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Chapter 4 – The Role of Vocational Rehabilitation in - OhioBWC.com

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					        TABLE OF CONTENTS



CHAPTER 4
THE ROLE OF VOCATIONAL REHABILITATION IN OHIO WORKERS’ COMPENSATION
Introduction .................................................................................................................... 4-1
    Remain at Work Programs ......................................................................................... 4-1
    Vocational Rehabilitation Program Coordinator ....................................................... 4-1
    Vocational Rehabilitation Laws, Rules, and Guidelines ........................................... 4-2
BWC, MCO and Vocational Rehabilitation Case Manager Responsibilities in Providing
    Vocational Rehabilitation ........................................................................................ 4-2
    BWC Responsibilities ................................................................................................ 4-2
      Customer Care Team .............................................................................................. 4-2
      DMC ....................................................................................................................... 4-3
      BWC Administrative .............................................................................................. 4-4
    MCO Responsibilities ................................................................................................ 4-4
    Vocational Rehabilitation Case Manager Responsibilities ........................................ 4-6
    Job Placement Specialist Responsibilities ................................................................. 4-7
    Injured Worker Responsibilities ................................................................................ 4-8
Vocational Rehabilitation Case Management ............................................................. 4-8
Qualifications ................................................................................................................... 4-8
Ethical Standards ............................................................................................................. 4-8
Case Management Compliance with Rehabilitation Policies .......................................... 4-9
Vocational Case Management Interns ............................................................................. 4-9
Intern Enrollment Process ................................................................................................ 4-9
Qualifications to Provide Intern Services ...................................................................... 4-10
Rehabilitation Recommendation Process .................................................................. 4-10
Vocational Rehabilitation Referral Process and Initial Feasibility Review ........... 4-11
    Vocational Rehabilitation Screening Tool ............................................................... 4-12
    Job Retention Referral ............................................................................................. 4-12
    Vocational Rehabilitation Referral Process: PPI/MMI............................................ 4-13
    Claim Reactivation Referrals ................................................................................... 4-13
Vocational Rehabilitation Eligibility Criteria .......................................................... 4-14
Vocational Rehabilitation Eligibility Process ............................................................ 4-17
Initial Feasibility Review ............................................................................................. 4-18
Referral Packets and Complexity Factor Forms ...................................................... 4-19
Plan Assessement/Development: Initial Contact and Interview, Assessment and
Progress Reports and Continued Feasibility Review ............................................... 4-19
Use of Interpreter Services During Vocational Rehabilitation................................ 4-23
Return-To-Work Hierarchy (Rule 4123-18-02) ........................................................ 4-25
Plan Elements including Plan Signature Requirements (prescriptions) ................ 4-25
Amended Vocational Rehabilitation Plan ................................................................. 4-30




April 2011 Final
        TABLE OF CONTENTS (continued)


Vocational Rehabilitation Plans and Reports for Job Placement Services ............ 4-30
DMC Authorization of Special Vocational Rehabilitation Plan Types................... 4-31
   RSC Coordinated Plans ......................................................................................... 4-32
   Plans Developed by Intern .................................................................................... 4-32
   Extension of Chapter 4 Reimburseable Service Guidelines ............................... 4-32
   Rehabilitation Injury Claims ................................................................................ 4-32
   Plans Needing Interpreter Services ...................................................................... 4-32
   Plans Using Return to Work Incentive Services ................................................ 4-33
   Plans With Services Paid “By Report” ................................................................ 4-33
Interruption to Vocational Rehabilitation Plan Services ......................................... 4-34
   Non-Medical Interruptions....................................................................................... 4-34
   Medical Interruption During Vocational Rehabilitation Plan.................................. 4-34
       MCO Responsibilities During a Medical Interruption....................................... 4-35
       BWC‟s DMC Responsibilities During a Medical Interruption.......................... 4-35
Case Management Follow-Up Services ...................................................................... 4-35
Vocational Rehabilitation Closure Procedure........................................................... 4-36
Vocational Case Closures Requesting Medical Hold................................................ 4-38
   MCO Responsibilities During a Medical Hold ........................................................ 4-38
   BWC‟s DMC Responsibilities During a Medical Hold ........................................... 4-39
Rehabilitation Services Commission/BWC Agreement ........................................... 4-39
Rehabilitation Injury Claims (RIC) ........................................................................... 4-40
Appeals .......................................................................................................................... 4-40
Living Maintenance Compensation ........................................................................... 4-41
Salary Continuation in Lieu of Living Maintenance Compensation ...................... 4-42
Suspension/Termination of Living Maintenance ...................................................... 4-42
Living Maintenance Wage Loss (LMWL) Compensation ....................................... 4-43
   Bureau Responsibilities ........................................................................................... 4-44
   Vocational Rehabilitation Case Manager Responsibilities with LMWL ................ 4-46
   DMC Responsibilities with LMWL......................................................................... 4-46
   Injured Worker Responsibilities with LMWL ......................................................... 4-47
Lump Sum Settlements and Vocational Rehabilitation Services ............................ 4-48
BWC Compliance and Performance Monitoring Unit ............................................. 4-49
MIRA Information related to Rehabilitation ............................................................ 4-49
Surplus Fund Expenditures ........................................................................................ 4-50
   Appropriate .............................................................................................................. 4-50
   NOT Appropriate ..................................................................................................... 4-50
Payment for Services ................................................................................................... 4-51
   Provider Enrollment Information ............................................................................. 4-51
   Provider Scope of Practice ....................................................................................... 4-51
   Reimbursement for Services .................................................................................... 4-51




April 2011 Final
        TABLE OF CONTENTS (continued)


Reimbursable Services................................................................................................. 4-52
   Automobile Repairs ................................................................................................. 4-52
   Biofeedback Training............................................................................................... 4-53
   Body Mechanics Education ..................................................................................... 4-53
   Child/Dependent Care .............................................................................................. 4-53
   Counseling ............................................................................................................... 4-53
   Employer Incentive Contract ................................................................................... 4-79
   Ergonomic Implementation ..................................................................................... 4-54
   Ergonomic Study ..................................................................................................... 4-54
   Exercise Equipment ................................................................................................. 4-64
   Gradual Return to Work........................................................................................... 4-81
   Injured Worker‘s Meals and Lodging ...................................................................... 4-55
   Injured Worker‘s Travel Expense ............................................................................ 4-55
   Injured Worker Travel, Meals and Lodging (Program Reimbursed) ...................... 4-55
   Interpreter Services (BWC Authorized) .................................................................. 4-56
   Job Analysis ............................................................................................................. 4-56
   Job Club ................................................................................................................... 4-57
   Job Coach ................................................................................................................. 4-57
   Job Modification ...................................................................................................... 4-83
   Job Placement and Development ............................................................................. 4-58
   Job Search ................................................................................................................ 4-59
   Job Seeking Skill Training ....................................................................................... 4-60
   Nutritional Consultation/Weight Control ................................................................ 4-61
   Occupational Rehabilitation – Comprehensive (Work Hardening) ......................... 4-61
   Occupational Therapy .............................................................................................. 4-62
   On-The-Job Training ............................................................................................... 4-84
   Physical Reconditioning, Unsupervised .................................................................. 4-62
   Physical Therapy...................................................................................................... 4-63
   Relocation Expenses ................................................................................................ 4-64
   Retraining Exercise Equipment ............................................................................... 4-64
   Situational Work Assessment .................................................................................. 4-64
   Tools and Equipment ............................................................................................... 4-85
   Training .................................................................................................................... 4-64
   Transitional Work and Work-Site PT/OT Services ................................................. 4-67
   Unallowed Conditions ............................................................................................. 4-68
   Vocational Evaluation (Screening and Comprehensive) ........................................ 4-68
   Vocational Exploration and Guidance ..................................................................... 4-70
   Vocational Rehabilitation Case Management .......................................................... 4-70
   Vocational Rehabilitation Provider Travel .............................................................. 4-74
   Work Adjustment ..................................................................................................... 4-77
   Work Conditioning .................................................................................................. 4-77
   Work Hardening....................................................................................................... 4-61



April 2011 Final
        TABLE OF CONTENTS (continued)
   Work Trial ................................................................................................................ 4-86
Return to Work Incentive Services ............................................................................ 4-78
   Employer Incentive Contract ................................................................................... 4-79
   Gradual Return to Work........................................................................................... 4-81
   Job Modifications..................................................................................................... 4-83
   On-The-Job Training ............................................................................................... 4-84
   Tools and Equipment ............................................................................................... 4-85
   Work Trial ................................................................................................................ 4-86

Appendix A – MCO Vocational Rehabilitation Screening Tool .............................. 4-88
Appendix B – Remain at Work................................................................................... 4-89
Appendix C –RTW Incentives Check Lists ............................................................... 4-92
Appendix D—Interpreter Services Approval/Denial letters .................................... 4-99
Appendix E—Labor Market Information through ODJFS websites ................... 4-102
Appendix F—By Report Template………………………………………………….4-103




April 2011 Final
                                                  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 #38in 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 4123-6-02.2(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.

             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


Spring 2011 Final                                    4-1
             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 e-mail at MCOUpdates@bwc.state.us within two business days of any change in this
             information.

      B.     Vocational Rehabilitation Laws, Rules, and Guidelines
             Sections 4121.61 to 4121.69 of the Ohio Revised Code and Rules 4123-18-01 to 4123-
             18-21 and applicable rules within chapter 4123-6 of the Ohio Administrative Code
             pertain to workers‟ compensation vocational rehabilitation. According to Rule 4123-18-
             01, 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 Disabililty Management
                  Coordinator (DMC).
             2.   Notify the DMC of external rehabilitation referrals.
             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 switching from temporary
                  total (TT) compensation to living maintenance (LM) compensation 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.).




Spring 2011 Final                                   4-2
             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.
             2.  Staff (telephonic or e-mail) 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.
             3.  Verify the MCO‟s initial identification of an injured worker's eligibility/non-
                 eligibility for vocational rehabilitation services and send letters with appeal
                 language. Add specific information regarding the reason for eligibility/non-
                 eligibility in letters and in V3 system notes.
             4.  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.
             5.  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.
             6.  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.
             7.  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.
             8.  Authorize via e-mail 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”.
             9.  Verify incentive payment calculations and notify the Claims Services Specialist
                 (CSS).
             10. Assist the MCOs in educating their internal staff, vocational rehabilitation case
                 managers and employers about vocational rehabilitation.
             11. Verify that factors identified on the Complexity Factor Form completed by the
                 vocational rehabilitation case manager and MCO are appropriately documented.
             12. 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.
             13. Inform the injured worker about living maintenance wage loss (LMWL) before
                 the rehabilitation file is closed.
             14. 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.
             15. Perform review of vocational rehabilitation plan costs for reasonableness and
                 appropriateness.



Spring 2011 Final                                 4-3
             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 rehabiliation 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 4123-18 and 4123-6 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 vocational rehabilitation case managers are appropriately credentialed
                 and knowledgeable of the vocational rehabilitation concepts listed in Vocational
                 Rehabilitation Case Manager (VCRM) Responsibilities below.
             5.  Insure that each VRCM is BWC certified.
             6.  Insure that all vocational rehabilitation providers included in a vocational
                 rehabilitation plan are enrolled as BWC providers
             7.  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.
             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.  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 e-mail) any MCO generated recommendation for
                 rehabilitation (not a referral from an external source) with the DMC prior to
                 making an actual referral.
             12. The MCO should discuss any IME recommendation for vocational rehabilitation
                 with the POR and IW. If they express interest, the recommendation should be




Spring 2011 Final                                  4-4
                    handled as an external referral. If not interested, the recommendation does not
                    have to be treated as a referral and given due process.
             13.    Determine the injured worker‟s initial eligibility for vocational rehabilitation
                    services and notify BWC immediately via e-mailed, password protected
                    vocational screening tool (or e-mail 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 4123-6-16
             21.    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. As needed, identify any additional factors
                    and provide location of documentation.
             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 or other vocational rehabilitation provider as needed; assure that
                    vocational rehabilitation case management and job placement documentation
                    submitted provides an adequate picture of the ongoing process and is submitted in
                    a timely manner; staff ongoing rehabilitation efforts with field case manager and
                    DMC and document progress in V3 notes; be flexible enough to adjust the
                    program as necessary including skill enhancement /training.
             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,



Spring 2011 Final                                   4-5
                    dismissing, or pending the plan or plan amendment due to insufficient
                    information, or otherwise acting in accordance with the provisions of Rule 4123-
                    18-05 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 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 IW,
                16.    foster relationships among MCO, DMC and IW so that plan services for the
                       IW 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-to-
                       work initiatives such as transitional work,
                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,



Spring 2011 Final                                  4-6
                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 job placement
                       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 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/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 area employers (know the employers, employment
                    websites and other resources in the targeted area for available job leads;
             2.     require that injured workers register with the Ohio Department of Job and Family
                    Services (ODJFS) full service offices for Ohio Workforce Systems (formerly
                    SCOTI) program;
             3.     provide leads/openings and/or assist with getting job interviews with employers,
                    placement agencies, and job fairs;
             4.     develop employer contacts in the local job market, provide written weekly
                    progress reports, maintain timely contact with vocational rehabilitation case
                    manager, provide necessary documentation to justify any plan extension or to
                    change vocational direction or to close the vocational rehabilitation case;
             5.     review the injured worker‘s record of Job Search and Contacts (RH10 logs);
             6.     constantly evaluate the need for skills enhancement or training programs
             7.     encourage and facilitate injured worker independence with the job search process
                    (finding jobs/leads/interviews on their own);
             8.     continuously evaluate feasibility;
             9.     identify RTW incentive opportunities and staff with field case manager
             10.    be knowledgeable of living maintenance wage loss benefits;
             11.    provide information about billing activity and units of service for each date of
                    service. No bundling of services by week.
             12.    document job development activities in the injured worker‟s geographic area.




Spring 2011 Final                                  4-7
             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 field 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 this
             chapter.

             Rule 4123-6-02.2(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)
                  American Board of Vocational Experts (ABVE).

             Ethical Standards for Vocational Rehabilitation Case Managers:
             The national associations of theseven 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.



Spring 2011 Final                                   4-8
             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 policy. 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 O 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.

             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
             www.ohiobwc.com. 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.




Spring 2011 Final                                   4-9
             Qualifications to provide intern services:
             Rule 4123-6-02.2(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. 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 4123-6-04.6. Written
                   Rehab Recommendations must be emailed 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 e-mail to the Rehab



Spring 2011 Final                                  4-10
                    Administrative Designee e-mail 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 e-mail 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 e-mail:
                    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 e-mail to appeal”.

      F.     Vocational Rehabilitation Referral Process and Initial Feasibility Review
             1.    Anyone can refer an injured worker for vocational rehabilitation, however
                   referrals from sources other than a party to the claim will be given due process
                   only when the IW and POR agree to participation in services. 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. 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). Whenever the MCO receives any vocational rehabilitation referral for an
                   injured worker, eligibility must be verified by BWC so that the bureau can
                   provide due process rights. Before the MCO sends a referral to BWC, attempts
                   should be made by the MCO to secure POR restrictions to facilitate the vocational
                   rehabilitation eligibility decision

             2.     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




Spring 2011 Final                                    4-11
                    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 e-mail 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.

             3.     When the MCO,BWC , IME or someone who is not a party to the claim believes
                    an injured worker could benefit from rehabilitation, the MCO and the BWC DMC
                    should staff the case with each other. The MCO and/or DMC should then contact
                    the POR and IW about services prior to actually making a referral. If the POR or
                    injured worker feel 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. If the POR and IW agree that rehab would be beneficial, due process
                    described in Section I of this chapter should be given.

             4.     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 e-mail it with the e-mail eligibility
                    verification request. The actual screening tool form does not have to be used.
                    When an e-mail is used in place of the form, it must provide all of the information
                    in the same order as the Screening Tool form.

             5.     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.



Spring 2011 Final                                    4-12
                    b. Percentage of permanent partial impairment award (%PP) or a
                       determination of maximum medical improvement (MMI)
                       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 4123-18-03, 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 4123-18-03(B)(6) states that a referral for vocational rehabilitation in an
                       inactive claim is processed in accordance with Rule 4123-3-15(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 C-9-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.




Spring 2011 Final                                   4-13
                       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
                       will contact Rehab Policy for further instructions. The DMC will coordinate
                       and work with the MCO and CSS to resolve and 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
             1.    To be eligible for rehabilitation services, the injured worker must meet the
                   following criteria:

                    a. a referred claim allowed by a BWC or Industrial Commission order with 8 or
                       more days off work 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, non-
                        working 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,




Spring 2011 Final                                  4-14
                    (b) The injured worker was granted a scheduled loss award (PP) under division
                        (B) of section 4123.57 of the Revised Code;

                       or,

                    (c) The injured worker received, or was awarded, a permanent partial award
                        (%PP) under division (A) of section 4123.57 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 continues to
                        have has job restrictions in the claim as documented by the physician of
                        record and 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 F. 5 (a) 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.



Spring 2011 Final                                   4-15
             5.     An injured worker is eligible for vocational rehabilitation services in a Job
                    Retention Status when currently working and experiencing a significant current
                    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 4123-18-5(E)(8),there can be no vocational rehabilitation in
                    settled claims, whether settled for medical or indemnity or both.

             7.     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

             8.     The injured worker must not be working on the date of referral, with the
                    exception of referral for job retention services.




Spring 2011 Final                                  4-16
             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 e-mail. 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 e-mail 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 Unit, 30 W. Spring St., level 20, Columbus,
                    Ohio 43215-2256.

             4.     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 e-mail of the vocational rehabilitation case
                    manager assignment and indicate if the case manager is an intern. The date of that
                    e-mail 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
                    4123-6-16 of the Administrative Code.




Spring 2011 Final                                   4-17
      I.     Initial Feasibility Review for Vocational Rehabilitation Services.
             1.      Per Rule 4123-18-03(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 4123-6-16 of the Administrative Code.




Spring 2011 Final                                   4-18
      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.
             Using the information provided, the rehabilitation case manager should begin completing
             the Complexity Factor Form, indicating where the complexities are documented.

             The Complexity Factor Form should be updated throughout the rehabilitation process
             with careful attention to where the factors are documented (referral packet, initial
             assessment, progress notes, closure report).

      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.




Spring 2011 Final                                  4-19
                    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:
                               1. Arrests/convictions
                               2. 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
                       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

             2.     Initial Assessment Report: The initial assessment report is primarily based
                    on the injured worker’s self-report at the initial interview along with file
                    information. The initial assessment report must be sent to the MCO and
                    DMC before any plan services are delivered.


Spring 2011 Final                                  4-20
             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.

             3.          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

                                                                         July              August         September             Duration
                                                         Start
                                Tasks                                                                                         (cumulative
                                                         Date
                                                                   1      15      31   1     15     31   1     15        30      days)

                         Case Manager Assignment          7/1     X                                                               1
                       Initial Assessment (IA) Report
                                                         7/31     -----------------X                                              30
                                    or Progress Report

                     Initial /Original Plan Submission
                           (due within 45 days of case   8/15                          ------X                                    45
                                 manager assignment)*


                     Subsequent Progress Report - 1st    8/30                               --------X                             60

                    Subsequent Progress Report - 2nd     9/30                                            ------------X            90


                  * or documentation of just cause
                  (see #8 below)


         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.

             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.


Spring 2011 Final                                                  4-21
                    The physician of record should provide written documentation of any restrictions
                    limiting participation in vocational treatment services or affecting the job goal.

             5.     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.

             6.     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.

             7.     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.




Spring 2011 Final                                   4-22
             8.      Integrating Information and Submitting the Plan:
                     The vocational rehabilitation case manager assesses and integrates all of the
                     information gathered and develops the initial individual written vocational
                     rehabilitation plan which is authorized by the MCO. If the VRCM 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.

                     The initial rehabilitation plan must be received by the DMC within 45 calendar
                     days of case manager assignment. On that date, written justification for any
                     exception to this time frame will be considered on a case-by-case basis by the
                     MCO and the DMC. Plan services begin after receipt of initial plan. 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.

             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 non-
                  enrolled interpreter in certain situations.


Spring 2011 Final                                   4-23
                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 and the 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;
                           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 S. 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 fee schedule (See Appendix C).
                The DMC will approve or deny requests for interpreter services in vocational
                 rehabilitation by using the Interpreter Services Approval/Denial Letter (See Appendix
                 D or in COR, DMC, Tips and Tools
                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.




Spring 2011 Final                                    4-24
                The DMC shall review the bill to verify the billed services are the same as those that
                 were requested, 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 re-
             employment 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
             of the hierarchy, when appropriate, to aid injured workers in successfully returning to
             work.

             The return-to-work hierarchy is outlined in Rule 4123-18-02(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.

             Note: Injured workers who wish to become self-employed shall be informed by the MCO
             of opportunities available through the Ohio Rehabilitation Services Commission (BVR
             and BSVI), the Federal Small Business Administration (e-mail at www.sba.gov), the local
             Ohio small business development center, the Ohio department of development, or other
             resources.

      N.     Vocational Rehabilitation Plan Elements
             The outcome of the plan development phase is an individualized written vocational
             rehabilitation plan which must be agreed upon by the injured worker, vocational
             rehabilitation case manager, employer (when required) and the MCO. 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, or, at a minimum, that the injured worker participates at least 3 days per
             week in plan activities. The vocational case manager must instruct the injured worker and
             treatment provider at the initiation of plan services to immediately notify the case




Spring 2011 Final                                   4-25
             manager of injured worker absences. The vocational 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.

             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.




Spring 2011 Final                                    4-26
         Services Requiring a POR      Services Requiring a POR        Services not Requiring a
               Prescription                     Release               POR Prescription or Release



         Code           Service       Code      Service               Code            Service
         CPT          Biofeed-back     No       Employer              CPT           Adjustment
         codes          Training      code      Incentive Contract    codes           /Career
                                                                                     Counseling
        W0638            Body          No       Gradual RTW           W0647         Auto Repairs
                       Mechanics      code
                       Education
        W0695           Exercise      W0660     Job Placement and     W0674          Child Care
                       Equipment                Development
        W0750         Nutritional       No      Job Search            W0644          Ergonomic
                        Consult        code                                            Study
         CPT            OT and        W0694     Long term training    W0645         Job Analysis
         Codes         Physical
                       Therapy
        W0637         Transitional     No       On-the-job            W0641           Job Club
                     Work Services    code      training
        W0648         Unsupervised    W0692     Short term training   W0672          Job Coach
                      Conditioning
        W0710            Work           No      Work Trial            W0663            Job
                      Conditioning     code                                        Modifications
        Initial 2        Work         W0650     Job Seeking Skill     Z0700         Relocation
          hr :       Hardening/Occ.             Training                             Expense
        W0702            Rehab

         Each
        add. hr:
        W0703
         CPT           Functional                                     W0635          Situational
         codes          Capacity                                                        Work
                       Evaluation                                                   Assessment
                                                                      W0665           Tools &
                                                                                     Equipment
                                                                                   (unless DME)

                                                                      W3000-      Vocational Case
                                                                       3036        Management
                                                                      W0610       Vocational Eval.
                                                                                  Comprehensive
                                                                      W0631          Vocational
                                                                                     Screening
                                                                      W0662            Work
                                                                                    Adjustment
                                                                                     (facility)


Spring 2011 Final                             4-27
             The initial signed rehabilitation plan must be received by the DMC within 45 calendar
             days of case manager assignment. On that date, written justification for any exception to
             this 45 day time frame will be considered on a case-by-case basis by the MCO and the
             DMC. Plan services begin after receipt of the initial plan. The DMC initiates living
             maintenance for the injured worker on the date the injured worker actually begins
             vocational plan services, as needed.

             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 relevant medical and vocational case history,
                           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 specific strategies to achieve that goal;
                         The clearly defined expectations of the injured worker and employer (as
                           applicable) when participating in vocational rehabilitation plan services
                           (i.e. specific responsibilities during incentive plans, Job Search plans,
                           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.

                    1. 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 field case manager).




Spring 2011 Final                                   4-28
                        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 email with an “email signature” is
                             not acceptable, unless the email 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 is
                           submitted to the DMC.

                          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
                           emailed 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.

                        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 30th date
                             after plan start date.
                           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.




Spring 2011 Final                                  4-29
      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.     Vocational Rehabilitation Plans and Reports for Job Placement and Job
             Development services:

                A vocational rehabilitation plan that includes job placement/development services
                must reflect that the injured worker will participate a minimum of 3 days per week. A
                release from the physician of record indicating that (s)he is supportive of the
                proposed job goal is required. The plan must be written and submitted timely.

                It is important to note the difference between job placement and job development
                services. A combination of these services must be provided. Job placement services
                assist injured worker in conducting an independent job search. Job development
                services entail working with employers to create jobs within injured worker‘s
                restrictions.

                The plan narrative must address, but will not be limited to the following:

                                  the targeted job
                                  attendance requirements
                                  the roles each participant is to provide
                                  staffing requirements
                                  discussion of each barrier and strategies to address them
                                  log sheets: how often, to whom, how they will be handled,
                                   signature requirements
                                  number of contacts required to be made and method to be utilized:
                                   phone, face to face, fax, internet (should be documented with
                                   printed copies from injured worker),US mail. meeting
                                   requirements: how often and with whom
                                  discussion on how the search will be expanded if necessary
                                  other agencies that may be involved
                                  consequences of lack of participation must be outlined
                                  report writing and submission requirements

                The plan must be reviewed with, and signed by, the injured worker to insure their
                understanding of the requirements and the injured worker must be given a copy.




Spring 2011 Final                                   4-30
               Job search plans should be closely monitored and amended to address injured
               worker‘s experience in job search. This will require weekly job search reports from
               the Job Placement/Job Development Provider.
              Reports for Job Placement Services
               A comprehensive narrative report for job services must include the injured worker‘s
               experience in job search and constructive advice provided by the job placement
               provider.

                The following features must be evidenced by the report:
                        barriers to return to work and strategy proposed to overcome them
                        changes to job search being made
                        timeframes of meetings, contacts
                        session length with injured worker should be noted
                        legible RH-10s
                        all job leads be specified as to the data source, time obtained, and verify
                           that the leads were for claim specific injured worker
                          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 worker‘s not completing assignments or contacts
                          injured worker‘s success as well as need for remediation

                    Note: All job placement 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 email.
             1.     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).
             6.     Return to Work Incentive Services plan including 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)



Spring 2011 Final                                   4-31
             Note: Any dispute concerning the DMC authorization of these special vocational
             rehabilitation plan types will follow the current DMC Rehab Recommendation process
             (see section F).
             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 email 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 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
                       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.




Spring 2011 Final                                  4-32
             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 4123-18-09)
                     “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 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.

                       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 e-mail
                        box including the information on the vocational rehabilitation by report


Spring 2011 Final                                   4-33
                       request template prior to requesting the claim be placed on review. (See
                       Appendix F)

                    ** 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 email.
                     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 4123-18-04(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
                    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.




Spring 2011 Final                                  4-34
                    a. MCO Responsibilities During a Medical Interruption:
                        Notify the DMC within 24 hours by phone, fax, or email 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-
             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.




Spring 2011 Final                                   4-35
             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 4123-18-21, 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)(1)(d)(2)). an eligible injured worker
             experiencing a wage loss during the follow-up period may be eligible for Working Wage
             Loss in accordance with Rule 4125-1-01, 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 IW 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;
                    (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.




Spring 2011 Final                                   4-36
             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 email. 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.

             7.     All closure reports should include the following elements, if applicable:
                    1. Injured worker‟s name;
                    2. Claim number;
                    3. Total length of service (including plan development phase and follow-up);
                    4. Total case costs:
                    5. Living maintenance costs;
                    6. Case management and services costs (including plan development phase and
                        follow-up);
                    7. Copy of the Physician of Record (POR) release;
                    8. Case closure explanation with return-to-work hierarchy level;


Spring 2011 Final                                   4-37
                    9. Job at time of injury;
                    10. Description of the job injured worker returned to including salary and hours
                        scheduled;
                    11. New employer;
                    12. Plan closure date;
                    13. 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 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
                    must sign a consent form for the bureau‟s DMC and treating physician to
                    communicate. 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. 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. If the treating physician happens to be the POR, no consent
                       form is necessary.


Spring 2011 Final                                  4-38
                    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.
                    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/non-
                       eligibility 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.

             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 43215-
                    2256 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


Spring 2011 Final                                  4-39
             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 counselor, 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. 4121.68, 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
                   If any party to the claim or provider disputes an MCO‟s vocational rehabilitation
                   decision, the ADR guidelines derived from Administrative Rule 4123-6 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 IW
                       Travel;
                     Rehab Recommendations on any vocational rehabilitation issue as described
                       in section E,1, of this chapter (appealed only by the MCO to BWC);



Spring 2011 Final                                   4-40
                    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
                    43215-2256 within 14 calendar days of receipt of the BWC decision.

             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 4123-18-03, 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 4123-18-03, 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 4123-18-04). Additionally, R.C. 4121.63 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
             4123-18-05 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 43271-
             0977. A note with a brief explanation must accompany the check so it may be deposited
             in the correct account.




Spring 2011 Final                                   4-41
      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.    Suspension/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 suspension or
             termination of living maintenance is made in accordance with Rule 4123-18-04. The
             decision to suspend 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 43215-
             2256 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



Spring 2011 Final                                    4-42
                    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

             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.

                    (a) 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.

                    (a) In determining whether an injured worker has voluntarily limited his or her
                        income, the bureau may review all relevant factors listed in Rule 4125-1-01,
                        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



Spring 2011 Final                                  4-43
                       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 will bureau shall review the criteria
                        set forth above to ensure that no voluntary limitation of income will occur the
                        job the injured worker wishes to change to 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.

                (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.

             1. Bureau Responsibilities:

                a. 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


Spring 2011 Final                                   4-44
                    while employed up to a maximum per week equal to the statewide average
                    weekly wage.

                b. The bureau shall ensure that injured workers who wish to become self-employed
                   shall be informed by the MCO of the opportunities available through the state
                   rehabilitation services commission, the federal small business, administration
                   office, the local Ohio small business development center, the Ohio department of
                   development, or other resources.

                c. 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 4123.34 of the Revised Code.

                d. 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 4123.56 of the Revised
                   Code.

                e. 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.

                    (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




Spring 2011 Final                                   4-45
                        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.

                f. 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.
                (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



Spring 2011 Final                                  4-46
                    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 43215-2256.

                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.

                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.



Spring 2011 Final                                   4-47
                    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 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.
                    i. if reemployed with a substantial variation in income, including self-
                       employment: 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.
                    j. if employed at the time of injury by a Self-Insured employer: submit all
                       LMWL documentation to the Self-Insured employer.

      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.




Spring 2011 Final                                   4-48
             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 4123-18 and 4123-6 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
             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%.




Spring 2011 Final                                   4-49
      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 4123-18-05.
                    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 4123-18-03.
                     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
                       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 non-
                       prescription 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 4123-
                       18-03(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.


Spring 2011 Final                                  4-50
      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) 621-1333.

                    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
                    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-1500. 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.




Spring 2011 Final                                   4-51
      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. 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. 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.

             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.

             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 www.kbb.com. 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.



Spring 2011 Final                                    4-52
                    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)
                    The Body Mechanics Education program instructs the injured worker on topics
                    such as spinal anatomy, the use of proper body mechanics, pacing techniques,
                    injury prevention, ways to manage pain and how lifestyles contribute to pain.

             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 5101:2-16-41.

                    Services are provided on an individual basis as determined by need with DMC
                    approval only.

             5.     Counseling (see CPT codes in CPT manual for psychotherapy procedures)

                    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: Assists injured workers in overcoming disability
                        related life changes, situational depression, and related return to work
                        concerns.

                       Career Counseling: Assists injured workers who require a substantial
                        change in vocation due to post injury physical and emotional issues.

                    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, LPCC, licensed psychologist, MD, or DO. If there is no psychological
                    allowance in the claim, counseling services (i.e. Career Counseling, Adjustment
                    Counseling) are reimbursed as an Unallowed Condition (see Unallowed
                    Conditions, service in this section).

                    All Careeer Counselors must be BWC certified and/or enrolled and bill under
                    their individual provider number, not the company they work for.



Spring 2011 Final                                  4-53
             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
                    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 this section)


Spring 2011 Final                                  4-54
             10.    Gradual Return to Work
                    See the section that follows on Return to Work Incentive Services.

             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 is
                    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 is
                    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.




Spring 2011 Final                                  4-55
                           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.

             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. Provided on a case-by-case 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” 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


Spring 2011 Final                                   4-56
                    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
                    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.



Spring 2011 Final                                   4-57
             19.    Job Placement and Development (W0660)
                    Job Placement 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, modified or created for the injured worker.

                    Job Placement Specialists 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. The
                    Job Placement Specialist sets job search procedures and goals, closely follows the
                    injured worker‟s progress, to 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.

                    In contrast, Job Development requires that a position be created. 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.

                    The specialized services of a Job Placement and Development specialist should be
                    provided only when the injured worker requires placement services above and
                    beyond the services provided by the vocational case manager during the Job
                    Search.

                    The job placement/job development provider and the VRCM must staff the case
                    to insure the best coordination of the case.

                    It is essential that the Job Placement and Development Specialist 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 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 placement contacts including employer name, date of
                    contact, and the specific outcome. The Job Placement and Development specialist
                    should be provided 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



Spring 2011 Final                                   4-58
                    the Job Search, the Job Placement and Development specialist must develop a Job
                    Search strategic plan in conjunction 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 workers‟s possession of
                    the expected skills for that job goal and based upon 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 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)

                    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: All job placement/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 Development services,
                    the Job Placement and 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.


Spring 2011 Final                                   4-59
                          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.

                    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 Skill 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 and 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.




Spring 2011 Final                                   4-60
                    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, or Job Placement and Development. JSST may be 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:



Spring 2011 Final                                  4-61
                              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 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


Spring 2011 Final                                   4-62
                    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.
                    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 $225.00 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 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.




Spring 2011 Final                                   4-63
                    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
                    determined by need up to $2,000.00 per injured worker, as per Rule 4123-18-08
                    (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:
                    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;
                    Short Term Training includes both training and skill enhancement from an
                    accredited academic, business or trade school that assists injured worker in



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                    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: Books and supplies necessary for the completion of training are covered
                    under the appropriate training code. 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).




Spring 2011 Final                                 4-65
                    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.




Spring 2011 Final                                   4-66
             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



Spring 2011 Final                                  4-67
                    specified in W3050 Other Provider Travel and W3052 Other Provider Mileage as
                    detailed in Vocational Rehabilitation Provider Travel in this section.
             34.    Unallowed Conditions (billing codes based on services provided)
                    Per Rule 4123-18-08(B), unallowed conditions may be treated within a vocational
                    rehabilitation plan, up to $2,000.00 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. If the service billed in this category is Career Counseling it can
                    be a stand alone service in some cases.

                    Medications are not reimbursed for unallowed conditions. There may be
                    situations when this necessitates case closure until medical stability is achieved.

             35.    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
                    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


Spring 2011 Final                                   4-68
                    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
                    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.


Spring 2011 Final                                   4-69
             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
                    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.




Spring 2011 Final                                   4-70
                    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 e-mails
                    The actual time spent sending and receiving phone calls and e-mails 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 e-mails
                     Telephone or e-mail staffings within the vocational rehabilitation case
                        management company
                     Telephone or e-mail staffing between the vocational rehabilitation case
                        manager intern and the supervising case manager
                     Telephone calls or e-mails regarding case management billing or
                        reimbursement issues

                    Vocational Rehabilitation Case       Surplus-funded plan:      Remain at
                    Manager Phone Call or Email to:                               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

                    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.


Spring 2011 Final                                 4-71
                      Billing exclusions:
                       Face-to-face supervision or staffings within the vocational rehabilitation
                          company.

                       Vocational Rehabilitation Case        Surplus-funded plan        Remain at
                    Manager Face-to-face meeting with:                                 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 e-mail 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.

                      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.



Spring 2011 Final                                    4-72
                    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):

                    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) and results.
                    Surplus funded plan (W3040)
                    RAW plan (Z3040)
                     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


Spring 2011 Final                                  4-73
                       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 614-621-1333. 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 2-15-10 to concur with the effective date of
                    the vocational rehabilitation provider fee schedule rule Rule 4123-18-09.

                    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 and mileage may be charged.

                    Note: 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.

                    Surplus funded plan (W3045)
                    RAW plan (Z3045)

                    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)




Spring 2011 Final                                  4-74
                    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 VRCM travel guidelines
                    outlined below.

                    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 placement
                    and development, job seeking skills training, vocational screening, vocational
                    evaluation, ergonomic study, ergonomic implementation, job analysis, and
                    transitional work. 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.

                    Billing exclusions:
                     Travel for the purpose of mailing vocational rehabilitation material.
                     Travel in RAW plan for Job Club, Job Placement and Development, and Job
                        Seeking Skills Training.

                    Surplus funded plan (W3050)
                    RAW plan (Z3050)

                    Other Provider Wait Time
                    Other Provider Wait Time is the actual time spent waiting for the injured worker
                    by the job club facilitator, job coach, job placement and 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 and Development, and
                        Job Seeking Skills Training.

                          funded plan (W3051)
                    Surplus
                    RAW plan (Z3051)




Spring 2011 Final                                  4-75
                    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 placement and development, job seeking skills training, vocational screening,
                    vocational evaluation, ergonomic study, ergonomic implementation, job analysis,
                    and transitional work. Mileage is reimbursed up to 65 miles one way.

                    Mileage must be in accordance with Rehabilitation Provider travel guidelines
                    outlined below.


                    Billing exclusions:
                     Mileage in RAW plan for Job Club, Job Placement and 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
                       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.




Spring 2011 Final                                  4-76
             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

                    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.


Spring 2011 Final                                  4-77
                                  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 in this section)

             42.       Work Trial
                       See the following section on Return to Work Incentive Services.

      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.

             Optional RTW Incentive checklists, which may be used by the DMC and/or the
             vocational rehabilitation case manager, are found in Appendix C of this chapter.

             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.




Spring 2011 Final                                    4-78
                     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
                      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.


Spring 2011 Final                                    4-79
                        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:         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.
                    Maximum:              13 weeks total per vocational rehabilitation referral



           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 e-mail 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.



Spring 2011 Final                                  4-80
           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.


             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 four (4) hours per day to a full-time 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 email and make corresponding
                    changes to the RH-24 form.




Spring 2011 Final                                   4-81
                     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:         employer‟s signature on the rehabilitation plan (RH-2) and
                                           completed RH-24 form. This service requires the
                                           employer‟s signature at the time the vocational
                                           rehabilitation plan is submitted.
                     Maximum:              13 weeks total.



           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 $200.00. BWC
               then pays the injured worker $10.00/hour x 20 hours (not worked) or $200.00.

                    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 e-mail 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 $352.00 and the goal is 40 hour week.
                    The first week, the employer pays the injured worker‟s full salary or $400.00. The


Spring 2011 Final                                   4-82
                    DMC asks the CSS to pay the employer $200.00 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.


             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.

                     An actual on-site job analysis or ergonomic study is necessary to begin the
                     process of Job Modification. The recommendation for the Job Modification
                     comes from the Occupational or Physical Therapist or Ergonomist who has
                     performed the job analysis/ergonomic study.

                     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.



Spring 2011 Final                                    4-83
                     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 e-mail 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.

             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


Spring 2011 Final                                    4-84
                    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
                    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 IW 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 has maintained employment for 90 days following closure,
                    the MCO releases the tools and equipment to the injured worker by signing the
                    appropriate section of the RH7. A copy of the RH7 is sent to the MCO and DMC.



Spring 2011 Final                                   4-85
                    If the injured worker is not working 90 days after return to work, the MCO
                    determines the reason for not working and may reclaim the equipment. If the
                    injured worker is seeking employment and needs the equipment to become
                    employed, the MCO 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 email that the equipment will be
                    recovered. The e-mail 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.
                    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:         Trainer Report Form (RH-5), Rehabilitation Plan (RH-2)
                                          with employer‟s signature at the time the plan is submitted.
                    Maximum:              4 week total per job, per plan


Spring 2011 Final                                  4-86
           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.




Spring 2011 Final                                 4-87
                                            APPENDIX A

                                          MCO Vocational Rehabilitation
                                               Screening Tool

           MCO Name ___________________________ MCO Number ___________________

           MCO Vocational Rehabilitation Coordinator _____________                Phone
             Number_____________

           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:

      This injured worker appears to be eligible for vocational rehabilitation.    Yes         No
           Please verify eligibility or ineligibility.


           NOTE: Upon receipt of positive eligibility verification the MCO must contact the injured
             worker to determine interest in vocational rehabilitation. An email will then be sent to
             the DMC outlining the results of the contact and/or case manager assignment or
             closure.




Spring 2011 Final                                         4-88
                                                  Appendix B


      REMAIN AT WORK PROGRAM
      According to Rule 4123-6-19 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);


Spring 2011 Final                                  4-89
                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 2-15-10 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 email and include the
         information from the “Vocational Rehabilitation By Report Request” template found as an
         appendix of Chapter 4.

      6.     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


Spring 2011 Final                                 4-90
             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 4123.57(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.




Spring 2011 Final                                    4-91
           APPENDIX C Employer Incentive Contract Checklist (no billing code)

           To be valid, the Employer Incentive Contract form (RH19) must contain:

           ____     Signatures from all three of the following: Injured Worker (injured worker), EOR
                     (Employer of Record), Vocational Rehabilitation Case Manager (VRCM)
           ____     Job title entered into number (1) on the form

           ____     Start date for the employment indicated in (2) on the form

           ____     Full gross hourly wage for the injured worker indicated in (2) on the form

           ____     Full gross weekly wage for the injured worker indicated in (2) on the form

           ____     Indication that the total number of weeks is less than or equal to 13 weeks

           ____     A schedule for how, as injured worker‟s productivity increases, the payments to
                    the employer decrease over the course of the entire incentive program

           ____     Indication that total reimbursement to the employer is less than or equal to 50% of
                    the injured worker‟s weekly wages

           ____     Period of reimbursement, employer contribution (% and amount paid) and BWC
                    contribution (% and amount paid) is indicated on the chart

           ____     Accurate computation

           ____     Calculated reimbursement to the employer excluding overtime hours

           ____     An account of injured worker‟s use of holiday, vacation, personal or other leave

           ____     Note that Living maintenance payments stop when the Employer Incentive
                    Contract begins

           Vocational Rehabilitation Case Manager is required to submit the following to the
              DMC:

           ____     A specific release to the identified job and job restrictions from the POR with an
                    indication whether job restrictions are temporary or permanent.

           ____     injured worker‟s wage statements or C94-A forms throughout the incentive plan




Spring 2011 Final                                   4-92
           Vocational Rehabilitation Plan that includes:

           ____     A plan outlined by field case manager to insure successful RTW

           ____     Evidence that injured worker does not have a full release for work to the original
                    job with the original employer

           ____     Documentation that there is no Gradual Return to Work program in place

           ____     Documentation of circumstances if employer is a state agency

           ____     Documentation of how the injured worker‟s restrictions will result in loss of
                    productivity and affect the employer‟s operations (as per 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.

           ____     Statement whether injured worker is experiencing a wage loss during the
                     incentive program based on his AWW or FWW.

           ____     Incentive employer‟s signature on the rehabilitation plan when the plan is
                    submitted (RH-2)




Spring 2011 Final                                  4-93
           Gradual Return to Work Checklist (no billing code used)

           To be valid, the Gradual Return to Work Plan narrative must contain:

           ____     Documentation that the injured worker is able to work at least 4 hours day at the
                    beginning of the program if regularly employed in a full time job and 50% of
                    normal work day if regularly employed in a part time job.

           ____     Reasonable expectation that injured worker will be able to increase to regular
                    work status within 13 weeks

           ____     POR prescription specifying the maximum number of hour per day and per week
                    the injured worker can work

           ____     Indication that POR reviewed the vocational rehabilitation plan to insure the
                    process is within injured worker‟s restrictions and provided the release for work

           ____     Documentation of scheduled work hours

           ____     Injured worker‟s and the employer‟s signatures on the rehabilitation plan (RH-2)
                    and Gradual Return to Work Agreement form (RH-24)

           ____     An outline of the injured worker and employer‟s responsibilities during the
                    GRTW plan.

           ____     Injured worker agreement to immediately notify the vocational rehabilitation case
                    manager if there are changes in the hours worked/wages earned in the GRTW
                    plan.

           ____     Vocational rehabilitation case manager agreement that once notified of changes
                    in hours or wages earned in GRTW plan, he/she must notify the DMC within 24
                    hours by phone, fax, or e-mail and make corresponding changes to the RH-24
                    form

           ____     Acknowledgment that reimbursement for this service must stay at or below the
                    injured worker‟s initial living maintenance rate

           ____     Statement from vocational rehabilitation case manager and injured worker that
                    they accept responsibility for getting wage statements to the DMC




Spring 2011 Final                                  4-94
           Job Modifications Checklist

           Vocational rehabilitation case manager must meet the following requirements for Job
           Modifications:

           ____ An actual on site job analysis performed by an occupational or physical therapist, or
                ergonomist.

           ____ Verification from the employer (for whom the job modification is intended), injured
                worker, POR and other professionals that the modification is suitable.

           ____ Justification of the need for the job modification and costs in the narrative of the
                rehabilitation plan.

           ____ Approval from the DMC for job modifications prior to negotiations with the
                employer.

           ____ Employer‟s (for whom the job modification is intended) signature on the vocational
                rehabilitation plan (RH-2) at the time the plan is submitted.




Spring 2011 Final                                  4-95
           On the Job Training (OJT) Checklist (billing codes for the specific services provided in
           the OJT may be used)

           The narrative of the rehabilitation plan must include the following:

           ___ An explanation of the job goal and skill to perform it.
           ___ Training outline, a schedule of training costs and equipment
           ___ Indication that the OJT is written for less or same amount of time listed in the
               Specific Vocational Preparation (SVP) timeframes identified in the Classification of
               Jobs (COJ).
           ___ Verification that reimbursement amount will not exceed 50% of injured worker‟s
               Weekly wages when averaged over the OJT period.
           ___ Statement regarding whether injured worker is suffering a wage loss as compared to
               his job of injury. If injured worker is suffering a wage loss, he should make a choice
               about applying for working wage loss during his training program or waiting until his
               rehabilitation file is closed and applying for retroactive living maintenance wage loss
               from the date he RTW.
           ___ Attached POR release

           The following signatures are required:

           ___ Signatures of the injured worker, the MCO, case manager and the employer/trainer
               are on the On-The-Job Training Agreement (RH-6)
           ___ Employer‟s signature on the vocational rehabilitation plan at time plan was submitted
               (RH-2)

           Required forms that the vocational rehabilitation counselor must submit to the DMC:

           ___   On-the-Job Training Agreement (RH-6)
           ___   Trainer‟s Report (RH-5) every 2 weeks.
           ___   Wage documentation in form of pay stubs for the OJT
           ___   RH-2 with MCO, injured worker, Employer, VRCM signatures




Spring 2011 Final                                   4-96
           Tools and Equipment (W0665) Checklist

           Tools and Equipment Requirements:

           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 Rehabilitation Policy who will make arrangements
           for the item to be delivered to the DMC. DMC will make arrangements for the item(s) to be
           delivered to the injured worker.

           If the requested item is not in the warehouse, the field rehabilitation case manager and
           MCO will identify the provider of the tools and equipment. The MCO will enroll the
           provider if the provider is not already enrolled with BWC by submitting a MEDCO 15 to
           Provider Relations.

           Once the item is purchased, a C19 needs to be completed by the MCO and submitted to
           Provider Relations. It should be noted on the C19 whether the provider or the injured
           worker was to be paid.

           In order for the injured worker to keep the tools provided during a vocational rehabilitation
           plan, the vocational rehabilitation case manager and MCO must submit the following to the
           DMC:

           _____    MCO and injured worker signatures on the Loan/Release agreement for Tools and
                    Equipment (RH-7) in the “Loan Agreement” section, as soon as the items are
                    provided to the injured worker.

           _____    Verification that the equipment cost was less than $2,250.00

           In order for the injured worker to keep the tools after a successful return to work as a result
           of a rehabilitation plan, MCO must verify that the injured worker was working 90 days
           after return to work. If injured worker is still working, the MCO completes the RH-7
           releasing the equipment to the injured worker.

           If the injured worker is not working 90 days after return to work, the MCO determines the
           reason for 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
           DMC who may approve a loan extension.




Spring 2011 Final                                    4-97
           Work Trial Worksheet (no billing code used)

           Requirements:

           Vocational rehabilitation case manager must submit the following:

           ____     Rehabilitation Plan (RH-2) signed by the employer who is offering the work trial.

           ____     Verification that the maximum time for the work trial is 4 weeks per job, per plan

           ____     Confirmation that, if job modifications are included, they portable

           ____     Indication that injured worker is receiving Living Maintenance during the work
                    trial and no salary from the employer

           ____     Completed Trainer Report Form (RH-5) at the end of the 4 week program




Spring 2011 Final                                  4-98
                                                   APPENDIX D

                              INTERPRETER SERVICES APPROVAL/DENIAL LETTER

                    (Use for Approval/Denial of Requests for Interpreter Services)

           Dear Injured Worker:

           BWC has received your request for the use of an interpreter to assist in your claim.


           (Insert for Approval of Interpreter Services)
           We have approved the use of an interpreter to assist you at insert service description and the
           date of service.

         Examples of Service Description. – Industrial Commission Hearings, medical specialist
         consultation, medical specialist examination, participation in vocational rehabilitation plan,
         catastrophic injury claim, routine office visits, durable medical equipment (DME) suppliers,
         physical or occupational therapy.

           The provider of the interpreter services should submit the request for payment to BWC by
           completing a Service Invoice (C-19). To access the form follow the steps listed below.

                 Visit ohiobwc.com.
                 Click on Medical Providers.
                 Click on the Forms link on the left-hand side of the page.
                 Click on the C-19 link.

           Send the completed C-19 to BWC to the attention of the assigned claims service specialist. BWC
           will make payment according to the BWC Fee Schedule for Interpreter Services.


           (Insert for Denial of Interpreter Services)
           We have denied your request for insert service description and the date of service because insert
           denial reason.

         Examples of Reasons to Deny Services - Routine office visits, durable medical equipment
         (DME) suppliers, hospital visits, excessive physical or occupational therapist visits.

           If the injured worker, the employer or their respective representatives disagree with this
           decision, they may file a Motion (C-86) with BWC. The party filing the C-86 should include
           any new evidence to be reviewed by BWC. The evidence BWC considered in making this
           decision is available upon request.

           cc Interpreter Service Provider
              Injured Worker Rep
              Employer Rep
              Any other provider involved with request
              MCO


Spring 2011 Final                                       4-99
                                                Billing instructions

      Bills must be submitted on BWC’s C-19 Service Invoice that can be found on BWC’s website
      www.ohiobwc.com under medical providers, forms. Instructions for completing the form can also be
      found on BWC’s website, under medical providers, services, billing and reimbursement manual,
      chapter 4. The following billing codes must be used:

        Code                                            Description
       W1930     Interpreter services, per 15 minutes. Each 15 minutes is equal to 1unit of service. This
                 represents the actual time spent providing face to face interpreter services.

       W1931     Interpreter wait time, per 6 minutes, maximum of 30 minutes per date of service,
                 including wait time if injured worker does not show up for appointment. Interpreter wait
                 time begins at the scheduled appointment time. Each 6 minutes is equal to one unit of
                 service.

       W1932     Interpreter travel time, per six minutes, including travel time if injured worker does not
                 show up for appointment. Each 6 minutes is equal to one unit of service. This
                 represents the actual time spent traveling to or from authorized interpreter
                 appointments

       W1933     Interpreter mileage, per mile. Each mile is equal to 1 unit of service.


      BWC providers are expected to bill their usual and customary rate. Reimbursement will be
      at the provider billed amount or at the BWC fee, whichever is lower.

                 The provider of the Interpreter Service must submit the request for payment on a
                  Service Invoice, C-19. The C-19 is sent to BWC to the attention of the assigned
                  DMC. Payment will be made according to the BWC Fee Schedule for Interpreter
                  Services.
                 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).




Spring 2011 Final                                         4-100
           Sample Interpreter C-19




                The DMC will approve or deny requests for interpreter services in vocational
                 rehabilitation by using the Interpreter Services Approval/Denial Letter which can be
                 found in COR, DMC, Tips and Tools.


Spring 2011 Final                                  4-101
                                            APPENDIX E

           Websites for Labor Market Information

           To check on job projections for specific occupations in geographic area:

           1. Go to: http://ohiolmi.com/proj/Projections.htm


           To research training programs in injured worker‘s geographic area:

           1. Go to:
           2. http://ohiolmi.com/asp/Career/SelectOcc.asp?Z=43215&E=E5001Central%20Ohio

           3. 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 http://www.careerinfonet.org/employerlocator/employerlocator.asp?nodeid=18
           1. Search by location and industry.


           To locate One Stop Centers:

           1. Go to: http://jfs.ohio.gov/owd/wia/wiamap.stm Click on map for the appropriate Ohio
              county.
           To check local job market:

           1. Go to ―Job Search‖ right column on Ohiomeansjobs home page
              https://ohiomeansjobs.com/omj/. Enter Keyword describing the target job goal and
              IW‘s location.




Spring 2011 Final                                  4-102
                                                APPENDIX F

           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 above 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
           (Policy.R.1@bwc.state.oh.us).




Spring 2011 Final                                  4-103

				
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