Source: http://www.vadrs.org/frsview.asp?cid=39
Timestamp: 2015-12-02 01:27:57
Document Index: 429860818

Matched Legal Cases: ['§ 361', '§ 361', '§ 361', '§ 361', '§ 361', '§ 361', '§ 54', '§ 361', '§ 361', '§ 361', '§ 361', '§ 361', '§ 361']

Chapter 8.14 Contents:
Chapter 8.14. - PHYSICAL AND MENTAL RESTORATION SERVICES (PHYS RES)
1. Physical and Mental Restoration Services
A. Eligibility for Physical and Mental Restoration Services
A1. Eligibility Criteria for Physical and Mental Restoration Services
A2. Ambulance Additional Criteria
A3. Cancer Treatment Additional Criteria
A4. Cardiac Exercise Physical Therapy Additional Criteria
A5. Cognitive Rehabilitation Services Additional Criteria
A6. Convalescent Care/Nursing Home/Rest Home Additional Criteria
A7. Dental Additional Criteria
A8. Dialysis Additional Criteria
A9. HIV Testing Additional Criteria
A10. Hearing Aids, Telecommunications, Sensory and Other Devices and Aids Additional Criteria
A11. Hospital Services Additional Criteria
A12. Medications and Medical Supplies Additional Criteria
A13. Nursing Services Additional Criteria
A14. Obesity Treatment Additional Criteria
A15. Occupational Therapy Additional Criteria
A16. Pain Control Additional Criteria
A17. Physical Therapy Additional Criteria
A18. Prosthesis and Orthotic Additional Criteria
A19. Psychiatric and Psychological Services Additional Criteria
A20. Specialists Additional Criteria
A21. Speech or Hearing Therapy Additional Criteria A22. Surgical Services Additional Criteria
A23. Visual Services Additional Criteria
A24. Wheelchair Additional Criteria
B. Consumer Responsibilities for Physical and Mental Restoration Services
B1. Consumer Responsibilities for Physical and Mental Restoration Services
C. Maximum Allowed for Physical and Mental Restoration Services
C1. Maximum Allowed for Physical and Mental Restoration Services
D. Procedures for Authorizing Physical and Mental Restoration Services
D1. S/I Code for Physical and Mental Restoration Services
D2. Qualified Vendor for Physical and Mental Restoration Services
D3. Bills for Unforeseen Medical Services
D4. Authorized Amount When Consumer has Medicaid or When Insurer Sets Allowable Fee for Physical and Mental Restoration Service
D5. Authorized Amount When Insurer Does Not Set Allowable Fee for Physical and Mental Restoration Service
D6. Authorized Amount for Physical and Mental Restoration Services Not Covered By Insurance
D7. Agency Fund Code for Physical and Mental Restoration Services
E. Procedures to Request Vendor Payment for Physical and Mental Restoration Services E1. Procedures to Request Vendor Payment for Physical and Mental Restoration Services Chapter 8.14. - PHYSICAL AND MENTAL RESTORATION SERVICES (PHYS RES)
[REVISED: 7/1/15] Definitions. Physical and mental restoration services means: (i) Corrective surgery or therapeutic treatment that is likely, within a reasonable period of time, to correct or modify substantially a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment; (ii) Diagnosis of and treatment for mental or emotional disorders by qualified personnel in accordance with State licensure laws; (iii) Dentistry; (iv) Nursing services; (v) Necessary hospitalization (either inpatient or outpatient care) in connection with surgery or treatment and clinic services; (vi) Drugs and supplies; (vii) Prosthetic and orthotic devices; (viii) Eyeglasses and visual services, including visual training, and the examination and services necessary for the prescription and provision of eyeglasses, contact lenses, microscopic lenses, telescopic lenses, and other special visual aids prescribed by personnel that are qualified in accordance with State licensure laws; (ix) Podiatry; (x) Physical therapy; (xi) Occupational therapy; (xii) Speech or hearing therapy; (xiii) Mental health services; (xiv) Treatment of either acute or chronic medical complications and emergencies that are associated with or arise out of the provision of physical and mental restoration services, or that are inherent in the condition under treatment; (xv) Special services for the treatment of individuals with end- stage renal disease, including transplantation, dialysis, artificial kidneys, and supplies; and (xvi) Other medical or medically related rehabilitation services (per 2001 Federal Regulation 34 CFR § 361.5 (b)(40)). Doctor or physician means Doctor of Medicine and Surgery, Doctor of Osteopathy, Doctor of Podiatry, Doctor of Chiropractic, and Optometrist. Assessment. The counselor may approve services for assessment purposes. For assessment by a specialist See Policy 1: Section A20. For HIV testing, See Policy 1: Section A9. For additional requirements for other services see the specific service within section A of this policy. Cross-reference: For policy and procedure, see Chapter 6, DIAGNOSTICS, Policy 1. Cross-reference: For services under Trial Work Experiences Plan or Extended Evaluation Plan, see Chapter 4.02, EXTENDED, Policy 1. Guidance: Items subject to consumer financial participation policy (wheelchairs, telecommunications and assistive listening systems, etc.) should be provided on a loan basis (rather than purchased) during eligibility determination. Additional criteria. For additional eligibility criteria for a specific service, see subsections A1, A2, etc. of this policy. Under Employment Plan. The counselor may approve services under an Employment Plan after the individual and counselor jointly establish the employment goal. Before committing to providing the service or authorizing it, the counselor shall (a) ensure it is consistent with policy and procedure for planned services, including requirements for physical or mental restoration Employment Plan, under Chapter 5, PLAN, Policy 2 and shall (b) document that all of the following eligibility criteria are met: The service is needed to achieve the Employment Plan employment goal (per 2001 Federal Regulation 34 CFR § 361.46). The physical or mental condition is medically documented as stable or slowly progressive (per State Regulation 22 VAC 30-20-120). The condition is not acute or transitory, or of such recent origin that the resulting functional limitations and the extent to which the limitations affect occupational performance cannot be identified (per State Regulation 22 VAC 30-20-120(b)). For acute or chronic conditions or medical emergencies, approval shall be allowed only according to the definition in subsection A1a above. The physical or mental impairment is a substantial impediment to employment. For definition of substantial impediment to employment, see Chapter 4.01, ELIGIBILITY, Policy 1. Documentation may include, but is not limited to, the counselor’s relevant case notes, intake interview notes, etc. The individual requires additional vocational rehabilitation services. This means the Employment Plan must have at a minimum, vocational counseling and guidance, and may have other services as appropriate (per State Regulation 22 VAC 30-20-120). This requirement is based on General Accounting Office September 22, 1982 report (GAO/HRD-82-95) to the U.S. Secretary of Education. C&G in Service status. During Service status, the counselor will provide counseling and guidance in areas such as length of treatment, projected date of return to work, work restrictions, information available on service provider, comparable benefits and billing procedures, necessary child care and housekeeping arrangements, following medical advice, DRS procedures for physical and mental restoration services, or other related topics. The decision of the dental consultant or medical consultant may be appealed through any of the avenues of appeal (see Chapter 15, APPEALS, Policy 1). Guidance: Include in the approval request: the medical (or dental) information and documentation that the condition is a substantial impediment to employment (e.g., intake interview, relevant case notes, etc.). Recommended by qualified vendor in writing. Personnel qualified as defined in state licensing and certification laws recommends the service in writing (e.g., doctor’s orders, prescription, report, etc.) and will provide the service (Title 54.1 of the Code of Virginia). Treatment services may be provided either by the same person who provided the assessment/diagnostic services or by someone else. For qualified personnel for each service, refer to subsections A1, A2, etc. of this policy; vendor policy in Chapter 14.1, PURCHASING, Policy 2; and the DRS Services Reference Manual. Pre-approval. The counselor documents pre-approval from the supervisor/medical consultant/dental consultant, as required for specific services (see subsections A2, A3, etc. of this policy). The pre-approval dollar level policy shall also apply (see Chapter 14.1, PURCHASING, Policy 3). Any medical service (this requirement does not apply to dental or mental services) not listed in the Services Reference Manual shall require written pre-approval from the DRS chief medical consultant. Written pre-approval from the DRS regional dental consultant may be required for any dental restoration services not listed in the Service Reference Manual. Over $5,000. With the local medical consultant’s (when the local consultant has a conflict of interest or is not available, use medical consultant for another office, or chief medical consultant, or Wilson Workforce and Rehabilitation Center physician), written pre-approval, the counselor may approve an Employment Plan and amendments that include physical restoration services in which the total cost of the physical restoration package exceeds $5,000 (per agency mandate). The medical consultant will record the results of the review and approval on the Medical Consultant’s Work Sheet (RS-3g). The counselor shall maintain the completed RS-3g form in the case file. This requirement is in addition to the pre-approval dollar limit policy (see Chapter 14.1, PURCHASING, Policy 3). Exception: This requirement shall not apply to: i. Dental services, including temporamandibular joint dysfunction treatment (TMJ) ii. Eyeglasses iii. Hearing aid iv. Prosthetic or orthotic devices v. Psychological or psychiatric services Refusal of service. An individual may refuse physical and mental restoration services even when it is the opinion of a licensed medical professional that the limitations that cause an impediment to employment can be removed without injury to the individual. The individual shall be eligible only for vocational counseling and guidance and job placement services (per State Regulation 22 VAC 30-20-120). Guidance: In order to make an informed choice, the individual must receive information on the prognosis with and without the recommended physical or mental restoration services. Second opinion. The counselor may authorize a second opinion at the individual’s request. In the event of conflicting medical opinions, the counselor shall authorize a third opinion and the decision shall be made on the two concurring opinions (per State Regulation 22 VAC 30-20-120). Bills for Unforeseen Medical Services. See Policy 1: Section D3 of this chapter. Disallowed services. DRS staff shall not approve experimental procedures (per State Regulation 22 VAC 30-20-120). Per the American Medical Association, “experimental” means not recognized under generally accepted medical standards as safe and effective for treating a particular condition. DRS staff shall not approve procedures that are high risk to the patient (per State Regulation 22 VAC 30-20-120). This shall be determined on a case-by-case basis by the treating physician. For invasive procedures (e.g., surgery, catheterizations) and stress tests, the counselor shall obtain a written statement from the treating physician regarding the risk level for the patient. See Services Reference Manual for services that require this statement. DRS staff shall not approve services expected to have an uncertain or limited outcome for the patient (per State Regulation 22 VAC 30-20-120(e)). If the medical report indicates a procedure has an uncertain or limited outcome, DRS approval of the procedure shall be determined on a case-by-case basis by the DARS chief medical consultant in consultation with the treating physician. DRS staff shall not approve services contraindicated for the patient. DRS staff shall not approve incidental procedures performed in conjunction with a surgical procedure authorized by the counselor. DRS shall not cover “spend-down” for clients with Medicaid (See Policy 1: Section D4 of this chapter). DRS staff shall request payment only for those services that are part of the individual’s Employment Plan. (This requirement does not apply to VR services provided for diagnostic and evaluation purposes before the Employment Plan is developed). DARS shall not request payment for service unless the service is authorized in writing by the counselor before the service is provided or before the individual incurs the expense (per 2001 Federal Regulation 34 CFR § 361.50). Monetary loans to individuals are strictly prohibited by agency mandate. DRS shall not pay bad debts, liens, or judgments (e.g., outstanding medical bills); entertainment expenses, including costs of amusements and social activities; fines, court costs, and similar expenses; or the consumer’s interest payments (per federal OMB Circular A-87 revised May 10, 2004). Consumer responsibilities. The client must satisfy all of the items in this policy (See Policy 1: Section B1 of this chapter). Financial participation. Physical and mental restoration services, except when diagnostic in nature, are subject to consumer financial participation policy (2001 Federal Regulation 34 CFR § 361.54). See Chapter 14.3, FINANCIAL, Policy 1. Comparable benefits. Physical and mental restoration services that are not medically necessary (per insurer or physician) but are required solely to determine eligibility or VR needs (and priority category for services if DRS is on Order Of Selection) are exempt from comparable benefits policy (per 2001 Federal Regulation 34 CFR § 361.53). Physical and mental restoration services, including diagnostic and evaluation services related to subsequent treatment of a medical or mental condition, are subject to comparable benefits policy (see Chapter 14.2, COMPARABLE, Policy 1). The counselor shall ensure that the insurer has pre-approved the service. Without pre-approval, the insurer may reduce or deny the insurance payment (thus increasing the DRS payment amount). Due to insurance contract restrictions, the service provider may not be able to bill DRS or the client for the unpaid balance (and would have to write off the loss). Guidance: When the insurer denies a pre-approval request, the counselor should only authorize the service when the counselor deems it essential to achieve the established employment goal (per agency mandate). Guidance: Comparable benefits resources include Medicare, Medicaid, Workers’ Compensation, private health insurance, Veterans Disability Benefits, employee benefit health insurance, Workers’ Compensation benefits, local Community Services Board (CSB), Medical College of Virginia, University of Virginia Hospital, etc. Purchasing. Physical and mental restoration services are subject to DRS established purchasing policies and procedures. See Chapter 14.1, PURCHASING, Policy 1. Back to Chapter Index A2. Ambulance Additional Criteria
[REVISED: 3/1/08] The counselor shall consider approving ambulance service only when (per agency mandate): the service is included in writing by a doctor as a component of the VR physical and mental restoration service, or the counselor documents that ambulance service is more cost effective and appropriate than the usual means of transportation the client uses to access VR services. Back to Chapter Index A3. Cancer Treatment Additional Criteria
[REVISED: 3/1/08] The counselor may consider approving initial treatment in exceptional cases (such as basal cell skin cancer) if: the medical report indicates the initial treatment is likely to eliminate the cancer, and the DRS chief medical consultant gives written pre-approval. Back to Chapter Index A4. Cardiac Exercise Physical Therapy Additional Criteria
[REVISED: 3/1/08] Additional requirements for cardiac exercise physical therapy (per State Regulation 22 VAC 30-20-120) are: the first therapy session will occur within six (6) months after the myocardial infarction (heart attack) or coronary bypass, and approving more than 24 sessions shall require the supervisor’s written pre-approval on the basis that the additional sessions are essential to achieve the employment goal. Back to Chapter Index A5. Cognitive Rehabilitation Services Additional Criteria
[REVISED: 7/1/12] The following are additional requirements for cognitive rehabilitation services: Counselors shall require vendors to submit the following for approval before initiating cognitive rehabilitation services (per agency mandate): (i) a written cognitive rehabilitation plan for counselor approval, and (ii) written justification for any cognitive rehabilitation plan exceeding six (6) months. Guidance 1: Written plans should offer a “step down” rate reduction as the frequency and intensity of service declines over time. Guidance 2: When the vendor’s plan exceeds six (6) months, the counselor should consult the supervisor or the Director of Brain Injury and Spinal Cord Injury Services in the DARS Central Office before approving the plan. Guidance 3: Services may include, but are not limited to, cognitive retraining, neuropsychological assessment/evaluation, neuropsychological/psychological counseling, and medical therapies. Guidance 4: It is recommended that the counselor initially authorize 3 to 5 days (day or inpatient) or 4 to 6 hours (individual or group outpatient) for the vendor to conduct an assessment and prepare the written plan. Assessment services may include, but are not limited to, neuropsychological assessment or update; speech, audiological, and optometric assessment or update; and other assessments. Guidance 5: Services are more effective when provided in the individual’s community environment. Therefore, DRS strongly encourages the delivery of services in home, work, and other community settings. Guidance 6: Staff from the DARS Central Office Brain Injury & Spinal Cord Injury Services Unit and from the WWRC Brain Injury Services Program are available to help counselors decide if cognitive rehabilitation services should be considered and if the vendor proposed plan is satisfactory. If an individual staff person is not licensed in a particular field for which that person is providing services, the individual must be supervised by someone who is licensed. It is strongly recommended that the vendor have a licensed professional (e.g., neuropsychologist, speech language pathologist) specializing in brain injury and trained and experienced in providing cognitive rehabilitation services be involved in overseeing or providing consultation on cognitive rehabilitation service plan development and/or implementation. Back to Chapter Index A6. Convalescent Care/Nursing Home/Rest Home Additional Criteria
[REVISED: 12/1/12] Additional requirements (per State Regulation 22 VAC 30-20-120) for convalescent care/nursing home/rest home are: the service is included in writing by a doctor as a component of the VR post-treatment plan and the client will resume the VR program. Back to Chapter Index A7. Dental Additional Criteria
[REVISED: 12/1/12] Additional requirements (per agency mandate) for dental servcies are: The dental evaluation indicates the service needed is significant (e.g., multiple extractions with denture replacement). Routine cleanings are not significant and may be approved only in conjunction with a significant dental service, The total cost of the dental treatment plan shall be subject to the pre-approval dollar levels listed in Chapter 14.1, PURCHASING, Policy 3. Depending upon the dollar pre-approval levels, the supervisor, regional director, or commissioner may require written pre-approval from a regional dental consultant. The regional dental consultant shall not be the treating dentist, to avoid a conflict of interest, and The counselor shall include on the Authorization form a request for a post-dental service report. Guidance 1: Generally a dental condition should be the secondary, rather than primary, impairment. Guidance 2: A full periapical x-ray is not required.
Back to Chapter Index A8. Dialysis Additional Criteria
[REVISED: 3/1/08] Additional requirements (per agency mandate) for dialysis are: medical report(s) document that medical prognosis is favorable, including other conditions (e.g., diabetes, cardiac conditions, neuro-muscular conditions) which may impact employability, and the counselor documents that dialysis and medical support services are available locally and will accommodate a work schedule. Back to Chapter Index A9. HIV Testing Additional Criteria
[REVISED: 3/1/08] Additional requirements (per agency mandate) for HIV testing are: the service is a) included in writing by the doctor as a component of the VR diagnostic or treatment services, or b) not recommended by a doctor, but the counselor believes HIV testing is essential to determine eligibility (and assign priority category if DRS is on an order of selection) or to develop the Employment Plan or to achieve the established employment goal (per 2001 Federal Regulation 34 CFR § 361.42). the counselor shall include on the Authorization form both pre- and post- test counseling by a person experienced in this type of counseling, and providers include the health or medical practitioner who administers the HIV test, the health department, other known state or local programs, or VR counselors specifically trained in this specialty (per state law). Back to Chapter Index A10. Hearing Aids, Telecommunications, Sensory and Other Devices and Aids Additional Criteria
[REVISED: 3/1/08] Definitions. Telecommunications and assistive listening systems apply to any transmission, emission, or reception of signs, signals, written images, and sounds of intelligence of any nature by wire, radio, visual, or other electromagnetic systems including any intervening process and storage. Sensory and other technological aids or devices are electronic or mechanical pieces of equipment or hardware intended to improve or substitute for one or more of a person’s senses. They include hearing aids, telecommunication systems (e.g., text telephone), assistive listening systems (e.g., individual auditory loop, room loop, amplified telephone), and alerting devices (e.g., visual smoke alarm, doorbell signaler, telephone signaler, alarm clock). Qualified personnel to fit and deal in hearing aids means a person licensed by the Virginia Board of Hearing Aid Specialists (per State Regulation 18 VAC 80-20-10). Qualified personnel for hearing aid orientation or speech reading means a specialist in hearing disabilities (per State Regulation 22 VAC 30-20-120). Additional requirements are: any purchase shall require pre-approval from the Rehabilitation Counselor for the Deaf (RCD) or the DARS State Coordinator of Deaf and Hard of Hearing (pre-approval does not have to be written), and all services and devices meet established federal and state safety standards and are recommended in an audiologist report (per state law and State Regulation 22 VAC 30-20-120). Hearing aid special requirements. In addition to the requirements in subsection A1 and paragraph 2 above, the counselor may approve a hearing aid only when: the counselor believes the client will benefit in terms of employability as a direct result of the hearing aid, and approving hearing aid services totaling more than $5,000 for the life of the case shall require written pre-approval from the State Coordinator of Deaf and Hard of Hearing, and the counselor may approve two hearing aids if two aids are recommended in the audiologist’s evaluation report, and the counselor specifies in the case file why two aids are essential for achieving the employment goal, and (iv) it is recommended in writing by an audiologist. Approving a hearing aid for any client under 18 years of age shall require an examination and written recommendation from an otolaryngologist within six months prior to fitting (per State Regulation 18 VAC 80-20-230), and approving a hearing aid for any adult whose hearing loss is newly diagnosed or for whom amplification is being recommended for the first time, shall require written recommendation in an otological examination (per State Regulation 22 VAC 30-20-120).The hearing aid price shall include: The hearing aid price shall include: One (1) session of hearing aid orientation, One (1) follow-up progress check, Necessary batteries, and Required ear mold(s). Back to Chapter Index A11. Hospital Services Additional Criteria
[REVISED: 3/1/08] Additional requirements for Hospital services (per State Regulation 22 VAC 30-20-120) are: the service is included in writing by a doctor as a component of the VR diagnostic or treatment service, and approval shall not exceed three (3) days for diagnostic purposes, and (iii) approval of more than 10 additional days for treatment purposes shall be allowed only when medically documented complications arise from the VR treatment service. Back to Chapter Index A12. Medications and Medical Supplies Additional Criteria
[REVISED: 3/1/08] The counselor may approve prescription medications and supplies the individual needs to participate in the vocational rehabilitation process. When needed on a continuous basis (e.g., treatment of diabetes, epilepsy, etc.), the counselor may approve it for the duration of the Employment Plan, not to exceed 90 days after achieving employment (per State Regulation 22 VAC 30-20-120). Approval for a longer period shall require written justification in the case file (per agency mandate). When counseling, medication, and job placement are the only services provided, the counselor may approve medications and supplies for a period not to exceed 90 days (per State Regulation 22 VAC 30-20-120). Generic drugs shall be used when approved by the medical practitioner (per State Regulation 22 VAC 30-20-120). Back to Chapter Index A13. Nursing Services Additional Criteria
[REVISED: 3/1/08] DRS cannot authorize for nursing services by Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.) unless the service is included in writing by the attending physician as a component of the VR treatment service.
Back to Chapter Index A14. Obesity Treatment Additional Criteria
[REVISED: 7/1/12] Additional requirements (per agency mandate) for obesity treatment are: the obesity is documented as a substantial impediment to employment; and the service is recommended in writing by a medical doctor; and any underlying psychological causes are identified and addressed; and the DARS chief medical consultant gives written pre-approval based on medical and vocational considerations, and other options shall be considered before considering surgery. Include in the pre-approval request all pertinent disability and impediment to employment, psychological, social, and medical information. Back to Chapter Index A15. Occupational Therapy Additional Criteria
[REVISED: 3/1/08] The counselor may authorize occupational therapy only when a licensed medical doctor prescribes it (per State Regulation 22 VAC 30-20-120). Back to Chapter Index A16. Pain Control Additional Criteria
[REVISED: 3/1/08] The counselor may approve post-operative pain treatment as recommended in the doctor’s post-operative treatment plan and according to policy regarding medications. Approval of non-post-operative pain control treatment or pain management shall require written pre-approval of the chief medical consultant (per agency mandate). Back to Chapter Index A17. Physical Therapy Additional Criteria
[REVISED: 3/1/08] The counselor may authorize physical therapy only when a licensed medical doctor prescribes it (per State Regulation 22 VAC 30-20-120 and § 54.1-3482 of the Code of Virginia).
Back to Chapter Index A18. Prosthesis and Orthotic Additional Criteria
[REVISED: 5/6/10] Additional requirements for prosthesis or orthotic are: Approving an original appliance shall require a prescription (per State Regulation 22 VAC 30-20-120). Approving prosthesis repair or exact replacement shall require the individual’s written request for repair (or exact replacement). The existing prescription is sufficient and a doctor’s examination is not required, unless the vendor recommends it upon examining the individual. For exceptions to the vendor approval process, see Chapter 14.1, PURCHASING, Policy 2, Section A3. Back to Chapter Index A19. Psychiatric and Psychological Services Additional Criteria
[REVISED: 12/1/12] Psychotherapy shall be provided only by a psychiatrist or psychologist qualified in the area of psychotherapy (per State Regulation 22 VAC 30-20-120). Although counseling services provided by licensed professional counselors (L.P.C.), licensed clinical social workers (L.C.S.W.), and clinical psychologists are given the same SI Code for Psychotherapy/Clinical Counseling, the fee for clinical psychologists is higher than for other behavioral health clinicians. See the Service Reference Manual to ensure that the correct fee is applied. Back to Chapter Index A20. Specialists Additional Criteria
[REVISED: 3/1/08] Additional criteria for specialists are: The counselor may approve diagnostic services from a specialist when the patient has been referred to the specialist by either the treating physician or the doctor or dentist whom the counselor authorized to provide examination services. Guidance: Before approving specialist services without having a doctor’s referral, the counselor may wish to consult the chief medical consultant about the appropriateness of the specialty. The counselor shall consult with the chief medical consultant before approving a visit to additional specialists when medical examination or testing reveals additional physical impairment(s). In fields of medicine where a specialty board is established, DRS shall use physicians who are certified members of the specialty board. When such specialists are not available in the community, the counselor may authorize to a physician who has similar training and is recognized by local physicians as being competent in the specialty. Back to Chapter Index A21. Speech or Hearing Therapy Additional Criteria [REVISED: 3/1/08] Qualified personnel for speech therapy means speech pathologist (per State Regulation 22 VAC 30-20-120).
Back to Chapter Index A22. Surgical Services Additional Criteria
[REVISED: 71/12] Additional requirements for surgical services are (per agency mandate): the counselor shall include on the Authorization form: i) a request for a post-operative report from the physician, and ii) a statement that the authorization encompasses one pre-operative hospital visit, admission examination, preparing hospital records, typical post-operative care and discharge day management, and post-hospital visits through 15 days. Incidental procedures (e.g., incidental appendectomy, puncture of ovarian cyst, scar excision, simple lysis of adhesions) performed in conjunction with a VR surgical procedure shall be at the individual’s expense regardless of the Client Financial Statement RS-13 form results and shall not be authorized or funded. Back to Chapter Index A23. Visual Services Additional Criteria
[REVISED: 7/1/12] Additional requirements for visual services are: Visual services may be provided to individuals who are unable to satisfactorily pursue their vocational rehabilitation program or achieve the established employment goal due to impaired vision. Visual services shall be provided in accordance with the cooperative agreement established between DARS and the Department for the Blind and Vision Impaired (DBVI) per Chapter 2.1, APPLICATION, Policy 1, Section A4. Back to Chapter Index A24. Wheelchair Additional Criteria
[REVISED: 3/1/08] Additional requirements for wheelchair are: approval of the first ever wheelchair for a VR client shall require a 1) prescription from a licensed medical doctor, and 2) a wheelchair evaluation with written work specifications from an occupational therapist, physical therapist, or other appropriate specialist. Replacing the existing wheelchair with a similar wheelchair does not require a wheelchair evaluation if the counselor obtains 1) a prescription less than one year old from a licensed doctor and 2) the work specifications for the current wheelchair. The counselor may specify a particular manufacture or type of wheelchair on the Authorization form only when the evaluation includes justification. Back to Chapter Index
[REVISED: 7/1/12] The VR client must: Assist the counselor to identify comparable services and benefits to pay for physical or mental restoration services that exist under any other program, including Medicaid, Medicare, Workers’ Compensation or other employee benefits, health insurance, etc. and, When comparable benefits are available at the time the service is needed, present the insurance policy or policy number to the hospital or service provider (per 2001 Federal Regulation 34 CFR § 361.53), and Participate in any diagnostic examination required under established DRS policy as a criteria for service eligibility, and Make any necessary appointments if the counselor asks. Keep and be on time for all appointments. Tell the counselor right away if you must reschedule an appointment (and also immediately notify the service provider). Follow through on any other consumer responsibilities as agreed by consumer and counselor, such as medications or medical program/regimen prescribed by treating physician. Back to Chapter Index
[REVISED: 7/1/12] Ambulance service maximum allowance is the actual cost. For other services see the Services Reference Manual. If the service is unlisted, the DARS chief medical consultant or dental consultant will determine the maximum allowance.
[REVISED: 2/1/10] See DRS Services Reference Manual. To authorize an unlisted service approved by the chief medical consultant or dental consultant, the counselor shall use the miscellaneous (X) code found at the end of the service listing.
Back to Chapter Index D2. Qualified Vendor for Physical and Mental Restoration Services
[REVISED: 2/1/10] For qualified vendors for a specific service, see subsections A2, A3, etc. of this policy.
Back to Chapter Index D3. Bills for Unforeseen Medical Services
[REVISED: 3/1/03] Guidance: Any test that can be planned in advance should be approved in advance. However, approval for an examination gives the implied DRS authorization for X-ray or laboratory procedures or tests that the doctor finds necessary to diagnose and make medical recommendations. If the counselor receives a bill for unforeseen medically-necessary service related to the approved service (non-incidental), the counselor shall prepare a separate Authorization for the additional cost. Use the same date as on the initial Authorization.
Back to Chapter Index D4. Authorized Amount When Consumer has Medicaid or When Insurer Sets Allowable Fee for Physical and Mental Restoration Service
[REVISED: 7/1/12] DRS is required by federal law (Rehabilitation Act of 1973 as amended in 1998 Title I Section 101(a) (8)) and regulation (per 2001 Federal Regulation 34 CFR § 361.5 (b)(10)) and Federal Regulation 34 CFR § 361.53) to use insurance as a comparable benefit before using VR funds, and the DRS Authorization form requires the service provider to bill insurance first. If the insurance contract requires the service provider to accept the reasonable and customary fee established in the contract and accept the insurance payment as payment in full, even if the service provider fee is higher, the service provider is prohibited by law from collecting additional amounts over the consumer co-pay and insurance payment. The VR counselor may only authorize the consumer co-pay, subject to consumer financial participation policy. DRS shall not cover “spend-down” for clients with Medicaid because payment by any state agency may jeopardize Medicaid eligibility (per Department of Medical Assistance Services Medicaid policy).
Back to Chapter Index D5. Authorized Amount When Insurer Does Not Set Allowable Fee for Physical and Mental Restoration Service
[REVISED: 7/1/12] DRS is required by federal law (Rehabilitation Act of 1973 as amended in 1998 Title I Section 101(a) (8)) and regulation (per 2001 Federal Regulation 34 CFR § 361.5 (b)(10)) and Federal Regulation 34 CFR § 361.53) to use insurance as a comparable benefit before using VR funds and is permitted by federal regulation (per 2001 Federal Regulation 34 CFR § 361.50) to establish a fee schedule for services. The DRS Authorization form requires the service provider to bill the insurer first, to accept the DRS maximum allowance as full payment for any remaining balance, and prohibits the service provider from billing the VR client for the difference between the provider fee and the insurance and DRS payments. The VR counselor shall not authorize more than the DRS maximum allowance less insurance payment amount, subject to consumer financial participation. For VR clients with Medicare, the VR counselor may authorize medical expenses not covered by Medicare in accordance with the DRS maximum allowance, Hospital agreements, and consumer financial participation policy. Example: In this example, under the insurance policy, the insurer is responsible for 50 percent of the cost remaining after the patient deductible and co-pay, and the patient is responsible for $100 annual deductible, $10 co-pay, and any unpaid amount after insurance. The DRS maximum allowance for this medical procedure is $250. The RS-13 consumer financial participation is 30% from client and 70% from DRS. The service provider charges $300 for this procedure. Insurance pays $95 [ 50% of (provider fee less patient deductible less patient co-pay) = 50% of ($300 less $100 less $10) = 50% of $190 = $95)]. The service provider then bills the patient or DRS for the $205 balance (provider fee less insurance = $300 less $95 = $205). Even though the DRS maximum allowance is $250, the VR counselor can only authorize $109 towards the patient co-pay and unpaid balance [ 70% of (DRS maximum allowance less insurance) = 70% of ($250 less $95) = 70% of $155 = $109)]. The service provider has been paid $95 from insurance and $109 from DRS, and has an unnpaid balance of $96. Under the conditions of the Authorization form, the service provider cannot collect the $96 unpaid balance from DRS or the VR client, even if the consumer financial participation is 30%.
Back to Chapter Index D6. Authorized Amount for Physical and Mental Restoration Services Not Covered By Insurance
[REVISED: 3/1/03] The counselor shall write on the Authorization form: “Bill DRS first.” Note 1: This notifies the service provider that the DRS requirement to bill insurance first is not applicable for this authorization. This statement is crucial because if the bill is submitted to the insurer for payment and the insurer denies payment, under certain insurance contracts the service provider is prohibited from collecting from other sources, including DRS. Note 2: Services not covered by medical benefits or services denied by the insurer may include, but are not limited to, services that: Insurer specifically excludes from insurance coverage, Insurer deems not medically necessary for the individual (e.g., when not recommended by a doctor), Insurer deems unrelated to a subsequent medical treatment, DRS approves even though insurer denied the pre-approval request, or DRS approves to be provided outside guidelines or restrictions specified by the insurer, such as outpatient basis only. Back to Chapter Index D7. Agency Fund Code for Physical and Mental Restoration Services
[REVISED: 1/21/99] Intentionally left blank.
E. Procedures to Request Vendor Payment for Physical and Mental Restoration Services E1. Procedures to Request Vendor Payment for Physical and Mental Restoration Services [REVISED: 7/1/12] See Chapter 14.1, PURCHASING, Policy 2, Section B1. If the Authorization form included a request for post-treatment or post-dental service report, DRS staff shall not request payment to vendor until the VR counselor receives the report.