2015 Georgia Code
Title 34 - LABOR AND INDUSTRIAL RELATIONS
APPENDIX: RULES AND REGULATIONS OF THE STATE BOARD OF WORKERS' COMPENSATION
§ 200.1 - Provision of Rehabilitation Services
(I) REHABILITATION SUPPLIERS. A rehabilitation supplier delivers and coordinates services under an individualized rehabilitation plan; facilitates coordination of medical care; provides vocational counseling, exploration, and assessment; performs job analysis, job development, modification, and placement; evaluates social, medical, vocational, psychological, and psychiatric information; and may provide additional services upon agreement of the parties or Board order.
(A) Qualified Certifications or Licenses. To provide rehabilitation services, the supplier must be registered with the Board. To provide services in catastrophic claims, the supplier must be registered with the Board as a catastrophic supplier.
Any rehabilitation supplier who wishes to supply services in a Workers' Compensation claim shall hold one of the following certifications or licenses:
(1) Certified Rehabilitation Counselor (CRC);
(2) Certified Disability Management Specialist (CDMS);
(3) Certified Rehabilitation Registered Nurse (CRRN);
(4) Work Adjustment and Vocational Evaluation Specialist (WAVES);
(5) Licensed Professional Counselor (LPC);
(6) Licensed Professional Counselor (LPC);
(7) Certified Occupational Health Nurse (COHN); or
(8) Certified Occupational Health Nurse Specialist (COHN-S).
(B) Registration with the Board.
(1) To register as a rehabilitation supplier or a catastrophic rehabilitation supplier, an applicant shall follow the application process as provided in the Board's Rehabilitation & Managed Care Procedure Manual.
(2) Notice of a rehabilitation supplier's registration approval will contain a supplier registration number with the November 30th expiration date, which shall be included on all reports submitted to the Board by the rehabilitation supplier.
(3) Within twenty (20) days of the date of a denial of an application for registration as a supplier, an appeal may be initiated by filing a written request with the Director of Managed Care and Rehabilitation (MC&R) for a conference. The applicant will be notified in writing of the date, time, and place of the conference within thirty days of the appeal. An applicant dissatisfied with the decision following the conference may request a hearing by written request within twenty (20) days of the conference decision.
(II) CATASTROPHIC REHABILITATION SERVICES.
(A) Appointment of Catastrophic Rehabilitation Supplier.
(1) Where catastrophic designation is undisputed, the employer/insurer shall appoint a registered catastrophic rehabilitation supplier within 48 hours of accepting the injury as compensable or notification of a final determination of compensability by filing a Form WC-R1 which may be filed simultaneously with the Employer's First Report of Injury (WC-1). If the employer/insurer does not timely appoint a registered catastrophic rehabilitation supplier as required pursuant to this subsection, the employee may file a WC-R1 to request the appointment of a registered catastrophic rehabilitation supplier with service to all parties and the requested supplier.
(2) When a catastrophic designation is disputed, employee or employee's attorney shall file a WC-R1CATEE to request catastrophic designation and appointment of a registered catastrophic rehabilitation supplier. The WC-R1CATEE must be accompanied by documentation as specified in the current edition of the Board's Rehabilitation & Managed Care Procedure Manual, or as requested by the Board, unless a hearing is requested within twenty (20) days of the filing of the WC-R1CATEE.
(3) Objection to the WC-R1CATEE must be filed on a Form WC-Rehab Objection with the Board within twenty (20) days of the certificate of service on the WC-R1CATEE. In the alternative, either party may file a Form WC-14 requesting an evidentiary hearing within twenty (20) days of the certificate of service on the WC-RICATEE. In the event a Form WC-14 is filed, the file shall be transferred to an administrative law judge for an evidentiary hearing without an administrative decision being rendered by the Rehabilitation Coordinator. The timeliness of the objection or hearing request will be processed in accordance with provisions of O.C.G.A. §9-ll-6(e).
(4) When a Board determination is made by the MC & R or an administrative law judge that an injury is catastrophic, the employer/insurer shall have twenty (20) days from the date of notification of the determination to select a Board registered catastrophic rehabilitation supplier by filing a WC-R1. If the employer/insurer fails to select a supplier, or files an appeal of the determination to the Appellate Division and the catastrophic designation is upheld on appeal, the Board will select the catastrophic rehabilitation supplier, and may, in the Board's discretion, appoint a supplier requested by the employee.
(B) Catastrophic Rehabilitation Supplier Duties.
(1) A catastrophic rehabilitation supplier is not a party to the case. The registered catastrophic rehabilitation supplier shall have sole responsibility for the rehabilitation aspects of each individual case. The registered catastrophic rehabilitation supplier shall communicate with the injured employee and others to assess, plan, implement, coordinate, monitor and evaluate options and services to meet an injured employee's rehabilitation needs to effect a cure, give relief or restore the employee to suitable employment.
(2) The registered catastrophic rehabilitation supplier shall meet with the injured employee within thirty (30) days of appointment and complete an initial rehabilitation evaluation and an appropriate plan (WC-R2A) for medical and/or vocational services.
(3) The designated rehabilitation supplier may arrange for services outside of his/her scope of expertise and qualifications.
(4) Form WC-R2 with accompanying progress/status reports shall be filed no less than every ninety days.
(5) A rehabilitation supplier will inform all parties of the responsibility to provide services in accordance with their professional qualifications. The rehabilitation supplier shall function within the scope of his or her role, training, and technical competency and will accept only those referrals and/or assignments for which he or she is professionally qualified.
(6) The rehabilitation supplier shall disclose any known conflicts of interest.
(7) The rehabilitation supplier shall recognize that the authorized treating physician directs the medical care of an injured employee.
(8) The rehabilitation supplier shall insure the confidentiality of the injured employee's medical records and shall not disclose the medical records to non-parties without the written consent of the injured employee or unless otherwise legally required to do so.
(9) A rehabilitation supplier shall refrain from activity pertaining to settlement negotiations, surveillance or provision of legal advice.
(10) Rehabilitation suppliers shall advise a non-represented injured employee to direct questions outside his/her area of expertise to the State Board of Workers' Compensation and a represented injured employee to direct questions to his or her counsel.
(11) A rehabilitation supplier shall not accept any additional compensation or reward from any source as a result of settlement of a case. A rehabilitation supplier shall not accept any additional compensation or reward from any source as a result of settlement of a case.
(12) The assigned rehabilitation supplier shall not perform any additional services for either party for compensation not contemplated by the approved plan, unless all parties agree.
(C) Rehabilitation Plans.
(1) The initial rehabilitation plan must be filed with the Board on Form WC-R2A within ninety (90) days of the supplier's appointment to the claim, unless excused by the Board. A current Rehabilitation Plan must be filed with the Board during all phases of service delivery and shall be in place no longer than one year. All rehabilitation plans shall provide for reasonable and necessary items and services and be submitted with supporting documentation. If the Board rejects the proposed rehabilitation plan, the registered catastrophic rehabilitation supplier shall have 30 days to submit a revised plan. An amended rehabilitation plan on a WC-R2A shall be filed at any time the circumstances change significantly. Amended or extended rehabilitation plans shall be submitted thirty days prior to the expiration of the current approved plan.
(2) Plans may include any or all of the items and services, including housing and transportation, which are reasonable and necessary to return the catastrophically injured employee to the least restrictive lifestyle possible, and/or return to work including: Medical Care Coordination, Independent Living, Extended Evaluation, Job Placement, Training and/or Self Employment.
(3) Return-to work plans, in order of preference, are: a) return to same job with the same employer; b) return to different job with same employer; c) return to work with new employer; d) short-term training; e) long-term training; or f) self-employment.
(4) Any party objecting to a proposed rehabilitation plan shall file a WC-Rehab Objection Form with the Board within twenty (20) days of the date of the certificate of service. The Rehabilitation Division will issue an administrative decision and may hold a rehabilitation conference.
(5) Signed plans submitted without objection are approved automatically.
(1) A catastrophic rehabilitation supplier shall simultaneously provide copies of all correspondence, written communication, and documentation of oral communications with the treating physician to all parties and their attorneys.
(2) The catastrophic rehabilitation supplier shall provide professional identification and shall explain his or her role to any physician at the initial contact with the physician.
(3) The employee has the right to a private physical examination with the medical provider. The catastrophic rehabilitation supplier shall attend such examination, only with revocable written consent of the employee, or his or her representative, after the employee has been advised of the right to a private examination. The catastrophic rehabilitation supplier may meet with the physician and the employee after the private exam.
(4) The catastrophic rehabilitation supplier shall not obtain medical information regarding an injured employee in a private meeting with any treating physician unless the catastrophic rehabilitation supplier has reserved with the physician sufficient appointment time for the conference and the injured employee and his or her attorney were given ten days advance notice of their option to attend the conference. If the injured employee or the physician does not consent to a joint conference, or if, in the physician's opinion, it is medically contraindicated for the injured employee to participate in the conference, the catastrophic rehabilitation supplier shall note this in his or her report and may in those specific instances communicate directly with the physician. Exceptions to the above notice requirements may be made in cases of medical necessity or with the consent of the injured employee or his or her attorney.
(E) Rehabilitation Conferences.
(1) A rehabilitation conference may be scheduled at the request of a party or the catastrophic rehabilitation supplier by filing a WC-R5, or at the discretion of an Administrative Law Judge or the Board's rehabilitation coordinator.
(2) All parties, attorneys of record, and the catastrophic rehabilitation supplier may be required to attend the conference or to be represented by a person with full authority to resolve the pending disputes. Only the parties, attorneys of record, and catastrophic rehabilitation supplier may attend a scheduled mediation or rehabilitation conference. Exceptions to attendance may be granted if approved in advance by the Board rehabilitation coordinator.
(3) Any person notified by the Board who fails to attend a Board scheduled rehabilitation conference without reasonable grounds may be subject to sanction pursuant to O.C.G.A. § 34-9-18. Any party requesting cancellation or rescheduling of a rehabilitation conference shall notify the Board and other parties with adequate notice to all parties.
(4) Following the rehabilitation conference, the Board will issue a conference administrative decision.
(F) Rehabilitation Closure.
(1) The registered catastrophic rehabilitation supplier shall submit a WC-R3, Request for Closure, with a closure report as follows: (a) sixty days after the employee's return to work; (b) at any time it is determined that further services are not needed or feasible; (c) when a stipulated settlement that does not include rehabilitation services has been approved by the Board; or (d) when the Board directs rehabilitation closure.
(2) At any time, upon review of the file, the Board may determine that rehabilitation closure is appropriate and may issue an order or an administrative decision to close rehabilitation.
(3) A party may request that the Board close rehabilitation services by filing a WC-R3 setting forth the specific reasons in support of their request for closure with copies to all parties and the supplier.
(4) Any party objecting to a proposed WC-R3 shall file a WC-Rehab Objection Form setting forth the specific reasons within twenty (20) days of the date of the certificate of service. The Board will issue an administrative decision on all requests for closure.
(G) Request to Reopen Rehabilitation.
(1) A request to reopen rehabilitation services may be submitted only by parties to the claim and must be approved by the Board. The WC-R1 requesting that rehabilitation services be reopened shall include the name and address of the catastrophic rehabilitation supplier and the specific reasons for such request. The requesting party shall complete the certificate of service and send copies of the WC-R1 to all parties, their attorneys and the catastrophic rehabilitation supplier.
(2) Any party objecting to a proposed reopening shall file a WC-Rehab Objection Form with supporting documentation within twenty days of the date of the certificate of service. The M C & R will issue an administrative decision on all requests to reopen rehabilitation.
(H) Change in Registered Catastrophic Rehabilitation Supplier.
(1) A change in registered catastrophic rehabilitation supplier shall be requested only by parties to the claim and must be approved by the Board. The WC-R1 requesting a change in supplier shall include the names and addresses of the involved suppliers and the specific reasons the change is requested. The requesting party shall complete the certificate of service and send copies of the WC-R1 to all parties, their attorneys and the catastrophic rehabilitation suppliers.
(1) When a WC-R1 is filed to request a change of registered catastrophic rehabilitation supplier, the current Board appointed rehabilitation supplier shall maintain responsibility for providing necessary rehabilitation services until all appeals have been exhausted, unless excused by the Board.
(3) Any party objecting to a change of catastrophic rehabilitation supplier shall file a WC-Rehab Objection Form setting forth the reasons in support within fifteen (15) days of the date of the certificate of service. The Rehabilitation Division may hold a rehabilitation conference. The Rehabilitation Division will issue an administrative decision on all change of supplier requests.
(I) Challenges to Administrative Decisions.
Any party to the claim dissatisfied with an administrative decision must file a WC-14, Request for Hearing, served on all parties and their attorneys and involved rehabilitation supplier(s) within twenty (20) days of the date of the administrative decision. The Board, in its discretion, may order the parties to participate in a mediation or rehabilitation conference before the scheduling of the de novo hearing. The administrative decision shall be admissible in evidence.
(J) Failure of a Party or Counsel to Cooperate.
(1) Benefits may be suspended for failure or refusal to accept or cooperate with authorized rehabilitation services only by order of the Board.
(2) A party or attorney may be subject to civil penalty or to fee suspension or reduction for failure to cooperate with rehabilitation services.
(III) VOLUNTARY REHABILITATION.
For non-catastrophic injuries, the parties may elect that the employer/insurer will provide a rehabilitation supplier on a voluntary basis for so long as the parties agree. The employee's consent must be in writing. The rehabilitation supplier utilized by the parties must hold one of the certifications or licenses specified in Rule 200.1( I.A.) and be registered with the State Board of Workers' Compensation.
(A) Duties of voluntary rehabilitation supplier.
The voluntary rehabilitation supplier shall simultaneously provide copies of all correspondence, written communications, and documentation of oral communications with the treating physician to all parties and their attorneys.
(B) Ethical standards required of voluntary rehabilitation supplier.
The rehabilitation supplier shall adhere to the ethical standards set forth by the approved professional certifying bodies.
(IV) ADMINISTRATIVE ENFORCEMENT--PROFESSIONAL CONDUCT, FEES AND COMPLIANCE WITH BOARD RULES.
Complaints against rehabilitation suppliers and medical case managers for revocation or suspension of registration, excessive or fraudulent charges, provision of unnecessary services or unethical or unprofessional behavior shall be filed in writing on a Rehab Complaint with the Director of Managed Care and Rehabilitation with copies sent to all parties and affected suppliers and case managers. Registration may be revoked or suspended, and/or penalties assessed.
(A) The Director of MC shall appoint a peer review panel of nine (9) registered suppliers who will review complaints regarding reasonable fees, appropriate services and unprofessional or unethical behaviors. The appointees shall serve for terms of three (3) years and may be re-appointed for a maximum of nine (9) years.
(B) The registration of a medical case manager or a rehabilitation supplier may be revoked or suspended, and/or penalties assessed upon a determination of violation of Board rules, excessive or fraudulent charges, provision of unnecessary services or unethical or unprofessional behavior.
(C) A written complaint against a medical case manager or rehabilitation supplier shall be filed with the Director of MC&R and copies sent to all parties to the case and to the medical case manager or rehabilitation supplier. Upon receipt of the written complaint, or upon the Board's knowledge of a violation, the Director of MC& R shall provide notification to the case manager/rehabilitation supplier by providing a copy of the written complaint.
(D) Within fifteen (15) calendar days of the notice by the Director of MC, the Director shall appoint a panel of three (3) members from the peer review panel to review the complaint. Where possible, at least one of the three (3) shall have the same certification or licensure as the person who is the subject of the complaint. The Director of MC shall provide Review Panel contact information to the complainant and the person who is the subject of the complaint.
(E) The medical case manager or rehabilitation supplier who is the subject of the complaint shall be provided fifteen (15) calendar days from the date of said notice from the Director to provide a written response to the allegations of the complaint. A copy of the response shall be served on the Director of MC&R the Review Panel, and the person who filed the complaint.
(F) The complainant may reply to the response within 10 days by serving a copy on the Director of MC&R, the person who is the subject of the complaint, and the Review Panel.
(G) The Review Panel may request additional information regarding the circumstances of the complaint from any person or party having relevant knowledge. Such additional information shall be provided to the person who is the subject of the complaint who will have 10 days to respond.
(H) The Review Panel shall report its findings and recommendations to the Director of MC&R within thirty (30) days of the final response. The Director of MC shall promptly provide a copy of the findings and recommendations to the medical case manager or rehabilitation supplier who is the subject of the complaint and the complainant.
(I) If the Review Panel determines that there is no inappropriate conduct, the Director of MC&R shall issue an administrative decision incorporating the Review Panel's findings and recommendation. Copies of the finding shall be sent to all parties to the case and to the medical case manager or rehabilitation supplier who was the subject of the complaint. The complainant or any party dissatisfied with the finding may challenge the finding by filing a WC-14 Request for Hearing within 20 days. The administrative decision shall be admissible in evidence.
(J) If the Review Panel determines that a violation has occurred, the Director of MC&R will refer the findings and recommendation to the Enforcement Division for further appropriate action which may include referral to an Administrative Law Judge for a hearing. If a hearing is held, the Administrative Law Judge shall issue a decision providing for any available remedy, including dismissal of the complaint, assessment of penalties, probation, and/or revocation or suspension of the registration of the rehabilitation supplier. The rehabilitation supplier may appeal the decision of the Administrative Law Judge in accordance with O.C.G.A. § 34-9-103 and § 34-9-105.
(K) The Director of MC shall also have the authority to order replacement of the rehabilitation supplier in the case where the conduct occurred if, in the judgment of the Director of MC&R, such action is necessary to effectuate the purpose of the Act.
(L) When appeals have been exhausted, the Director of MC&R shall report any violations to the appropriate certification or licensing Board.
(M) The members of the peer review panel shall be immune from any subpoena requiring their testimony in any form regarding their participation in the review process.
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