Current through Register Vol. XLI, No. 45, November 8, 2024
Section 85-15-5 - Identification of Rehabilitation Candidates; the Rehabilitation Assessment/ Evaluation Process5.1. The Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, may, in its sole discretion, determine whether a claimant would be assisted in returning to suitable gainful employment with the provision of rehabilitation services.5.2. The Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, may authorize a rehabilitation evaluation by a qualified rehabilitation professional of its sole choosing to determine whether physical and/or vocational rehabilitation services are appropriate for an injured worker. No provider is entitled to referrals from the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable. The Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, is in no way required to adopt any referral method or system designed to include any or all of the vocational rehabilitation service providers or qualified rehabilitation providers, and the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, has the sole discretion in the assignment of any referrals for an evaluation.5.3. The rehabilitation evaluation process is comprised of a series of steps, as set forth in the following subsections. a. Once referred to a vocational rehabilitation service provider or qualified rehabilitation professional, a qualified rehabilitation professional shall conduct a rehabilitation evaluation. In doing so, a qualified rehabilitation professional must: 1) conduct a personal interview of the injured worker; 2) contact, by telephone or otherwise, the injured worker's employer to ascertain return to work options and otherwise discuss the case; 3) obtain necessary input from the injured worker's attending physician and other treatment providers; and 4) analyze information about the injured worker's medical, educational, vocational, social, legal, and economic circumstances, including present physical and mental ability to participate in vocational rehabilitation services. The evaluation may also include additional vocational testing if the qualified rehabilitation professional opines that the testing is warranted in order to provide a full evaluation and the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, preauthorized the additional testing. The qualified rehabilitation professional must then decide and report in the form of a rehabilitation evaluation report, the format of which and method of transmission of which shall be approved by the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, as to whether the injured worker is likely to benefit from vocational rehabilitation services based upon the rehabilitation evaluation. The qualified rehabilitation professional must also report whether or not the evaluation was complete, and if not why not, and whether the injured worker, the injured worker's employer, or the injured worker's attending physician and other treatment providers cooperated in the process and must state the facts that form the basis of the conclusion.b. The qualified rehabilitation professional must issue the rehabilitation evaluation report to the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, with copies to the parties within sixty (60) days of receipt of the referral. A proposed rehabilitation plan, signed by the qualified rehabilitation professional and preferably the injured worker, the injured worker's employer, may be included with the rehabilitation evaluation report. Upon receipt, the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, may approve the plan as submitted, request modifications to the plan, or request plan development. Failure to provide the rehabilitation evaluation report within sixty (60) days of receipt of the referral shall cause a 10% reduction in the agreed to fee due and owing the vocational rehabilitation service provider or the qualified rehabilitation provider. Failure to provide the rehabilitation evaluation report within ninety (90) days of receipt of the referral shall cause a 20% reduction in the original agreed to fee due and owing the vocational rehabilitation services provider and/or the qualified rehabilitation provider. Finally, failure to provide the rehabilitation evaluation report within one hundred twenty (120) days of receipt of the referral shall result in no payment for the referral and shall require the vocational rehabilitation services provider and/or the qualified rehabilitation provider to immediately return the referral to the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable,.c. The purpose of a rehabilitation plan is to clearly identify the return to work objectives and to describe action steps to assist the injured worker in returning to suitable gainful employment. The following standards apply.d. The injured worker is an active participant in rehabilitation plan development.e. The plan must be signed by the injured worker and the qualified rehabilitation professional for the plan to be implemented. Failure to sign a plan the injured worker has actively participated in developing, without good cause, as determined in the sole discretion of the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, shall cause the suspension of all benefits payable to the claimant until such time as the plan is signed. The claimant is not entitled to the lost benefits upon signing the plan. The Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, shall reject the proposed plan based upon the claimant's failure to cooperate if the claimant refuses to sign the plan and will thereafter, within fifteen (15) days of such acceptance or rejection issue a protestable order within fifteen (15) days.f. The plan must clearly outline the specific goals and actions required to achieve the goals.g. The plan must identify the respective responsibilities, if any, of the injured worker, the employer, the physician, the qualified rehabilitation professional, the Commission, Insurance Commissioner, private carrier or carriers, and other parties involved in the claim.h. The time frames for completion of the plan must be specified.i. The qualified rehabilitation professional must provide a plan justification explaining the need for rehabilitation services.j. The qualified rehabilitation professional must provide plan rationale explaining how the goal was selected.k. The qualified rehabilitation professional must describe placement prospects and earnings potential, if appropriate.l. Criteria for completion and termination of the plan must be fully defined.m. Costs associated with the services to be provided and the periods of temporary indemnity are to be listed in the plan.n. The plan must be served upon the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, and all parties to the claim by the qualified rehabilitation professional.o. A rehabilitation plan must require that all vocational rehabilitation services be delivered by providers who are qualified rehabilitation professionals. Except with the prior consent of the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, no other providers may deliver vocational rehabilitation services to an injured worker under an approved rehabilitation plan. To the extent it is economically and otherwise feasible, providers who are located in the injured worker's geographic area are to be given preference. In-state providers and out-of-state providers are both to be compensated pursuant to section 10 of these rules.p. A rehabilitation plan that provides for vocational retraining must give preference to schools and training facilities located in the injured worker's geographic area, thereby reducing the need for the injured worker to travel extensively or to relocate. A plan may be denied by the Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, if it concludes, in its sole discretion, that the plan requires the injured worker to travel excessively or to locations unreasonably distant from his or her home.q. Any rehabilitation plan developed and implemented under this rule is subject to the seniority provisions of a valid and applicable collective bargaining agreement, or arbitrator's decision there under, or to any court or administrative order applying specifically to the injured worker's employer, and will further be subject to any applicable federal statutes or regulations.5.4. The Commission, Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, shall enter a protestable order, within twenty (20) days of receipt of the finalized rehabilitation plan signed by the qualified rehabilitation professional and the injured worker.