual basis as determined by need with DMC approval only. January 2014 Final 4-57

62 5. Counseling Counseling assists injured workers in managing personal/emotional issues that interfere with vocational rehabilitation progress and present barriers to return to work. Professional counseling services that may be used in the course of vocational rehabilitation plans include: Adjustment Counseling: (see CPT codes in CPT manual for psychotherapy procedures) Assists injured workers in overcoming disability related life changes, situational depression, and related return to work concerns. If there is no psychological allowance in the claim, adjustment counseling is reimbursed as an Unallowed Condition (see Unallowed Conditions service in this section.) Career Counseling In Person (W0523): This is a counseling service that assists an injured worker in managing the personal and emotional issues that interfere with vocational rehabilitation progress and present barriers to return to work. This service specifically assists the injured worker who requires a substantial change in vocation due to the work related injury to identify and adjust to a new job goal that is realistic in terms of their current physical and mental status, and the availability of jobs in the injured worker s chosen area of residence. The counselor may utilize a variety of assessments and techniques to help the injured worker explore areas of vocational interest. Once the occupational field is narrowed, the counselor helps the injured worker to identify the skills, training availability and earnings potential for the identified job. Career Counseling In Person is used when the counselor is face-to face and one-on-one with the injured worker. Only professional who are licensed as one of the following provider types may provide Career Counseling services: Licensed Social Worker, Licensed Independent Social Worker, Licensed Professional Counselor, Licensed Professional Clinical Counselor, Licensed Psychologist, Doctor of Medicine or Doctor of Osteopathy. Providers of this service may be reimbursed for travel and mileage according to the codes for Other Provider Travel and Mileage. For this service, Licensed Social Workers and Licensed Professional Counselors are reimbursed at 75% of the established fee, while Licensed Independent Social Workers and Licensed Professional Clinical Counselors will receive 85% of the established fee. Progress notes and a final report are expected for this service. The service may be used in conjunction with W0524 Career Counseling Research and Reporting. Career Counseling Research and Reporting (W0524): This service provides a limited amount of time for a career counselor to complete research of specific occupational requirements and/or report writing when the injured worker receiving career counseling is not present. The service may only be provided in conjunction with Career Counseling In January 2014 Final 4-58

63 Person as part of an approved vocational rehabilitation plan, and must be performed by the same person who is providing the Career Counseling In Person services in the plan. Note: Although Career Counseling Research and Reporting has fee service limits listed as an up to 40 units of service, additional units of this service should be approved only in extraordinary circumstances with appropriate justification. Guidelines for Career Counseling services At the outset of Career Counseling, a written plan for the counseling should be developed with the injured worker. The plan should include: o Clearly defined goals for the service, o List of expectations for the individual injured worker while participating in career counseling, o Schedule of meeting dates. (If this is a standalone service, these must be at least one to three times per week and include homework assignments) o Explanation of the homework that will be assigned and recognition that all services together for an injured worker should approximate full time or the level of the injured workers release; The Career Counselor must submit at least bi-weekly reports summarizing the progress of career counseling. At the end of the service, the Career Counselor will submit a report providing the recommendations for vocational goal and relevant labor market information. When billing for career counseling, the counselor will submit an activity log which indicates dates of services, units of service billed, place and time of service delivery. Note: According to Ohio laws governing the practice of counseling, only professionals who are licensed to provide counseling may provide Career Counseling and Adjustment Counseling. These licensures include: LSW, LISW, LPC or PC, LPCC or PCC, licensed psychologist, MD, or DO. All Counselors must be BWC certified and/or enrolled and bill under their individual provider number, not the company they work for. Activity logs should be submitted along with reports, and summary notes (MEDCO 16), if applicable 6. Employer Incentive Contract See the section that follows on Return to Work Incentive Services. 7. Ergonomic Implementation (W0513) Ergonomic Implementation allows for additional follow up with the injured worker when a job modification is recommended. The purpose is to ensure that January 2014 Final 4-59

64 the modification is appropriate and that the injured worker is trained to use the modification correctly. This service may be provided by an Occupational Therapist, Physical Therapist, Certified Ergonomist (CPE), Certified Human Factors Professional (CHFP), Associate Ergonomics Professional (AEP), Associate Human Factors Professional (AHFP), Certified Ergonomics Associate (CEA), Certified Safety Professional (CSP) with Ergonomics Specialist designation, Certified Industrial Ergonomist (CIE), Assistive Technology Practitioner (ATP) or a Rehabilitation Engineering Technologist (RET). Service providers may be reimbursed for travel or mileage using the fees and guidelines specified in W3050 Other Provider Travel and W3052 Other Provider as detailed in Vocational Rehabilitation Provider Travel in this section. Requirement: This service requires the employer s signature at the time the plan is submitted 8. Ergonomic Study (W0644) An ergonomic study is an analysis of how the worker responds when performing the job in relation to the work environment. It examines the "fit" between the worker and the job requirements. An ergonomic study takes into account the worker's size, strength and ability to handle the tasks, tools and work environment. It is generally used to evaluate the risks of the job and to recommend job modifications. An ergonomic study may be provided by an Occupational Therapist, Physical Therapist, Certified Professional Ergonomist (CPE), Certified Human Factors Professional (CHFP), Associate Ergonomics Professional (AEP), Associate Human Factors Professional (AHFP), Certified Ergonomics Associate (CEA), Certified Safety Professional (CSP) with "Ergonomics Specialist" designation, Certified Industrial Ergonomist (CIE), Assistive Technology Practitioner (ATP) or a Rehabilitation Engineering Technologist (RET). Service providers may be reimbursed for travel and mileage using fees and guidelines specified in W3050 Other Provider Travel and W3052 Other Provider Mileage as detailed in Vocational Rehabilitation Provider Travel in this section. The ergonomic study must be signed and dated by the actual servicing provider and specify his/ her credentials. Requirement: This service requires the employer s signature at the time the plan is submitted. 9. Exercise Equipment (See Retraining Exercise Equipment #29 this section) 10. Gradual Return to Work See the section that follows on Return to Work Incentive Services. January 2014 Final 4-60

65 11. Injured Worker Meals (W0601) and Lodging Expenses (W0602) BWC reimburses injured worker s meals and lodging expenses for the cost of necessary meals and lodging occurring in specific situations. IC/BWC guidelines and rates apply. (See the C60A for the current rates and guidelines. BWC provides reimbursement for this service on an individual basis as determined by need. Note: Out of State travel reimbursement must be pre-approved and greater than 50 miles round trip. Required forms: Travel Expense Statement (C-60), including receipts. Form must be legible and signed by injured worker. Note: Travel, meal, and lodging expenses must be included on an approved Rehabilitation Plan (RH2). The C-60 and any supporting documentation are submitted to the DMC for review and authorization. 12. Injured Worker Travel Expense (W0600) (Injured worker reimbursed) BWC reimburses injured worker s travel expenses for personal automobile travel and public transportation, e.g. bus pass, in specific situations. IC/BWC rates and guidelines apply with 45-mile round trip minimum. BWC provides reimbursement for this service on an individual basis as determined by need when included on the Vocational Rehabilitation Plan Grid. Mileage greater than 400 miles round trip must be authorized by BWC in advance of travel. Required forms: Travel Expense Statement (C-60). Form must be legible and signed by injured worker. Note: Travel, meal, and lodging expenses must be included on an approved Rehabilitation Plan (RH2). The C-60 and any supporting documentation are submitted to the DMC for review and authorization. 13. Injured Worker Travel, Meals, and Lodging (Program reimbursed, not reimbursed to the injured worker) These codes are used when the program used in the vocational rehabilitation plan has a contractual agreement with other facilities to provide travel, meals, and or lodging to the injured worker. Z0600 Vocational rehabilitation program, not injured worker reimbursed, travel Note: This code would be used to reimburse a company for a bus pass, i.e., reimbursing COTA or Metro for a monthly bus pass. Z0601 Vocational rehabilitation program, not injured worker reimbursed, meals Z0602 Vocational rehabilitation program, not injured worker reimbursed, lodging Services are provided on an individual basis as determined by need. January 2014 Final 4-61

66 Note: When reimbursing a public transit company for a bus pass for an injured worker s travel, Z0600 is used and the payment is processed by the MCO. 14. Interpreter Services Foreign language interpretation services for injured workers with communication difficulties dues to limited English proficiency or sign language interpretation for injured workers who are hearing impaired. Services are provided on a case-bycase basis when needed at critical junctures in the rehabilitation process as determined by the DMC. Code/Reimbursement: (W1930): Interpreter services. The actual time spent providing face-to-face interpreter services. (W 1931): Interpreter Wait Time, The actual time spent waiting for injured worker, employer, physician or other vocational provider. Wait time begins at the scheduled appointment time and is billed for a 5 unit maximum (30 minutes) per date of service (including no shows ). (W 1932) Interpreter Travel Time. The actual time spent traveling to or from authorized interpreter appointments (including travel time for no show appointments.) (W 1933) Interpreter Mileage Requirement: This service is authorized and arranged by BWC not the MCO; see section Use of Interpreter Services during Vocational Rehabilitation Section L of this chapter for more information, including billing for interpreter services. 15. Job Analysis (W0645) A job analysis is a process for examining a job and collecting measurements while the job is being performed. It explains what the worker does, how the worker performs the work and what the outcomes of the work are. It identifies the essential functions of the job and describes the physical demands of the required tasks, working conditions, and the knowledge, skill and experience generally required to safely perform the job. A job analysis includes information about the tools and equipment used in performing the job. Note: When the job analysis is provided by the vocational rehabilitation case manager, it is not billed using the W0645 code. It is considered vocational rehabilitation professional time, W3012. A job analysis may be provided by an Occupational Therapist, Physical Therapist, Certified Professional Ergonomist (CPE), Certified Human Factors Professional (CHFP), Associate Ergonomics Professional (AEP), Associate Human Factors Professional (AHFP), Certified Ergonomics Associate (CEA), Certified Safety Professional (CSP) with "Ergonomics Specialist" designation and a Certified Industrial Ergonomist (CIE), Assistive Technology Practitioner (ATP) or a January 2014 Final 4-62

67 Rehabilitation Engineering Technologist (RET). Service providers may be reimbursed for travel and mileage using fees and guidelines specified in W3050 Other Provider Travel and W3052 Other Provider Mileage as detailed in Vocational Rehabilitation Provider Travel in this section. The job analysis must be signed and dated by the actual servicing provider and specify his/her credentials. Requirement: This service requires the employer s signature at the time the vocational rehabilitation plan is submitted. 16. Job Club (W0641) Job clubs are highly structured group meetings composed of job seekers and a facilitator. Participants cultivate skill through actively conducting their job search with training and guidance from the job club facilitator. This program aids a group of injured workers in obtaining job leads and supports their job search performance. Note: Sessions must be facilitator led and at least one-hour in duration. Mileage, travel time and wait time may also be billed by Job Club providers within BWC guidelines Other Provider Travel Wait and Mileage, see Vocational Rehabilitation Provider Travel in this section. 17. Job Coach (W0672) A Job Coach is a vocational specialist who provides on-site guidance, training and assistance to the injured worker focusing on job performance in the actual work situation. This behaviorally based program concentrates on teaching specific skills to assist in completing the job s required tasks and maintaining appropriate work behaviors. Note: This service is customarily used with individuals who have traumatic brain injuries, psycho-behavioral conditions, catastrophic injuries, developmental disabilities or individuals who have difficulty adapting to new job settings. Mileage, travel time and wait time may also be billed by Job Coach Providers within BWC guidelines, see Vocational Rehabilitation Provider Travel in this section. Note: All job coach providers must be enrolled and bill under their provider number, not the company they work for. 18. Job Modification See the section that follows on Return to Work Incentives. January 2014 Final 4-63

68 19. Job Placement (W0660) and Job Development (W0659) Job Placement (W0660) is a vocational service that assists an injured worker in returning to work by matching the injured worker s vocational skill and restrictions with jobs that may be available or modified for the injured worker. Job Placement providers use their knowledge and contacts from the local labor market to facilitate return to work by providing leads to the injured worker and making contacts with potential employers on behalf of the injured worker for advertised jobs. The Job Placement provider must also set job search procedures and goals, closely follows the injured worker s progress and correct/redirect the performance of activities through frequent, documented face-to face meetings with the injured worker. Specifically, job placement services match an injured worker to an existing position in the community. This job may or may not require modifications to suit the individual injured worker s need; however, the position is not new. Both job placement and job development services should be provided for injured workers who enter the job search phase of a vocational rehabilitation plan. If the vocational rehabilitation case manager provides job placement services, he/she should also perform job development or choose someone to perform job development. If the vocational rehabilitation case manager is not providing job placement, he/she should choose one provider for both job placement and job development services. Job Development (W0659) is a vocational service that assists an injured worker in returning to work by uncovering the hidden job market (i.e., unadvertised positions) and/or creating a job that matches the injured worker s vocational skills and restrictions. The Job Development provider must have a working knowledge of an industry or geographic area and its employers to be effective. Job Development requires a marketing and sales frame of reference. Providers of this service must be aware of the need of both injured workers and potential employers and be knowledgeable of return to work incentive programs for negotiation purposes. Providers use their knowledge and contacts from the local job market to facilitate return to work by contacting potential employers on behalf of the injured worker and arranging interviews for unadvertised or newly created jobs. Job Development involves negotiation with a potential employer to create a position for the individual injured worker that formerly did not exist. This would require that the provider has more than a casual knowledge about the area and its employers to be effective. There are specific differences between job placement services and job development but both should be provided during job search. Proper staffing of the case will reveal what is needed for the specific injured worker. When Job Development services are included in a vocational rehabilitation plan, Job Placement services must also be provided. If the Job Placement January 2014 Final 4-64

69 provider is not the vocational rehabilitation case manager, the Job Development provider must either be the Job Placement provider or the vocational rehabilitation case manager. Providers of this service may be reimbursed for travel, wait time, and mileage according to the codes for Other Provider Travel, Wait Time, and Mileage. The specialized services of a Job Placement and Job Development providers should only be included in a vocational rehabilitation plan when the injured worker requires placement and development services above and beyond the services provided by the vocational case manager during the Job Search. The job placement and job development provider and the VRCM must staff the case to insure the best coordination of the case. It is essential that the both Job Placement and Job Development providers possess a thorough knowledge of BWC return-to-work services and concepts such as Gradual Return to Work, Work Trial, Employer Incentive Contracts, and On-the- Job Training. When using one of these services to negotiate a job offer with an employer, it is important that the Job Placement and Job Development Specialist work in conjunction with the BWC DMC and the VRCM. Specific compensation information must always be referred to BWC. The specialist should assist the injured worker in providing the MCO with documentation of all job contacts including employer name, date of contact, and the specific outcome. Job Placement and Job Development services should be based on a labor market analysis for the target job(s) from the VRCM. The labor market analysis must include job availability within a certain industry and the names of specific employers who are currently hiring. Prior to the start of the Job Search, a Job Search strategic plan should be developed with the VRCM. This Job Search strategy must include a periodic reevaluation of the direction of the Job Search and possible adjustments when expected outcomes are not reached. It is important to remember that Job Placement and Development services are typically authorized in 4-6 week plans / amendments. Continuation of this service should be justified based on the availability of openings for employment related to the identified job goal of the injured worker, the injured worker s possession of the expected skills for that job goal and the injured worker s active participation in the job search process, if the injured worker was identified as having transferable skills for the targeted job. However, it is determined that the injured worker lacks a specific skill that is now expected by most employers for the job goal, training (OJT or short-term) should be considered. Job Placement and Job Development Specialists must use their own servicing provider number when billing for these services. Note: See Section P for details regarding the job placement plans and report requirements. Suggested Forms: Injured Worker Report of Employer Contacts (RH-10) January 2014 Final 4-65

70 Mileage, travel time and wait time may also be billed by Job Placement and Development providers within BWC guidelines, see Vocational Rehabilitation Provider Travel in this section. Note: MCOs and DMCs should be flexible when considering the need to extend job development or job placement services beyond the fee schedule limit of 40 hours when presented with justification. Part of the consideration of such a request may be that the provider demonstrates use of both placement and development, especially if the service has been predominately one or the other and has not proven successful. It is important to recognize that there is not a requirement for a one to one match for placement and development hours; some injured workers may require more of one than the other. At the same time, BWC expects that both services will be utilized in a rehabilitation plan. Note: All job placement and job development providers must be enrolled with BWC and bill under their individual provider number, not the company they work for. 20. Job Search (no billing code used) Job Search is an individualized self-directed program monitored by the rehabilitation case manager. Its purpose is to expedite employment in a position that can/will provide a reasonable standard of living. It is developed for an injured worker who can t return to the original employer and has the transferable skill and physical capacities to return to the labor force. The injured worker conducts a self-directed job search monitored by the vocational rehabilitation case manager (VRCM). It is important that the VRCM and the injured worker, with input from the DMC and MCO, establish ground rules for job search. When job search is included in plan in conjunction with Job Placement and Job Development services, the Job Placement and Job Development Specialist should also help to develop the ground rules. The ground rules should address the following: The job goal The number of contacts to be made. The minimum amount of time the injured worker is expected to engage in job search activities each week. The type of contacts to be made (i.e. in person, phone, fax, internet, US mail, etc.) Note: The job goal should help to determine the number of job contacts and the type required per week. The method for documenting contacts When the documentation of contacts will be submitted To whom the documentation of contacts will be submitted. How often the injured worker will meet with the VRCM and / or the job placement and development specialist. January 2014 Final 4-66

71 When a job search is not going as planned, barriers will be discussed and expectations will be documented on the vocational rehabilitation plan (RH-2). The vocational rehabilitation case manager and MCO are responsible for assuring that the injured worker is actively participating in a full-time job search program, as described in the vocational rehabilitation plan. As the job search progresses, care must be given to the quality of contacts versus the number of contacts. Although the injured worker must fulfill their obligation to participate in job search, it is most important that the contacts they make are appropriate and represent jobs they can actually perform based on their physical capacities, skill and aptitudes. Average Duration: up to 20 weeks Suggested Forms: Injured Worker Report of Employer Contacts (RH-10) Note: An injured worker is ready to participate in job search/job placement when all medical treatments that could interfere with a successful return to work have been completed. The injured worker must have a clearly defined, workable job goal that is supported by the restrictions set forth by the physician of record and available in the geographic area. The injured worker must have the skill and/or aptitudes to perform the chosen goal. Personal issues must be addressed and /or resolved such as transportation, child care, telephone availability, wage expectations, etc. The injured worker must be able to legally work in the United States. It is also important to consider the injured worker s feelings as to whether they are ready to begin the work of returning to gainful employment. It is the vocational rehabilitation case manager s responsibility to document the above. 21. Job Seeking Skills Training (JSST) (W0650) JSST is a specialized individualized or group program focused on job goals, application process, and developing the skills necessary to obtain employment, such as interviewing, effective employer contacts with follow up, internet job search, online applications, and resume development. The injured worker should learn how to network, find job leads and use forms (RH10) for recording job contacts. The injured worker s presentation must be reviewed with tips on how to improve where necessary. The injured worker should learn how to address difficult interview questions, including questions about their disability and workers compensation. The provider and injured worker must develop a list of prospective employers and the provider must explain the different ways that successful contacts can be made. These would include face to face, phone, fax, US mail, and internet contacts. At the end of JSST, the provider must be able to provide concrete support with documentation addressing the information and content provided during the JSST program, the injured worker s strengths and areas of additional need, and whether the injured worker is ready for job search. This service is provided in person and is usually used in conjunction with Job Search, Job Club, Job Placement, and/or Job Development. JSST may be January 2014 Final 4-67

72 provided individually if waiting for a group program to begin that would hinder case progress. Mileage, travel time and wait time may also be billed by JSST providers within BWC guidelines, see Vocational Rehabilitation Provider Travel in this list of Reimbursable Services. Note: All JSST providers must be enrolled with BWC and bill under their individual provider number, not the company they work for. 22. Nutritional Consultation/Weight Control (W0750) These services are offered for weight reduction and weight maintenance when the condition presents a barrier to participation in vocational rehabilitation plan services and return to work. These services must focus on behaviorally oriented nutritional counseling and not on quick weight loss techniques primarily based on dieting supplements or packaged foods. 23. Occupational Rehabilitation - Comprehensive (Work Hardening), Initial 2 Hour Session (W0702), Each Additional Hour (W0703) A Comprehensive Occupational Rehabilitation program is multi-disciplinary, individualized, progressive therapy program with measurable outcomes. It is focused on assisting the injured worker to return to work through progressive physical conditioning and work simulation. In addition to therapy, Occupational Rehabilitation Comprehensive assesses the injured worker across a combination of disciplines and provides intervention to meet the needs of the injured worker to achieve a goal of returning to work. Recommendations for reasonable accommodations or adaptations to work environment while minimizing the risk of re-injury are made as part of this service. To be eligible for reimbursement for this code, the provider must have valid CARF accreditation for Occupational Rehabilitation Comprehensive services. Evaluations by OTs and PTs at the start of the program are considered part of the initial C-9 authorization for Occupational Rehabilitation Comprehensive; however, they are billed separately using CPT codes. The following are treatment indicators for an Occupational Rehabilitation - Comprehensive program: Injured worker has no specific job to return to with a specific employer but a targeted job (or job group) goal has been identified. While the goal appears realistic, the injured worker does not currently have all of the physical tolerances for the targeted job, or, Injured worker has a specific job to return to with a specific employer, but does not currently have the physical capacities to safely return to the job and/or the employer does not have appropriate job accommodations and, January 2014 Final 4-68

73 Injured worker presents with more severe vocational issues or has complications beyond physical impairments that require an interdisciplinary team approach to address physical, psychological and vocational issues. 24. Occupational Therapy (See CPT Codes in CPT manual) For Occupational Therapy (OT) or Physical Therapy (PT) services to be included within a vocational rehabilitation plan, the services must simulate the work tasks of the injured worker s job or job goal. Active occupational or physical therapy services may also be provided in the vocational rehabilitation plan, as long as they are provided in conjunction with services that simulate the work tasks of the injured worker s job or job goal. Active physical or occupational therapy is defined as services which are: Provided after the acute recovery phase Not passive modalities Focused on overall body conditioning and not body part specific Focused on return-to-work goals. OT or PT services require written justification within the vocational rehabilitation plan narrative of how the service specifically addresses the return-to-work goal and must include justification for length of services. No passive modalities (i.e. massage, ultrasound, etc.) may be charged to the surplus fund, even if provided on a limited basis within an active OT/PT program. Service providers will not be reimbursed for travel or mileage expenses. Service Duration: up to 6 weeks. Minimum acceptable level of participation is 3 days per week if the service is the only service in a plan. 25. On-The-Job Training -- See the section that follows on Return to Work Incentives 26. Physical Reconditioning, Unsupervised (W0648) This service provides short term membership at a health club, YMCA/YWCA, spa or nautilus facility when requested by a physician of record to allow the injured worker to independently continue or maintain physical reconditioning necessary for return to work. This code may only be used in an approved vocational rehabilitation or Remain at Work (RAW). It does not include supervision by a licensed physical therapist. The vocational rehabilitation plan must describe the injured worker s expected activities and the frequency of participation per week. An unsupervised program must not be the only service in the vocational rehabilitation plan. January 2014 Final 4-69

74 Maximum: One program per referral for vocational rehabilitation services. This service could last for 3 months if there continues to be an active vocational rehabilitation plan for 3 months. Can be billed up to $ per program. BWC/MCOs shall not approve reimbursement for an unsupervised physical reconditioning program, such as services that are provided at a health club, YMCA, spa or nautilus facility, or home exercise equipment unless it is approved per the specific guidelines when an injured worker is participating in a vocational rehabilitation or remain at work program. Unsupervised physical reconditioning program services outside of vocational rehabilitation or during a remain at work program that BWC set to reimburse at $0.00 should NOT be processed through ADR. The MCO may deny request for these services as they are usually supplied as an integral part of another reimbursable service and will not be reimbursed separately. 27. Physical Therapy (See CPT Codes in CPT manual) For Physical Therapy (PT) or Occupational Therapy (OT) services to be included within a vocational rehabilitation plan, the services must simulate the work tasks of the injured worker s job or job goal. Active occupational or physical therapy services may also be provided in the vocational rehabilitation plan, as long as they are provided in conjunction with services that simulate the work tasks of the injured worker s job or job goal. Active physical or occupational therapy is defined as services which are: Provided after the acute recovery phase Not passive modalities Focused on overall body conditioning and not body part specific Focused on return-to-work goals. PT or OT services require written justification within the vocational rehabilitation plan narrative of how the service specifically addresses the return-to-work goal and must include justification for length of services. No passive modalities (i.e. massage, ultrasound, etc.) may be charged to the surplus fund even if provided on a limited basis within an active OT/PT program. No services may be provided in the home. Service providers will not be reimbursed for travel or mileage expenses. Service Duration: up to 6 weeks. Minimum acceptable level of participation is 3 days per week if the service is the only service in a plan. 28. Relocation Expenses (Z0700) This service provides financial assistance to injured workers who have obtained employment and must relocate because the job location is beyond the reasonable expectation of daily commuting. Services are provided on an individual basis as January 2014 Final 4-70

75 determined by need up to $2, per injured worker, as per Rule (C) (3) 29. Retraining Exercise Equipment (W0695) This service allows for the purchase of retraining exercise equipment for the injured worker for the sole purpose of maintaining the injured worker s physical conditioning for rehabilitation plan participation when access to an exercise facility is not available. The physician of record must recommend the equipment. BWC provides reimbursement for this service on an individual basis as determined by need. 30. Situational Work Assessment (W0635) A simulated tryout of the job (or job family) which evaluates an injured worker's ability to perform the specific job tasks through vocational skill assessments. The vocational rehabilitation plan must include details about the tasks the injured worker will be assigned, if the assessment could lead to employment, the name and contact information for the person acting as trainer/evaluator on the job site. The trainer will provide a report on injured worker s attendance and performance on the Trainer Report (RH-5) or its equivalent. Services typically occur over a 1-3 week period. Service Providers will not be reimbursed for travel 31. Tools and Equipment See the section that follows on Return to Work Incentive Services. 32. Training/skill enhancement: Training Books, Supplies and Testing (W0690) This service provides reimbursement for books, supplies, and testing necessary for participation in or completion of a training program. Books and supplies are limited to the course-required books, manuals, software, and equipment. This service is not intended to reimburse incidental supplies, such as, pens, pencils, notebooks, highlighters, etc., unless the course requirements specifically include those items. Reimbursement for testing may include fees for testing and required certifications or other occupationally required testing. This would include payment for background checks required for participation in services by some providers. Remedial training (such as GED) W0691; Remedial training assists injured workers in developing academic skills towards completion of their GED or remediation classes needed for admission to a training program beyond the high school level, such as business or trade school. The training must be in the form of organized instruction from an accredited academic, business and/or trade school. In some situations, the instruction may be provided through distance education, also called e-learning or on-line learning, in which the student communicates with the instructor via the Internet. Short term training/skill enhancement (less than one year) W0692; January 2014 Final 4-71

76 Short Term Training includes both training and skill enhancement from an accredited academic, business or trade school that assists injured worker in developing new occupational skills. Short term training is up to one year in duration. Long term training (more than one up to two years) W0694 Training and skill enhancement assists injured workers in developing new occupational skill through receipt of organized instruction from an accredited academic, business and/or trade school. Long Term Training requires prior approval from BWC. In some situations, the instruction may be provided through distance education, also called e-learning or on-line learning in which the student communicates with the instructor via the internet. Note: DMCs must document approval for each amendment submitted, especially while the injured worker is in long term training. Necessary assessments to justify training goals: Long-term training must be provided at schools with effective employment placement programs. Documentation of the placement statistics, when available, from the school, is required. Long-term training justification must include a comprehensive vocational evaluation. The vocational evaluation must address the injured worker s academic abilities and other relevant vocational factors in relation to the requirements of the training program and the targeted job. The vocational evaluation must provide a professional opinion regarding the injured worker s chances for success at training and resulting employment. Both long and short term training justification for a specific job goal must include a transferable skill analysis (TSA) and labor market assessment (see definitions below). A TSA does not need to be done for short term training for skills that can be applied to multiple job goals. But a labor market assessment is necessary for all short and long term training programs The labor market assessment must indicate that the targeted occupation(s) will be available in sufficient quantity upon completion of training program. Long and short-term training plans must address medical/ physical documentation which indicates the injured worker can perform the physical aspects of the training and the job tasks. Requirements for continuation of training plan: The vocational rehabilitation case manager must submit a copy of the injured worker s official grade report to the DMC at the end of each grade period to verify full time attendance and successful completion of course work. Successful completion of course work means documentation of receipt of a 2.0 grade point average while carrying a full time course load (generally 12 credit hours). January 2014 Final 4-72

77 If grades fall below a 2.0 or attendance is less than full time, the MCO may permit a one-term extension to allow injured worker to improve grades or increase course load. Note #1: Less than full time attendance may occur due to class scheduling situations that are no fault of the injured worker. If this occurs, the case manager must provide documentation to the MCO verifying this situation. In these situations, the case manager must also coordinate the injured worker s involvement in other relevant vocational activities to assure full time participation and continuation of living maintenance. Relevant vocational activities may include but are not limited to: conducting informational interviews, researching occupational opportunities via classified advertisements or the internet and preparing a resume or engaging in other appropriate job seeking skill. Note #2: If no courses are available for a one-term period, through no fault of the injured worker, and the injured worker is not participating in any other vocational activities, the rehabilitation plan may be interrupted for the term without payment of living maintenance compensation. The case manager must notify the DMC when this occurs. The CCT should facilitate the reinstatement of any other form of compensation when LM is stopped, if the injured worker is otherwise eligible. Definitions: Transferable skill -work tasks learned and performed on the job generally in the last 15 years that the injured worker can physically perform and would reasonably equip the job seeker to compete with other candidates. Transferable skills are generally not aptitudes or capabilities to learn a new skill that has never been performed on the job. The injured worker must have performed the work task for a sufficient duration to have acquired the skill. Transferable Skill Analysis (TSA) - an analysis of injured worker s residual skill in order to identify job tasks and occupations that can be safely performed. The TSA must specify the assessment method used (i.e. VDARE, OASYS, McCroskey, Skiltran, VocRehab.com) and results. The TSA is a tool, used along with other sources of information, to help determine an appropriate vocational direction. Labor market assessment for training plans- an analysis of the appropriateness of the targeted occupation based on labor market factors. Growth potential of the occupation in the local labor market must be documented along with salary estimates for new graduates. The assessment method used for the analysis (i.e. internet sources of labor market data, software programs, etc.) must be identified. January 2014 Final 4-73

78 33. Transitional Work Services (W0637) Transitional work services are provided at the work site by an occupational or physical therapist. The services primarily focus on using the injured worker s functional work tasks to progress the worker to a target job. Progressive conditioning, therapeutic exercises, training in safe work practices such as proper body mechanics and other work-site services may be used as part of the therapeutic program developed for that injured worker. Transitional Work services are separate and distinct from on-site Occupational or Physical Therapy services provided to injured workers at the work site. Transitional work services are usually within an overall Transitional Work program. A Transitional Work program is a work-site program that provides an individualized interim step in the recovery of an injured worker with job restrictions resulting from the allowed conditions in the claim. The overall program is often developed in conjunction with the employer, the collective bargaining agent (where applicable) and rehabilitation professional. The services should be provided within a specified time limit which is usually determined by the overall Transitional Work program guidelines, if there is a Transitional Work Program in place. If a program is not in place, the limits of the service would be defined by the vocational rehabilitation plan. When reporting Transitional Work services, the actual servicing provider must: identify services provided report injured worker s present status identify the goal and timeframes to achieve the goal identify the plan to achieve the goal with timeframes sign and date reports, specify credentials and license number report the time spent delivering services to injured worker Transitional Work services may be continued for a short time after the injured worker has been released to full-time, regular duty with MCO authorization to insure that the injured worker has a stable return to work. Transitional Work services should generally be provided in one to two hour time frames since some jobs repeat similar duties multiple times. Transitional Work services over two hours must be closely monitored by the MCO. Initial evaluations should not exceed three hours. An injured worker may receive Transitional Work services as part of the Presumptive Authorization program, as described in chapter 3 of this Guide. A C- 9 must be submitted prior to the implementation of services. The Presumptive Authorization program permits up to 10 sessions of Transitional Work services. A session within the Presumptive Authorization program is defined as one-hour of face-to-face contact with the injured worker, after the initial evaluation. Providers may be reimbursed for travel and mileage using fees and guidelines specified in W3050 Other Provider Travel and W3052 Other Provider Mileage as January 2014 Final 4-74

79 detailed in Vocational Rehabilitation Provider Travel in this section.34. Unallowed Conditions (billing codes based on services provided) Per Rule (B), unallowed conditions may be treated within a vocational rehabilitation plan, up to $2, maximum per claim, if these conditions are clearly aggravating the injury, preventing healing, impeding rehabilitation, or are barriers to return to work. If the service billed in this category is Adjustment Counseling, it must be concurrent with vocational rehabilitation plan services and not be the primary focus of the plan.. Medications are not reimbursed for unallowed conditions. There may be situations when this necessitates case closure until medical stability is achieved. Services must be provided by BWC certified or enrolled providers and are subject to the appropriate BWC provider fee schedule to the maximum allowed per claim unless the required service is not part of the BWC fee schedule. Inclusion on a vocational rehabilitation plan as an unallowed condition, does not automatically invalidate BWC fee schedule limits and conditions; i.e. if eye glasses are included as an unallowed condition, BWC would cover frames and lenses that meet the injured worker s medical or vocational need in accordance with the fee schedule, but generally not deluxe features such as designer frames, tint, etc Vocational Evaluation A vocational evaluation is a process, which gathers vocational information about an injured worker, usually through the use of real or simulated work, to assist in determining vocational direction. Transferable skill analysis is a necessary component of reimbursable vocational evaluations. The overall results are based on integrating the injured worker s physical capacities, medical, psychological, and vocational data with realistic vocational options which exist in the labor market. Note: A vocational evaluation may be used in the vocational rehabilitation plan development phase or later in a vocational rehabilitation plan when the vocational goal must change. In some situations, with DMC approval, it may be used in the initial vocational rehabilitation plan, as long as it is not the only plan service. This service requires detailed written documentation including time spent for assessment and reporting. Types of Vocational Evaluation: Vocational Screening (W0631) The vocational evaluator uses simple paper and pencil tests and transferable skill analysis (see definition in service Training/Skill Enhancement of this section) to make recommendations about the vocational goal of the injured worker. The evaluator relies primarily on the vocational interview, the physician reports of the injured worker s capacities, and the injured worker s self-reports of interests and job history. Vocational screening are conducted by a Certified Rehabilitation January 2014 Final 4-75

80 Counselor (CRC), Certified Disability Management Specialist (CDMS), Certified Occupational Health Nurse (COHN), Certified Rehabilitation Registered Nurse (CRRN),Certified Case Manager (CCM),Certified Vocational Evaluator (CVE) or a diplomat or fellow of the American Board of Vocational Experts (ABVE). Mileage, travel time and wait time may be billed by Vocational Evaluation Screening providers within BWC guidelines for Other Providers Travel, Wait and Mileage as detailed in the Vocational Rehabilitation Provider Travel in this list of Reimbursable Services. Comprehensive Vocational Evaluation (W0610) This is a process during which a certified vocational evaluator gathers vocational information about an injured worker, usually through the use of real or simulated work to assist in determining vocational directions. The vocational evaluator uses extensive client interview and vocational exploration, as well as, psychometric testing which may include aptitude, dexterity, academic and vocational interest testing. The overall result is a report that provides recommendations about the injured worker s options for returning to work, within a vocational rehabilitation program. The report is based on integrating the injured worker s residual transferable vocational skills with their current physical capacities, and realistic return to work options which exist in the current labor market. Only individuals with one (or more) of the following credentials who are also BWC certified as vocational rehabilitation case managers are able to provide comprehensive vocational evaluations: Certified Rehabilitation Counselor (CRC), Certified Vocational Evaluator (CVE), a diplomat or fellow of the American Board of Vocational Experts (ABVE) or a licensed psychologist. A vocational evaluation must address the injured worker s academic abilities and other relevant vocational factors in relation to the requirements of any proposed training program or targeted job. The evaluator must provide a professional opinion regarding the injured worker s chances for success at any proposed training and resulting employment. Mileage, travel time and wait time may also be billed by Comprehensive Vocational Evaluation providers within BWC guidelines for Other Providers Travel, Wait and Mileage as detailed in Vocational Rehabilitation Provider Travel in this section. Comprehensive vocational evaluations may be provided by BWC enrolled case manager interns who stated on the intern enrollment addendum form that they are qualified to take the CRC or CVE exam. The BWC Rehabilitation Policy unit may be contacted to verify if a specific intern may provide a comprehensive vocational evaluation. Vocational evaluations conducted by these interns must be authorized (signed off) by a BWC enrolled provider qualified to provide a comprehensive vocational evaluation. Enrolled interns use the W codes for comprehensive vocational and the January 2014 Final 4-76

81 Vocational Rehabilitation Provider codes for mileage, travel, and wait time, in this section of this chapter. The intern fees are paid by BWC at 85% of the rate associated with those codes except for mileage, which is reimbursed at regular rates. Note: All Vocational Evaluation and vocational screening providers must be BWC certified and/or enrolled and bill under their individual provider number, not the company they work for. 36. Vocational Exploration and Guidance (case management services must be provided during the Vocational Exploration and Guidance time period, and billed using vocational rehabilitation case management codes, see service listing in this section). Vocational Exploration and Guidance provides a period of time for the vocational case manager to accomplish both of the following: assist the injured worker in formulating a new vocational direction when it is determined that the injured worker cannot attain the physical requirements necessary for the previously identified vocational goal. The vocational rehabilitation plan must identify the specific methods used to clarify the vocational goal (i.e. face-to-face meetings with injured worker to review vocational interests or work history, job shadowing, informational interviews, registration at local or full service ODJFS One Stop Shops, research on types of jobs available in injured workers geographic area, identification of requirements for employment in readily available jobs, internet job search, volunteering opportunities, development of work trials and other RTW incentive programs. There must be evidence of active participation in these activities as per Rehabilitation Agreement (RH-1) during this period) obtain information from the physician of record or other evaluations to provide case direction after completion of a rehabilitation service and awaiting discharge information. Vocational Exploration and Guidance can only be provided by the assigned case manager. It cannot be offered as the first service in an initial vocational rehabilitation plan or following a Medical Interrupt. Maximum: of 4 weeks 37. Vocational Rehabilitation Case Management Vocational rehabilitation case managers develop and coordinate a variety of restorative services with the goal of assisting the injured worker to remain at work or to return to work. The actual time spent in providing these case management services is billed to the BWC surplus fund. Bills must report the specific date the activity was provided with each separate date of service reported on a separate line (line-by-line billing). Reports of activities must always identify the specific party contacted. Only January 2014 Final 4-77

82 BWC enrolled vocational rehabilitation case managers or vocational case manager interns may bill for vocational rehabilitation case management services. The individual who actually performs the service will be identified as the servicing provider. Vocational rehabilitation case management services provided by interns will be reimbursed at 85% of the case manager rates. Mileage for interns will be at regular rates. When vocational rehabilitation case management services are provided to injured workers with medical only claims with 7 or less days off work due to the allowed conditions in the claim as a Remain at Work (RAW) service, the focus is on keeping the injured worker on the job. RAW case management services use Z- codes instead of W-codes and the services are charged to the employer s risk. Note: All Vocational Rehabilitation Case Managers must be BWC certified and/or enrolled and bill under their individual provider number, not the company they work for. Vocational rehabilitation case manager phone calls or s The actual time spent sending and receiving phone calls and s as part of vocational rehabilitation case management duties. Billing exclusions: Voice mail messages beyond 1 unit (6 minutes) per call. (note: reimbursable voice mail messages must briefly address issue and be documented) Unanswered phone calls without voice mail message Courtesy copies (cc) of s Telephone or staffings within the vocational rehabilitation case management company Telephone or staffing between the vocational rehabilitation case manager intern and the supervising case manager Telephone calls or s regarding case management billing or reimbursement issues. Vocational Rehabilitation Case Manager Phone Call or to: Surplus-funded plan: Remain at Work (RAW): Injured worker or representative W3000 Z3000 Physician or representative W3001 Z3001 Employer or representative W3002 Z3002 BWC W3003 Z3003 MCO W3004 Z3004 Service provider W3005 Z3005 Other- (must specify) W3006 Z3006 January 2014 Final 4-78

83 Vocational rehabilitation case manager face-to-face meetings with The actual time spent in a face-to-face meeting to staff the vocational rehabilitation case, coordinate services or provide other necessary communication. Billing exclusions: Face-to-face supervision or staffings within the vocational rehabilitation company. Vocational Rehabilitation Case Manager Face-to-face meeting with: Surplus-funded plan Remain at Work (RAW): Injured worker or representative W3010 Z3010 Physician or representative W3011 Z3011 Employer or representative W3012 Z3012 BWC W3013 Z3013 MCO W3014 Z3014 Service provider W3015 Z3015 Other- (must specify) W3016 Z3016 Documentation review by vocational rehabilitation case manager The actual time spent reviewing medical, psychological and vocational information from reports, files and correspondence. Reports must specify type and source information reviewed. Surplus funded plan (W3020) RAW plan (Z3020) Initial assessment report writing vocational rehabilitation case manager The actual time spent writing the initial vocational rehabilitation assessment report. Report must include all relevant history and demographic information Surplus funded plan (W3025) RAW plan (Z3025) (Z3025): Plan writing by vocational rehabilitation case manager The actual time spent writing the initial or amended rehabilitation plan. Only time spent writing new/original information is reimbursable. January 2014 Final 4-79

84 Billing Exclusions: time spent cutting and pasting previously submitted information Surplus funded plan (W3030): Note: There is no corresponding Z- code for this service. Report writing by vocational rehabilitation case manager The actual time spent in writing vocational rehabilitation progress reports, labor market report, and closure report. Only time spent writing new/original information is reimbursable. Billing Exclusions: Time spent cutting and pasting previously submitted information Preparing or submitting billing documentation Surplus funded plan (W3035) RAW plan (Z3035)Letter writing by vocational rehabilitation case manager The actual time spent in developing/writing letters and correspondence including new/original information that is faxed. Billing exclusions: Time spent submitting the information (actual faxing) Surplus funded plan (W3036) RAW plan (Z3036): Labor Market Survey (LMS) by the vocational rehabilitation case manager (W3039) The actual time spent researching, developing and writing the LMS report when completed by the vocational rehabilitation case manager assigned to the rehabilitation plan. This code is only used when the vocational rehabilitation case manager is preparing an LMS independent of a vocational evaluation or career counseling report. Billing Exclusions: Time spent submitting the information (actual faxing) Transferable skill analysis (TSA) report writing by vocational rehabilitation case manager The actual time spent developing and writing the TSA report. This report is used to systematically analyze an injured worker s residual skill in order to determine jobs or job tasks that can safely be performed. Hard copy TSA report must be submitted and it must specify assessment method used (i.e. VDARE, OASYS, Skiltran, VocRehab.com) and results. Surplus funded plan (W3040) RAW plan (Z3040) January 2014 Final 4-80

85 Guidelines for attending physician appointments: A case manager must receive permission in advance from the injured worker and the physician s office when planning to attend a physician appointment with the injured worker. Guidelines for managing out-of-state cases: When an MCO is providing vocational case management services for an eligible injured worker whose residence is not Ohio, services must be provided by a case manager in close proximity to the injured worker. The out-of-state vocational case manager must become BWC enrolled to provide services under the direction of the Ohio MCO in accordance with chapter 4 guidelines. To prevent service delays, the out-of-state case manager may begin providing vocational rehabilitation case management services after case assignment and application for provider enrollment but before confirmation of enrollment. Only the assigned out-of-state case manager incurs case management charges. To expedite the enrollment process, the MCO completes and signs an MCO non-certified application (the short version of the provider enrollment application) and faxes it to their representative on the Provider Enrollment team. The MCO then follows-up with the MEDCO 13, HPP Application for Provider Enrollment and Certification, completed and signed by the provider. The MEDCO 13 is faxed to If there are delays in the enrollment of an out-of-state case manager, contact the BWC Rehabilitation Policy Unit for assistance. 38. Vocational Rehabilitation Provider Travel (includes Mileage, Travel time and Wait time) The following guidelines are effective to concur with the effective date of the vocational rehabilitation provider fee schedule rule For services provided on or after 1/1/04 the following codes for mileage, travel time and wait time must be used: Vocational Rehabilitation Case Manager Travel Time Vocational Rehabilitation Case Manager Travel Time is the actual time spent traveling to or from necessary vocational rehabilitation appointments by the Vocational Rehabilitation Case Manager (VRCM) to meet with the injured worker, employer, physician of record, or other vocational rehabilitation provider. In most cases, the VRCM may be reimbursed up to one hour of travel time each way for a necessary trip. If multiple appointments related to an injured worker s rehabilitation case occur on the same day within the same area, additional appropriate travel time may be charged. Surplus funded plan (W3045) RAW plan (Z3045) January 2014 Final 4-81

86 Vocational Rehabilitation Case Manager Wait Time Vocational Rehabilitation Case Manager (VRCM) Wait Time is the actual time spent waiting by the VRCM for injured worker, employer, physician of record, or other vocational rehabilitation provider. Wait time begins at the scheduled appointment time and may be billed for a maximum of 5 units per occurrence (30 minutes) including no shows. Surplus funded plan (W3046) RAW plan (Z3046) Vocational Rehabilitation Case Manager Mileage Reimbursement for actual miles traveled by the Vocational Rehabilitation Case Manager to meet with the injured worker, the employer, the physician of record, and other vocational rehabilitation providers. Mileage is reimbursed up to 65 miles one way. Mileage must be in accordance with the rehabilitation provider travel guidelines outlined below. If multiple appointments related to an injured worker s rehabilitation case occur on the same day within the same area, additional appropriate mileage may be charged. Surplus funded plan (W3047) RAW plan (Z3047) Other Provider Travel Time Other Provider Travel Time is the actual time spent traveling to or from necessary vocational rehabilitation appointments to meet with the injured worker or employer by a provider of the following services: job coaching, job club job placement, job development, job seeking skills training, vocational screening, vocational evaluation, ergonomic study, ergonomic implementation, job analysis, transitional work, and career counseling in person. Provider travel time is reimbursed in 6 minute units of service up to 10 units of service one way. If multiple appointments related to multiple injured workers occur on the same day within the same area, travel time should be prorated to the various claims. If during job development, multiple appointments related to an injured worker s rehabilitation case occur on the same day within the same area, additional appropriate mileage may be charged. Billing exclusions: Travel for the purpose of mailing vocational rehabilitation material. Travel in RAW plan for Job Club, Job Placement, Job Development, and Job Seeking Skills Training. Surplus funded plan (W3050) RAW plan (Z3050) Other Provider Wait Time January 2014 Final 4-82

87 Other Provider Wait Time is the actual time spent waiting for the injured worker by the job club facilitator, job coach, job placement specialist, job development specialist, job seeking skills specialist, vocational screening provider or the vocational evaluator. Wait time begins at the scheduled appointment time and may be billed for a maximum of 5 units per occurrence (30 minutes) including no shows. Billing exclusions: Wait time in RAW plan for Job Club, Job Placement, Job Development, and Job Seeking Skills Training. Surplus funded plan (W3051) RAW plan (Z3051) Other Provider Mileage Reimbursement for actual miles traveled to attend necessary meetings with the injured worker or employer by a provider of the following services: job coaching, job club, job placement, job development, job seeking skills training, vocational screening, vocational evaluation, ergonomic study, ergonomic implementation, job analysis, transitional work, and career counseling in person. Mileage is reimbursed up to 65 miles one way. If multiple appointments related to multiple injured workers occur on the same day within the same area, mileage should be prorated to the various claims. If during job development, multiple appointments related to an injured worker s rehabilitation case occur on the same day within the same area, additional appropriate mileage may be charged. Mileage must be in accordance with Rehabilitation Provider travel guidelines outlined below. Billing exclusions: Mileage in RAW plan for Job Club, Job Placement, Job Development, Job Seeking Skills Training. Surplus funded plan (W3052) RAW plan (Z3052) Rehabilitation Provider Travel Guidelines: If an MCO attempts to use a vocational provider who is in close proximity (65 miles each way/ one hour travel time each way) to the injured worker s home community and no vocational provider is available, the MCO must discuss this issue with the DMC and use the next closest provider. The next closest provider will be reimbursed in full for mileage and travel time. If an MCO chooses to assign a vocational provider who is not in close proximity to the injured worker s home community (65 miles each way/ one hour travel time January 2014 Final 4-83

88 each way) that provider will be reimbursed at a maximum of 65 miles each way and one hour travel time each way. Vocational rehabilitation case manager will be reimbursed in full for mileage and travel time to necessary employer and physician appointments if the injured worker s physician or employment site is located beyond 65 miles each way/ one-hour travel time each way from the injured worker s home community Travel time and mileage must be prorated, fairly apportioned to each claim served in the same day. For Job Placement and Development occurring in an approved vocational rehabilitation plan, additional appropriate travel time and mileage may be considered to be presumptively authorized if multiple appointments with the injured worker or employers related to an injured worker s rehabilitation plan occur on the same day within the same area. If the one-way, single appointment travel or mileage guidelines will be exceeded for a necessary trip to meet with an injured worker, employer or provider, DMC approval note is needed in order for the provider to be reimbursed as per special plan types. This does not apply if the one-way travel or mileage guidelines are exceeded based on multiple appointments in a trip. If multiple appointments related to multiple injured workers occur on the same day within the same area, travel time and mileage should be prorated to the various claims. 39. Work Adjustment, Facility Based (W0662), Employer Based (W0620) Work Adjustment is a specialized structured program that uses an employer s work site or a facility site to improve an individual s work abilities skills and behaviors. The injured worker is placed in training or work situations with the facility or employer site, their overall performance is assessed and specific measurable goals are developed to improve their performance to facilitate successful return to work. Work Adjustment services focus on both the specific job skills and the soft skills associated with employment; such as, stamina grooming and hygiene, attendance, punctuality, social skills, team work, problem solving, customer services and productivity. Weekly attendance reports and at least bi-weekly progress reports must be submitted to the MCO while the injured worker is participating in these services. The minimum level of participation expected is 3 days per week for 4 hours per day. Any services below this level should be staffed by the Vocational Rehabilitation Case Manager, the MCO and the DMC January 2014 Final 4-84

89 Work Adjustment Facility Based (W0662) Services occur within a facility and the injured worker is placed in training or work situations as part of this service. Work Adjustment Employer Based (W0620) Services occur within an employer s work site and the injured worker is placed in real work situations as part of this service. 40. Work Conditioning (W0710) A Work Conditioning programs consists of a progression of treatments using physical conditioning and job simulation/real work tasks to help the injured worker regain optimal function and return to work. The program goals should address improvements in cardiopulmonary, neuromuscular, musculoskeletal functions, education and symptom relief. When appropriate, the program addresses reasonable accommodations for the worker and adaptations to the work environment. The following are treatment indicators for a Work Conditioning program: Injured worker has no specific job to return to with a specific employer but a targeted job (or job group) goal has been identified. While the goal appears realistic, the injured worker does not currently have all of the physical tolerances for the targeted job. or, Injured worker has a specific job to return to with a specific employer, but does not currently have the physical capacities to safely return to the job and/or the employer does not have appropriate job accommodations. and, Injured worker does not require interdisciplinary services since the impediments to return to work are primarily physical. During the program the need for a limited number of individualized services such as OT, PT, psychological or nutritional services may occasionally arise. These services should be separately billed using CPT codes. Evaluations by OTs and PTs at the start of the program are considered part of the initial C-9 authorization for Work Conditioning and they are billed separately using the appropriate CPT code. 41. Work Hardening (See Occupational Rehabilitation #23 in this section) 42. Work Trial See the following section on Return to Work Incentive Services. January 2014 Final 4-85

90 II. Return to Work Incentives Return to Work Incentives include: Employer Incentive Contract, Gradual Return to Work, Job Modifications, On the Job Training, Tools and Equipment, and Work Trial. A case manager may use these services when negotiating a return to work. The intent of incentives is to offer them where needed, but not to offer them unless needed. It is expected that the employer will retain the injured worker at the successful completion of the incentive as long as business conditions allow. The vocational rehabilitation case manager is responsible for these negotiations with the employer, the injured worker and other parties where appropriate. It is important to note that incentives negotiated by the vocational rehabilitation case manager that do not meet policy guidelines and are not approved by the DMC may not be paid. It is therefore important, when there may be a doubt, for the case manager to staff the case with the MCO and DMC prior to negotiating terms with the injured worker or employer. Changes to the incentive must result in an amended plan and an amended contract (when applicable) which must be signed by all concerned parties. The case manager is responsible for maintaining contact with the employer and the injured worker to insure the appropriateness of the chosen incentive. Notes: The conditions and maximum limits for Return to Work Incentive Services in this section cannot be exceeded. RTW Incentive services for State Agency employers must be carefully assessed due to their payment of workers compensation expenses on a dollar for dollar basis. There may be circumstances in which they may be used to be enhance the return to work process, e.g. agency budget monies may not be readily accessible for unexpected expenses or the injured worker is returning to a different job/different employer, etc. These circumstances must be documented. These types of miscellaneous payments have recently been included in the logic for reserve suppression so no notification for manual reserve suppression is necessary. 1. Employer Incentive Contract (EIC) (no billing code used) An EIC is a method of returning an injured worker to work, while compensating an employer for a loss in productivity and hours worked due to the allowed conditions in the claim. EIC can be used for injured workers with temporary restrictions trying to return to regular job or to overcome fear of RTW and/or can it be used for injured workers with permanent restrictions who are learning how to perform a new job Living January 2014 Final 4-86

91 maintenance payments are terminated prior to the start of the Employer Incentive Contract (RH-19). The contract is set up so that as the injured worker s productivity increases, the payments to the employer decrease over the course of the entire incentive program. Reimbursements will include no overtime hours to be worked by the injured worker. The total reimbursement to the employer cannot exceed 50 percent of the injured worker s weekly wages and will not be extended beyond 13 weeks total per vocational rehabilitation referral. When negotiating an EIC, the vocational case manager must appropriately account for and document in the contract, the injured worker s use of holiday, vacation, personal or other leave. During the EIC, the vocational case manager is responsible for submission of the injured worker s wage information. An EIC requires the following be submitted to the DMC by the case manager: A specific release from the POR to the identified job; Documentation of how the injured worker s restrictions will result in a loss of productivity; A vocational rehabilitation plan narrative which includes: Written restrictions from the POR Whether the restrictions are felt to be temporary or permanent Discussion as to how the restrictions will affect the employer s operations (as per the employer) Discussion as to how the restrictions are being accommodated with this plan. Documentation regarding the employer s intent to maintain employment with the injured worker at the successful completion of the vocational rehabilitation plan. If the injured worker is in a job retention status, an EIC can be offered to the employer for the loss of productivity. An EIC will not be offered when: An injured worker has a full release to return to work and is returning to the original employer in the original job. A Gradual Return to Work program is in place. Requirements: Maximum: completed Employer Incentive Contract (RH-19), wage documentation (C94-A), and the employer s signature on the Vocational Rehabilitation Plan (RH-2). This service requires the employer s signature at the time the plan is submitted. 13 weeks total per vocational rehabilitation referral January 2014 Final 4-87

92 Reimbursement Method: VRCM and DMC verify that gross wages indicated on pay stubs or C94 match the amounts indicated on the EIC contract (RH-19). If gross wages match, the DMC sends an to the Claims Service Specialist to pay the reimbursement to the employer under Miscellaneous payments in V3. If the amounts do not match VRCM contacts the incentive employer and injured worker for an explanation of the discrepancy. This explanation must be discussed with the MCO and DMC who will determine what amount, if any, should be reimbursed to the employer. At that time it will also be decided if the employer incentive program should continue. If the decision is that the incentive contract should continue, the RH-19 must be revised and VRCM must submit a plan amendment to the MCO and DMC. If the MCO and DMC decide that the incentive contract should not continue, they will discuss whether an amended plan for other services should be developed or the rehabilitation file should be closed. Working Wage Loss. If the injured worker experiences a wage loss during the incentive plan, the DMC must help the injured worker apply for Working Wage Loss and work with the Claims Service Specialist to pay the injured worker during the contract period. If the rehabilitation plan was closed successfully and the injured worker was hired by the incentive employer for less than the higher of his or her AWW or FWW, and the injured worker received working wage loss during the incentive program, the DMC must approve Living Maintenance Wage Loss to begin the day after the incentive plan stopped. Note: These instructions assume that before the injured worker started an employer incentive contract, current (within the last 6 months) POR restrictions were on file. Living Maintenance Wage Loss: If the rehabilitation plan was closed successfully and the injured worker was hired by the incentive employer for less than the higher of his AWW or FWW, and the injured worker did not receive wage loss during the incentive plan, the DMC must approve Living Maintenance Wage Loss retroactively to the date the incentive program started. Note: These instructions assume that before the injured worker started an employer incentive contract, current (within the last 6 months) POR restrictions were on file. Unsuccessful Employer Incentive Contract: If the employer incentive contract did not result in employment for the injured worker, the DMC and MCO shall decide whether to approve the development of an amended plan or close the rehabilitation file. January 2014 Final 4-88

93 2. Gradual Return to Work (GRTW) (no billing code used) This program allows an injured worker to return to work on a graduated basis typically building up from the POR-specified hours per day to regular work status within 13 weeks total per vocational rehabilitation referral date. If the final job goal is a return to work at a position that is less than or greater than a 40-hour per week position, the work schedule may be adjusted proportionately, when necessary. The prescription from the POR must always specify the maximum number of hours per day and per week the injured worker can work. The POR must also review the vocational rehabilitation plan to ensure the process will be within the injured worker s restrictions and to provide the release to return to work. A GRTW plan must include documentation of the scheduled work hours and be signed by both the employer and the injured worker. The employer must agree to provide wage statements that specifically indicate the days and hours worked per pay period. The vocational rehabilitation case manager must provide the injured worker and employer with a clear understanding of their responsibilities during the GRTW plan, as outlined in these guidelines. The injured worker must immediately notify the vocational rehabilitation case manager if there are changes in the hours worked/wages earned as identified in the GRTW plan. Since reimbursements may be affected by these changes, the case manager must notify the DMC within 24 hours by fax, phone, or and make corresponding changes to the RH-24 form. Reimbursement for this service will not exceed the injured worker s initial living maintenance rate. Documentation of wages paid and hours worked per day must be submitted to the DMC. There are two types of gradual return-to-work reimbursement methods: Living maintenance method: The employer will pay the injured worker according to the hours worked as specified in the GRTW plan. The injured worker will receive living maintenance for hours not worked after submission of wage statements. Employer reimbursement method: The employer will pay the injured worker s full salary and be reimbursed for hours not worked as specified in the GRTW plan. The reimbursement type must be identified on the vocational rehabilitation plan and coordinated with the DMC. Requirements: Maximum: employer s signature on the rehabilitation plans (RH-2) and completed RH-24 form. This service requires the employer s signature at the time the vocational rehabilitation plan is submitted. 13 weeks total. January 2014 Final 4-89

94 Reimbursement Method: There are two types of GRTW reimbursement: 1. Living Maintenance (Injured Worker Payment) Method: The employer pays the injured worker for actual hours worked a full gross wage per hour and BWC pays the injured worker for hours not worked, not to exceed the injured worker s regular LM rate. Example: The injured worker s LM rate is $352 and the goal is a 40 hour week. The first week, the employer pays injured worker $10.00/hour x 20 hours or $ BWC then pays the injured worker $10.00/hour x 20 hours (not worked) or $ The DMC computes the LM amount to be paid to the injured worker, based on wage statements provided by rehabilitation case manager and injured worker. The DMC then sends that information to the CSS by so the CSS can pay it. 2. Employer Reimbursement Method: The employer pays the injured worker s full salary and is reimbursed by BWC for hours the injured worker did not work as specified in the GRTW plan. Example: The injured worker s LM rate is $ and the goal is 40 hour week. The first week, the employer pays the injured worker s full salary or $ The DMC asks the CSS to pay the employer $ out of miscellaneous payments on V3. Working Wage Loss: If the injured worker experiences a wage loss during the GRTW plan, the DMC must help the injured worker apply for Working Wage Loss and work with the Claims Service Specialist to pay the injured worker. Living Maintenance Wage Loss: Injured workers cannot retroactively get LMWL for the period during which they participated in a GRTW program, even if no LM is paid during the GRTW. However, if the rehabilitation plan was closed successfully and the injured worker was hired by the incentive employer for less than the higher of his or her AWW or FWW, the DMC will approve Living Maintenance Wage Loss to begin the day after the incentive plan stopped. Note: These instructions assume that before the injured worker started a GRTW plan, current (within the last 6 months) POR restrictions were on file. Unsuccessful Gradual Return to Work plan: If the GRTW plan did not result in employment for the injured worker, the DMC and MCO shall decide whether to approve the development of an amended plan or close the rehabilitation file. January 2014 Final 4-90

95 3. Job Modifications (W0663*) A Job Modification is the removal or alteration of physical barriers that may prohibit an injured worker from performing the essential job functions and prevent the worker from returning to work or maintaining current employment. It may change the physical demands of the job thus allowing the worker to perform their essential job functions without restrictions. Coordination among the employer, injured worker, physician of record and other professional is required to ensure the suitability of the modification. Job modifications require prior approval by BWC. A Job Modification is generally used for a permanent position and is not to be used with a Work Trial unless the modification is portable. The vocational rehabilitation plan must justify in the narrative the need for the Job Modification program and the anticipated costs. The assessments must also be available to justify the costs. Job Modifications must be staffed and authorized by DMC prior to final negotiations with the employer. Requirements: employer s signature on the vocational rehabilitation plan at the time the plan is submitted. * The W0663 code is used when reimbursing a Job Modification provider. The W0663 code is not used when reimbursing the employer for a Job Modification. When the employer provides the Job Modification, the DMC facilitates payments directly to the employer. 50% of the costs are reimbursed to the employer upon completion of the Job Modification. The remaining 50% is reimbursed after 90 days provided the injured worker continues working with that employer. Reimbursement Method: (Preferred Method) When the employer provides the Job Modification, the DMC facilitates payments directly to the employer in this way: The DMC sends an to the CSS asking that 50% of the costs are reimbursed to the employer upon completion of the Job Modification. The DMC reimburses the other 50% after 90 days provided the injured worker continues working with that employer. If reimbursing a Job Modification Provider, the W0663 code is used and the MCO processes the payment. January 2014 Final 4-91

96 4. On-the-Job Training (OJT) (billing codes for the specific services provided in the OJT may be used) On-the-Job training allows an injured worker to obtain or upgrade vocational skill through actual work experience. This training will be provided under the close supervision of an experienced person skilled in the job. The vocational rehabilitation plan narrative must be very specific as to the responsibilities of each participant and include: An explanation of the job goal and skill necessary to perform it; The POR s release; The training outline, a schedule of training costs and equipment; Signatures of the injured worker, the MCO, case manager and the employer/trainer. As a guideline, the On-the-Job Training program must not exceed the SVP (Specific Vocational Preparation) timeframes identified in the COJ (Classification of Jobs). The reimbursement to the employer must not exceed 50% of the injured worker s weekly wages when averaged over the OJT period. Note: The Trainer s Report form (RH-5 must be completed by the trainer every two weeks, shared with the injured worker and copied to the DMC. Requirements: employer s signature on the vocational rehabilitation at the time the plan is submitted. On-the-Job-Training Agreement (RH-6), wage documentation or a Wage Documentation form (C-94-A), completed RH-5 every two weeks. Reimbursement Method: The DMC checks the terms of On-the-Job Training Agreement (RH-6) against the Trainer s Report and the injured worker s pay stubs weekly or bi-weekly to make sure there are no discrepancies and that reimbursement does not exceed 50% of injured worker s weekly wages (while in the OJT). If there are discrepancies, these must be worked out by the vocational rehabilitation case manager and employer. The On-the-Job Training Agreement may have to be revised. If there are no discrepancies regarding the plan, the DMC computes the amount and sends an e- mail to the CSS to pay the employer out of Miscellaneous. 5. Tools and Equipment (W0665) This service provides tools and / or equipment (i.e., chairs, etc.) necessary for employment to the injured worker once he or she has obtained a job or has an approved rehabilitation plan that requires specific tools and equipment. Note: Prior to including the purchase of tools and equipment, the Vocational Rehabilitation Case Manager contacts the DMC and requests the DMC to January 2014 Final 4-92

97 determine if the requested item is available on the Tools and Equipment Tracking list. (List is located on the DMC page in COR. See process below.) The Vocational Rehabilitation Case Manager and injured worker sign the Loan/Release Agreement for Tools and Equipment (RH7) when the equipment is loaned to the injured worker during a rehabilitation plan and at the time of a successful return to work closure. A copy of this form is then submitted to the DMC along with the other closure documents by the MCO. The injured worker must be informed by the Vocational Rehabilitation Case Manager that the Tools and Equipment are the property of BWC and may be reclaimed should vocational rehabilitation plan prove to be unsuccessful If the injured worker is not working 90 days after return to work, the MCO determines the reason for the injured worker is not working and may reclaim the equipment. If the injured worker is seeking employment and needs the equipment to become employed, the MCO should discuss with the DMC, who may provide a loan extension. Reclaiming Tools and Equipment from an injured worker: If the injured worker does not remain employed for 90 days (non-successful return to work), the MCO is responsible for retrieving the equipment from the injured worker and transporting it to the local service office. The MCO notifies the assigned DMC via that the equipment will be recovered. The must include: model/serial numbers, size, weight, etc. anticipated date of arrival contact name and number (must be familiar with the item) The equipment must be packaged and labeled (contents and delivery location) and delivered to the local service office. There it will be accepted by the DMC who ships it to the BWC warehouse. In some situations it may be more convenient for the MCO to return an item to a different service office. The assigned DMC must make arrangements for processing the item with the DMC at the receiving service office. This should be done prior to the MCO s shipping of the item. A database will be maintained by BWC for returned equipment. Prior to the purchase of any new Tool/Equipment, the DMC must go to BWCWEB, Tasks and Tools, Claims tools, COR, DMC, Tools and Equipment Processing, Tools and Equipment Tracking to see what is available in the warehouse. If the item needed is listed the DMC can contact Rehab Policy who will make arrangements for the item to be delivered to the DMC. Forms Required: Tools and Equipment Loan Agreement (RH-7) 6. Work Trial (no billing code used) A Work Trial program permits an injured worker to attempt a return to work in the original job, or at a new job with either the same employer or a new employer. January 2014 Final 4-93

98 It allows an employer to test, evaluate and observe the worker at the actual job prior to hiring. BWC pays the injured worker living maintenance during this time. The case manager will monitor and document the injured worker s progress based on reports from the injured worker s direct supervisor at the workplace. Unless the modification is portable, Job Modification services cannot be used with Work Trial. Requirements: Maximum: Trainer Report Form (RH-5), Rehabilitation Plan (RH-2) with employer s signature at the time the plan is submitted. 4 week total per job, per plan Reimbursement Method: There are no reimbursements for this service unless portable job modifications are provided. If the work trial results in employment with the employer who offered the work trial, then the job modifications are reimbursed according to the guidelines for job modifications. If the work trial does not result in employment with the employer who offered the work trial, then the job modifications are removed according to the Tools and Equipment Policy and kept in the BWC warehouse until an injured worker needs them to RTW. Injured worker is paid Living Maintenance during a Work Trial and no wage loss payments are made. January 2014 Final 4-94

99 APPENDIX A MCO Vocational Rehabilitation Screening Tool MCO Name MCO Number MCO Vocational Rehabilitation Coordinator Number Phone MCO Contact: Phone Number: injured worker Name Claim # Referral: Internal External (Specify) 1. Is injured worker medically stable to actively participate in vocational rehabilitation services geared toward RTW? (THIS IS FROM A FILE REVIEW PERSPECTIVE) 2. Are there opportunities for TW or does alternative work exist at the injured worker s employer? 3. What is this injured worker s significant impediment for RTW? 4. Is this a re-referral for vocational rehabilitation? (Yes/No) If yes, what are the new or changed circumstances now making the injured worker feasible for vocational rehabilitation services geared toward RTW? 5. Other relevant information including: a. Has the injured worker s current (or previous) MCO ever denied physical restorative or vocational services in this claim? (specify) b. Has the Industrial Commission or Bureau ever denied any related services? c. Are there specific IME recommendations given for the related services? d. Briefly list any physical or vocational services provided in previous referrals: This injured worker appears to be eligible for vocational rehabilitation. Yes Please verify eligibility or ineligibility. No NOTE: Upon completion of initial feasibility review and receipt of positive eligibility verification the MCO must contact the injured worker to determine interest in vocational rehabilitation. An will then be sent to the DMC outlining the results of the contact and/or case manager assignment or closure. January 2014 Final 4-95

100 APPENDIX B REMAIN AT WORK PROGRAM According to Rule BWC shall take measures and make expenditures, as it deems necessary, to aid injured workers who have sustained compensable injuries or contracted occupational diseases to remain at work. 1. Remain at Work (RAW) Services Remain at work is the process of assisting injured workers in maintaining employment and avoiding lost time following an industrial injury. An injured worker s participation in RAW services is voluntary. 2. Eligibility An injured worker is eligible to participate in a remain-at-work program when: The injury results in a claim with 7 or less days off work due to the allowed injury which is certified by the employer or is allowed pursuant to a BWC or Industrial Commission order; and, It is documented by the employer, the injured worker or the Physician of Record (POR) that the injured worker is experiencing problems that are work-related and result from the allowed conditions in the claim. A C-9 from the POR or notes in the claim file by the Managed Care Organization (MCO) documenting contact with the employer, injured worker or POR would fulfill this requirement. 3. Referrals Anyone can refer an injured worker for RAW services; however, the Managed Care Organization (MCO) shall determine the need for services and document those needs in the notes they enter into the claim file and BWC website. The MCO will assess claim information to determine the type of RAW services appropriate for the claim. 4. Services Provided in a Remain at Work Program and Billing Codes RAW services include one or any combination of (but not limited to) the following: Transitional Work with PT/OT if focused on job progressions and offered on-site (W0637); Ergonomic study (W0644); Ergonomic implementation (W0513) Functional capacity evaluation (CPT code); Job analysis (W0645); Physical therapy, on-site (CPT code); Occupational therapy, on site (CPT code); Physical reconditioning (W0648); Gradual Return to Work (no billing code); January 2014 Final 4-96

101 On the Job Training (OJT) (billing codes for the specific services provided in OJT may be used); Job Modification (W0663 when reimbursing provider but not when employer provides the Job Modification); Tools and Equipment (W0665); and Remain-at-Work Vocational Rehabilitation Case Management (VRCM) (Z codes as listed in Chapter 4, Section Reimbursable Services Vocational Rehabilitation Case Management ). Remain at Work case management services are available but are not required to give it a Remain at Work status. Effective Providers of the following services: ergonomic study, ergonomic implementation, job analysis and transitional work may be reimbursed for travel and mileage using codes Z3050 RAW service Other Provider Travel and Z3052 RAW Service Other Provider Mileage. Note: Job Club, Job Search/Placement and Job Seeking Skills Training Services are not RAW services 5. Billing and RAW services Although the above services are traditionally associated with Surplus Fund (i.e. W codes), if offered as a RAW service, they will be charged to the employer s risk. The bureau will not reimburse an employer for remain at work services that are provided out of pocket by the employer. The MCO has an obligation to inform the employer if services are available via the BWC or RSC at no charge, such as ergonomic assessments or work station enhancements. Written information regarding those services must be sent to the employer prior to encumbering fees the employer will be expected to reimburse so that the employer may make an informed decision. If the claim is subsequently disallowed, BWC will not be responsible for the cost of RAW services that were provided. Note: By Report codes For vocational rehabilitation services reimbursed by report, the MCO must request a V3 note approving payment from Rehab Policy as there is not a DMC for medical only claims. The request must be sent via password protected and include the information from the Vocational Rehabilitation By Report Request template found as an appendix of Chapter RAW and Established Transitional Work Programs RAW programs are sometimes easier to provide in an established Transitional Work Program, but a Transitional Work Program does not have to be in place to offer RAW services. 7. Initiation of Services January 2014 Final 4-97

102 To insure payment for the services they provide, PT/OT providers must staff all RAW referrals with the MCO before the initiation of services. It cannot be assumed that Presumptive Approval is still available for the particular claim. (See section on Presumptive Approval in Chapter 3). A C-9 must be submitted prior to the implementation of PT/OT services. Vocational Rehabilitation Case Management services do not require C-9 s; however, MCO must give prior approval before these services are implemented. Vocational Rehabilitation Case Manager must staff the referral with the MCO at the initiation of the services and periodically to track injured worker s progress. 8. Remain at Work Services terminate when: a BWC, IC or court order subsequently disallows the claim, or injured worker declines to participate, or the claim changes to a lost time claim because the injured worker has missed 8 or more days due to the allowed conditions in the claim. However, in this situation, the injured worker may be referred, if eligible, for surplus funded services under vocational rehabilitation. [Note: if the claim changes to lost time solely due to a % PP award granted pursuant to Ohio Revised Code (A), the injured worker may complete those RAW services previously authorized; however, no new services may be authorized]. the lump sum settlement date becomes effective, or injured worker successfully maintains employment and no further services are needed. 9. Initial and Final RAW Report Initial: The MCO shall enter a note into the claim file which includes the problems the injured worker is experiencing on the job and the RAW services being provided. Final: Within 5 business days of notification of the completion of RAW services, the MCO must enter a note in the claim file. This note must indicate injured worker s work status, (i.e., released for full duty original job or full duty different job) and the date RAW service were completed. APPENDIX C January 2014 Final 4-98

103 Websites for Labor Market Information To check on job projections for specific occupations in geographic area: 1. Go to: To research training programs in injured worker s geographic area: 1. Go to: Enter a zip code and select an occupation. 4. You can then click on View Occupational Summary, View Job Postings in Selected Area, and/or Training Options To identify local employers: Go to 1. Search by location and industry. To locate One Stop Centers: 1. Go to: Click on map for the appropriate Ohio county. To check local job market: 1. Go to Job Search right column on Ohiomeansjobs home page Enter Keyword describing the target job goal and injured worker s location. January 2014 Final 4-99

104 APPENDIX D Vocational Rehabilitation By Report Code Template This is the preferred template for requesting review of BR codes for Vocational Rehabilitation, rather than using the Medical Policy BR/NC Code Template. Note: If there is already a BR Code Wxxx DMC Approval note for the service requested and the amount authorized in the DMC note is greater than the amount of payment the MCO is authorizing, you would simply ask to have the claim placed on review and send the date of the DMC BR Code note to MBA with your request. If there is already a BR Code Wxxx DMC Approval note for the service requested and the amount authorized in the DMC note is less than the amount of payment the MCO is authorizing, you will need to complete the template below and include the MCO s explanation of its approval of the greater amount. This information would be part of Please explain any special conditions that apply to the current request. When requesting vocational rehabilitation policy review of a retrospective or RAW Service By Report code, please be sure to include the following: Date of the request: IW Name: Claim Number: Servicing Provider Name: Service Code: Dates of Service: Amount Billed: Amount MCO authorizes: CIN #: (If the service has already been billed this should also be included.) Date the MCO authorizes the plan Location of the authorization (original plan or plan amendment) Please explain any special conditions that apply to the current request for a by report note. These requests should be submitted to the Rehab Policy Mailbox ([email protected]). January 2014 Final 4-100