Section 4 Rehabilitation Benefits

Under Minnesota workers’ compensation law, vocational rehabilitation services can be provided to employees and surviving spouses. The intent of rehabilitation is set out in Minnesota Statutes §176.102, Subd. 1(b) as follows: “Rehabilitation is intended to restore the injured employee so the employee may return to a job related to the employee’s former employment or to a job in another work area which produces an economic status as close as possible to that the employee would have enjoyed without disability. Rehabilitation to a job with a higher economic status than would have occurred without disability is permitted if it can be demonstrated that this rehabilitation is necessary to increase the likelihood of reemployment. Economic status is to be measured not only by opportunity for immediate income but also by opportunity for future income.” The law gives employers the opportunity to bring employees back to work with the date of injury employer without formal rehabilitation. For example, employers can engage the services of disability case managers as agents of insurers to assist the employee in returning to work. If the employee requires assistance in returning to work with the date-of-injury employer or will not be able to return to work with the date-of-injury employer, a rehabilitation consultation becomes necessary to determine whether formal rehabilitation services are needed. Any party can request a rehabilitation consultation at any time. In addition, a consultation must be provided under certain conditions which are described later in this chapter.

Selection and Change of Qualified Rehabilitation Consultant (QRC)
An employee who is eligible to receive rehabilitation services has the right to choose a QRC. The employee may do this once during the period beginning before the consultation and ending 60 days after the plan is filed. The employee’s right to choose a QRC ends 60 days after the rehabilitation plan has been filed with the department. After this time period, the parties may agree to additional QRC changes. However, if the parties disagree and the employee’s right to choose the QRC has expired, the department makes the decision according to the best interest of the parties.

Disability Status Report (DSR)
To ensure that a rehabilitation consultation is provided when necessary, Minnesota Rules Part 5220.0110, Subp. 7 requires that the insurer send the employee a DSR and file a copy with the department, when any of the following occur: • within 14 calendar days of knowledge that the employee’s TTD is likely to exceed 13 cumulative weeks; or
July 2007 4-1

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Rehabilitation Benefits

• •

within 90 calendar days of the date of injury when the employee has not returned to work following a work injury; or within 14 calendar days after receiving a request for a rehabilitation consultation, whichever is earlier.

In addition, a DSR must be filed within 14 calendar days of expiration of an approved waiver of rehabilitation services. An insurer who files a DSR must refer the employee for a rehabilitation consultation or request a waiver of rehabilitation services. A rehabilitation waiver is granted when the employer documents that the otherwise qualified employee will return to suitable gainful employment with the date-of-injury employer within 90 calendar days after the request for the waiver is filed. The waiver shall not be effective more than 90 calendar days after the waiver is granted. If the insurer is requesting a waiver, please note the Instructions to Insurer on the back of the prescribed DSR form. Documentation that the employee will return to suitable gainful employment is satisfied by submitting a written offer of suitable gainful employment, signed by the employer, that is within the treating doctor’s restrictions and to which the employee will return within 90 calendar days after the waiver is filed. The department reviews all requests for waivers and notifies the insurer whether a waiver is granted or denied. If the department grants a waiver, it is only effective until 90 calendar days after the waiver is granted. A waiver of consultation and rehabilitation services may not be renewed. If a waiver is not granted, the insurer must provide a rehabilitation consultation. When referring an employee to a QRC for a consultation, the insurer must send a copy of the DSR, the FROI, and the treating physician’s RWA to the QRC prior to the consultation. If the insurer does not refer the employee for such a consultation, the department will order a consultation by the department’s Vocational Rehabilitation unit or by the employee’s choice of QRC. Example 1: Tom broke his leg while working as a roofer. The treating physician said he would release Tom to work within 85 days of the date of injury and that he will be able to resume work within certain restrictions. He can return to his job, starting at two hours a day for the first week, then four hours the 2nd week, six hours a day the 3rd week and finally eight hours a day the 4th week. The roofing company offered Tom his date-of-injury job as a roofer. The offer was in writing, effective whenever Tom is released to return to work. The insurer filed a DSR requesting a waiver and documenting the medical information and job offer. The department will grant the waiver for the following reason because the roofing company has documented that Tom will be able to return to suitable employment with the company, within the treating physician’s restrictions, and within 90 days of the date of injury.
July 2007 4-2 Basic Adjusters’ Training Guide MN Department of Labor and Industry

Rehabilitation Benefits

Example 2: As an educational assistant for K-4th graders, it was Ned’s job to serve meals to children at low tables and to lift children frequently. He sustained a low back injury and needed surgery. The treating physician said that Ned would have lifting and bending restrictions after surgery, but was not able to specify what they would be. The school district did not have employment available to accommodate lifting and bending restrictions. Because of the above, the insurer filed a DSR stating that a rehabilitation consultation would be provided. The QRC met with Ned and determined that he was qualified for rehabilitation services because he couldn’t be expected to return to his date-of-injury position or another suitable job with the employer, within the projected restrictions of the treating physician.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 4-3

Rehabilitation Benefits

July 2007 4-4

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Disability Status Report
Filed as required by Minn. Rules 5220.0110, subp. 7
D S 0 1

Enter dates in MM/DD/YYYY format.

DO NOT USE THIS SPACE 1. SOCIAL SECURITY NUMBER 2. DATE OF INJURY

3. EMPLOYEE NAME

4. EMPLOYEE ADDRESS

CITY

STATE

ZIP CODE

5. EMPLOYEE PHONE #

6. EMPLOYER

7. EMPLOYER CONTACT PERSON

8. PHONE #

9. INSURER/SELF-INSURER/TPA

12. TITLE OF JOB AT DATE OF INJURY

10. INSURER ADDRESS

13. AVERAGE WEEKLY WAGE AT DATE OF INJURY STATE ZIP CODE 15. NUMBER OF DAYS OF DISABILITY

14. JOB AT DATE OF INJURY FULL TIME PART TIME 16. IS THE EMPLOYEE CURRENTLY WORKING? YES NO

CITY

11. INSURER CLAIM NUMBER

17. WILL THE DISABILITY LIKELY EXTEND BEYOND 13 WEEKS? (see instructions on back) YES NO

18. REASON FOR FILING THE DISABILITY STATUS REPORT: (Check A or B) Was a consultation requested? Insurer A. Employer
NO YES

If yes, consultation requested by: (date of request)

Employee on

The employee is being referred for a rehabilitation consultation. (Insurer must send a copy of this Disability Status Report, the First Report of Injury, and the treating physician’s Report of Work Ability to the QRC before the rehabilitation consultation.) Name of QRC

B.

A waiver of the rehabilitation consultation is being requested. (An offer of suitable gainful employment signed by the date-of-injury employer and the Report of Work Ability must be attached.)

Projected return to work date

Name of insurer representative completing form

Phone number

Extension

Date served on employee

MN DS01 (12/05)

Distribution: Workers’ Compensation Division, Employee

Instructions to Insurer The Disability Status Report (DSR) is used to notify parties that you are either referring the injured worker for a rehabilitation consultation or requesting a waiver of the consultation. The DSR, with a Report of Work Ability (RWA), must be mailed to the injured worker and filed with the Department of Labor and Industry: • Within 14 calendar days of knowledge that the employee’s temporary total disability is likely to exceed 13 cumulative weeks; or • Within 90 calendar days of the date of injury when the employee has not returned to work following a work injury; or • Within 14 calendar days after receiving a request for a rehabilitation consultation, whichever is earlier; or • Within 14 calendar days of expiration of an approved waiver of rehabilitation services. To Refer for a Rehabilitation Consultation: If you are referring the injured worker for a rehabilitation consultation, check Box 18A. Send a copy of the DSR form, the First Report of Injury and the treating physician’s Report of Work Ability to the QRC prior to the consultation. Fill in the name of the QRC on the form and indicate which party requested the consultation. If the employee requested the consultation, fill in the date of the request. To Request a Waiver of a Rehabilitation Consultation: M.S. § 176.102, subd. 4 and Minn. Rules 5220.0110 and 5220.0120 provide that the commissioner may grant a waiver of a rehabilitation consultation to an otherwise qualified employee if there is documentation that the employee will return to suitable gainful employment with the date-of-injury employer within 90 calendar days after the request for waiver is filed. A waiver will not be granted unless documentation is submitted that a suitable job offer within the treating doctor’s restrictions has been made. If you are requesting a waiver, check Box 18B and attach the following documentation: • Report of Work Ability or other medical report with the same information from the treating doctor which indicates that the employee will be released to return to work within 90 calendar days after the request for waiver is filed and specifying the employee’s work restrictions in functional terms. • Written offer of suitable gainful employment signed by the employer that is within the treating doctor’s restrictions to which the employee will return within the timeframe indicated above. Include one of the following: • If the employer is offering the employee his/her date-of-injury job, any modifications of the job to accommodate the employee’s restrictions must be noted. If the written offer of suitable gainful employment (which does not include temporary, light-duty) is for a different job with the date-of-injury employer, the offer must include the job title, job environment, work tasks, weekly wage, physical, mental and educational demands of the job, and/or employer modifications of the job to accommodate the employee’s restrictions.

Instructions to Employee If you do not agree with the insurer’s recommendation for a rehabilitation consultation or a waiver of rehabilitation consultation, you may file a Rehabilitation Request with the Department of Labor and Industry. If you have questions call the Benefit Management and Resolution Unit at 1-800-342-5354 or 651-284-5032.

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.

ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Rehabilitation Benefits

Rehabilitation Consultation and Eligibility
The rehabilitation consultation is a meeting between the injured employee and a QRC to determine whether the employee is eligible for rehabilitation services. According to Minnesota Rules Part 5220.0100, Subp. 22, an employee is eligible if, because of the effects of an injury or disease, whether or not combined with the effects of a prior injury or disability, the employee: • is permanently precluded or is likely to be permanently precluded from engaging in the employee’s usual and customary occupation or from engaging in the job the employee held at the time of injury; and can not reasonably be expected to return to suitable gainful employment with the date-of-injury employer; and can reasonably be expected to return to suitable gainful employment through the provision of rehabilitation services, considering the treating physician’s opinion of the employee’s work ability.

• •

During the consultation, the QRC must disclose to the employee any affiliations the QRC has with the employer or insurer and must discuss the information on the “Rehabilitation Rights and Responsibilities of the Injured Worker” form. To determine the employee’s eligibility for rehabilitation services, the QRC talks not only with the employee, but also the employer and the treating doctor, when necessary. The QRC completes the Rehabilitation Consultation Report (RCR) which spells out the likelihood that the employee will return to the pre-injury employer or pre-injury occupation, and gives an assessment of whether or not the employee is a qualified employee for rehabilitation services. This form must be filed with the department within 14 days of the first in-person meeting with the employee. The QRC is required to provide copies of the RCR, a signed Rehabilitation Rights and Responsibilities of the Injured Worker form, and a narrative report explaining the basis for the determination to the employer, the employee, any attorney for the employee, and the insurer (see Minnesota Rules Parts 5220.0130, Subp. 3C(4) and 5220.0100, Subp. 31).

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 4-5

Rehabilitation Benefits

July 2007 4-6

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Rehabilitation Consultation Report
Enter dates in MM/DD/YYYY format.

R C 0 1

DO NOT USE THIS SPACE 2. DATE OF INJURY

1. SOCIAL SECURITY NUMBER 3. EMPLOYEE NAME 4. EMPLOYEE ADDRESS CITY 7. EMPLOYER NAME 10. INSURER CLAIM NUMBER 11. INSURER/SELF-INSURER/TPA 12. INSURER ADDRESS CITY 13. CLAIM REPRESENTATIVE 21. Date of rehabilitation consultation

STATE

ZIP CODE

5. EMPLOYEE PHONE NUMBER 6. DATE OF BIRTH 9. PHONE #

8. EMPLOYER CONTACT PERSON 15. QRC NAME 16. QRC FIRM 17. ADDRESS STATE ZIP CODE 14. PHONE # CITY 18. QRC #

STATE

ZIP CODE

19. QRC FIRM # 20. PHONE NUMBER

File this form with the Department of Labor and Industry within 14 days of date of rehabilitation consultation. See Minn. Rule 5220.0130, subp. 3 D. Yes Yes Yes Yes Yes Yes No No No No No No Unknown Unknown Unknown

22. Is the employee receiving assistance from employer in returning to work there? If “NO”, do you recommend such assistance in returning to the date-of-injury employer? 23. In your opinion is the employee expected to return to the date-of-injury employer? 24. In your opinion is the employee expected to return to the date-of-injury occupation? 25. Can the employee be expected to return to suitable gainful employment through rehabilitation services considering the treating physician’s Report of Work Ability? 26. Is the employee eligible for rehabilitation services at this time?

ATTACH A NARRATIVE REPORT EXPLAINING THE BASIS FOR YOUR DETERMINATION 27. QRC Signature Date

QRC: If the employee is eligible for rehabilitation services, a Rehabilitation Plan (R-2) must be developed and implemented within 30 days of the initial meeting and filed with the Department within 45 days of the initial meeting. Employee: If you disagree with or have questions about the information provided on this form, you are encouraged to contact the QRC and insurer to discuss any concerns. If your concerns are not resolved, you may call the Department’s Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354 or request a determination by filing a Rehabilitation Request with the Department. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

MN RC01 (12/05)

cc: Employee, Employer, Insurer, and Attorney(s)

Rehabilitation Rights and Responsibilities of the Injured Worker
Enter dates in MM/DD/YYYY format.

I W

0 5

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

The purpose of vocational rehabilitation is to assist you (the injured worker) so that you may return to your former job, to a job related to your former employment, or to a job in another work field. The job should be physically appropriate and produce an economic status as close as possible to that which you would have enjoyed without disability. The first step in this return to work process is a Rehabilitation Consultation with a Qualified Rehabilitation Consultant (QRC) to determine if you qualify for rehabilitation services. If the QRC determines that you are qualified, the next step is the development of a rehabilitation plan. Your QRC will help you develop and implement this plan. Consideration will be given to your former employment, the current labor market and your qualifications, including transferable skills, previous work history, age, education and interests.

YOUR RIGHTS Under the provisions of the Minnesota Workers’ Compensation Law, you (the injured worker) have certain rehabilitation rights. These rights include: • Selection of your own Qualified Rehabilitation Consultant (QRC). The employer/insurer will generally refer you to a QRC. You may choose your own QRC up to 60 days after a written rehabilitation plan is filed with the State. Any further change of QRC must be mutually agreed upon or determined to be in the best interest of the parties by the Commissioner or a compensation judge. When a QRC first meets or writes to contact you, he or she is required to disclose to you in writing, any affiliation or ownership interest between the QRC (or the QRC firm) and your employer/insurer or adjusting company. The QRC is also required to disclose to you and all parties to a case, any affiliation or business referral arrangement between the QRC (or the QRC firm) and any other parties to the case, including attorneys and doctors. If the QRC determines that you are eligible for vocational rehabilitation, a rehabilitation plan, which may include training if needed, will be developed. The rehabilitation services required to carry out the plan will be provided at no cost to you. The right to request a change in your rehabilitation plan. The right to receive a copy of your rehabilitation plan. The right to obtain a copy of any required progress records upon request. The right to request assistance from the Workers’ Compensation Division of the Minnesota Department of Labor and Industry. If you have questions about your rehabilitation plan, call 651-2845032 or 800-342-5354. If there is a dispute about your eligibility for statutory rehabilitation services or the rehabilitation plan, you may file a Rehabilitation Request and the Department may schedule an administrative conference in order to resolve the dispute.
(over)

• •

MN IW05 (12/06)

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME
I W 0 5

YOUR RESPONSIBILITIES In addition to the above rights, you (the injured worker) have certain rehabilitation responsibilities under the workers' compensation law. These responsibilities include the following: • • • You must cooperate with reasonable medical and rehabilitation examinations and evaluations as ordered by the Commissioner. You must make a good faith effort to participate in your rehabilitation plan. Failure to do so may result in suspension or termination of your rehabilitation or monetary benefits. You must advise your QRC and insurance company of your wage, hours, employer and job title when you return to work and when your hours or wages change. This is necessary to accurately calculate your wage loss benefits and to ensure rehabilitation services are appropriate. Failure to accurately report wages earned while receiving workers’ compensation benefits may result in civil or criminal consequences.

The statements below are requested to verify whether you received the documents listed and that the information on this form has been explained to you. You are not required to provide the information requested below or sign this form. Your workers’ compensation benefits will not be affected if you choose not to provide the information or sign the form. This form will be filed with the Minnesota Department of Labor and Industry, and may also be provided to the Office of Administrative Hearings and law enforcement agencies. Employee, check any that apply: The above information has been explained to me and I have been provided with a copy of this form. I have received written notification from the QRC disclosing any affiliation or business referral arrangement the QRC or QRC firm may have with any parties to my case and a written explanation of any affiliation or ownership interest the QRC or QRC firm may have with my employer/insurer, and any other insurer or adjusting company. The QRC has informed me that he/she and the QRC firm have no affiliation or ownership interest or business referral arrangement with any parties to my case or any other insurer or adjusting company.
EMPLOYEE SIGNATURE QRC SIGNATURE QRC NUMBER DATE DATE

PROVIDING THE INFORMATION ON THIS FORM TO THE INJURED WORKER IS REQUIRED BY MINNESOTA STATUTES SECTION 176.102, SUBD. 4C AND MINNESOTA RULES, PART 5220.1803, SUBP. 1 AND 1A. THIS MATERIAL CAN BE MADE AVAILABLE IN DIFFERENT FORMS, SUCH AS LARGE PRINT, BRAILLE OR ON TAPE. REQUEST, CALL (651) 284-5030 OR 1-800-342-5354 (DIAL-DLI)/VOICE OR TDD (651) 297-4198. TO

ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

The QRC must sign and date this form at the first in-person contact with the employee, and must provide a copy to the employee and the insurer. The QRC must also provide a copy of this form to the Department of Labor and Industry. Minnesota Department of Labor and Industry Workers’ Compensation Division 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5032 1-800-342-5354 (DIAL-DLI)

Rehabilitation Benefits

R-2 Rehabilitation Plan
If the employee is eligible for rehabilitation services, the QRC will write a rehabilitation plan, circulate it to all the parties for signatures, and then file it with the department, along with the Initial Evaluation Narrative report. The QRC provides the services necessary to carry out the plan. These services may consist of (but are not limited to) any of the following; medical management to facilitate the employee’s return to work, vocational evaluation, counseling, job analysis, job modification, job development, job placement, labor market survey, vocational testing, transferable skills analysis, work adjustment, job seeking skills training, onthe-job training, and retraining. The purpose of the plan is to communicate to all parties the vocational goal, the rehabilitation services to be provided, and the projected amounts of time and money needed to achieve the vocational goal. The QRC must complete a proposed plan and send it to the parties within 30 days of the consultation. Upon receipt of the proposed plan, each party must, within 15 days, either sign and return the plan to the QRC or promptly notify the QRC of any objection to the plan and work with the QRC to overcome this objection. If the objection is not resolved, the objecting party must file a Rehabilitation Request form with the department within the 15 days of receipt of the proposed plan. A plan signed by all parties is considered approved upon filing with the department. If a party fails to sign the plan or file a Rehabilitation Request within 15 days, it shall be assumed that the parties are in substantial agreement with the plan’s vocational objective and the rehabilitation services proposed.

R-3 Rehabilitation Plan Amendment
The QRC submits a Rehabilitation Plan Amendment whenever circumstances indicate that the plan’s objectives are not likely to be achieved. The procedure for filing, approval, and requirements follow the same pattern for the plan amendments as for plans.

Plan Progress Report (PPR)
The PPR is used to inform parties of the current status of the plan and provide a current estimate of the plan cost and duration. The PPR must be filed with the department (with copies to parties) within 15 days after six months have passed from the date the plan was filed. If the QRC has filed a plan amendment 15 days before or after the six month time period, it is not necessary to also file the PPR.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 4-7

Rehabilitation Benefits

July 2007 4-8

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

R-2 Rehabilitation Plan
Enter dates in MM/DD/YYYY format.

R E 0 1

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

1. SOCIAL SECURITY NUMBER 3. EMPLOYEE NAME 4. EMPLOYEE ADDRESS CITY 7. EMPLOYER NAME 10. INSURER CLAIM NUMBER 11. INSURER/SELF-INSURER/TPA 12. INSURER ADDRESS CITY 13. CLAIM REPRESENTATIVE 21. Occupation at time of injury

2. DATE OF INJURY

STATE

ZIP CODE

5. EMPLOYEE PHONE NUMBER 6. DATE OF BIRTH 9. PHONE #

8. EMPLOYER CONTACT PERSON 15. QRC NAME 16. QRC FIRM 17. ADDRESS STATE ZIP CODE 14. PHONE NUMBER 22. Pre-injury AWW CITY 18. QRC #

STATE

ZIP CODE

19. QRC FIRM # 20. QRC PHONE NUMBER

25. Highest grade completed (select one) a. No high school diploma or GED

23. Job at date of injury: 24. Employee’s work status

Part time

Full time

b. High school diploma or GED c. Some post secondary course work d. Post secondary vocational/technical program e. Bachelor’s degree f. Master’s, PhD or professional degree Yes No

a. Off work from DOI to start of rehabilitation b. Some work between DOI and start of rehabilitation, not working at start of rehabilitation c. Working at start of rehabilitation

26. Employee may require an interpreter:

27. Date of rehabilitation consultation (start date)

28. Vocation goal a. RTW same employer Comments:

b. RTW different employer

MN RE01 (6/05)

(over)

cc: Employee, Insurer, Attorney(s) or other parties

VOCATIONAL REHABILITATION PLAN SERVICE CATEGORY and CODE (from VRI) DESCRIPTION SERVICE START DATE SERVICE END DATE ESTIMATED DAYS ESTIMATED COST

TOTALS

Employee Comments:

STATEMENT OF EMPLOYER/INSURER RESPONSIBILITY: The employer/insurer understands its responsibility to pay for services reasonably required and to monitor the costs and timelines of the services. M.S. § 176.102, subd. 9 and Minn. Rules 5220.1900, subp. 1g. STATEMENT OF QRC RESPONSIBILITY: I understand that I am responsible for the timely delivery of the above specified services pursuant to M.S. § 176.102 and Minn. Rules 5220.0100-.1900 and agree to conscientiously carry out my professional duties as a Qualified Rehabilitation Consultant in the interest of the employee’s rehabilitation. Should the estimated cost of this plan be exceeded or if additional time is required for completion of the plan, I will notify the Department and the parties by submitting a Rehabilitation Plan Amendment (R-3) in accordance with M.S. § 176.102, subd. 8 and Minn. Rules 5220.0510. STATEMENT OF EMPLOYEE RESPONSIBILITY: I understand that it is my responsibility to cooperate with all parties involved in my rehabilitation and I agree to make a good faith effort to participate in this plan. This includes attendance at scheduled activities and appointments, and adherence to reasonable medical advice. TO THE PARTIES: If you disagree with the plan, you have 15 days from the receipt of the proposed plan to resolve the disagreement or object to the proposed plan. The objection must be filed with the Department on a Rehabilitation Request form. Send a copy of this plan to the employee's treating health care provider if permitted by Minn. Rules 5220.1802, subp. 5 (Minn. Rules 5220.0410, subp. 7). Attach a copy of your initial evaluation report (Minn. Rules 5220.1803, subp. 5).

Employee has read and signed the form “Rights and Responsibilities of the Injured Worker” Employee has read and declined to sign the form “Rights and Responsibilities of the Injured Worker”
Employee Signature Date

Claim Representative Signature

Date

QRC Signature

Date

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

R-3 Rehabilitation Plan Amendment
Enter dates in MM/DD/YYYY format.

R P 0 1

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

1. SOCIAL SECURITY NUMBER 3. EMPLOYEE NAME 4. INSURER/SELF-INSURER/TPA 5. INSURER CLAIM NUMBER 6. EMPLOYER NAME

2. DATE OF INJURY 7. QRC NAME 8. ADDRESS CITY 9. QRC # 10. QRC FIRM # STATE ZIP CODE

11. PHONE NUMBER

12. CHANGE OF QRC

13. WITHDRAWAL OF QRC? 14. PROPOSED AMENDMENT/RATIONALE (attach separate sheet as necessary)

Yes Yes

No No

PREVIOUS QRC #

NEW QRC #

15. EMPLOYEE COMMENTS Plan costs to date 16. Costs 17. Plan duration from plan filing date (in weeks) Duration to date + + Expected additional duration to plan completion = Other costs necessary to complete plan = Estimated total duration Estimated total cost

18. Specify any additional rehabilitation services or changes to the current plan that will be required: SERVICE CATEGORY and CODE (from VRI) DESCRIPTION PROJECTED COMPLETION DATE COST

19. Is this form being filed in lieu of a Plan Progress Report? See Minn. Rule 5220.0450, subp. 3.A. 20. Is the employee released to return to work? 21. Current work status: Not working
with

Yes

No
without

If yes, complete #20-22. Medical report date If working, is this a temporary job? Yes No

Yes, restrictions Part time Full time

Yes, restrictions Seasonal layoff

No

Yes No 22. Do barriers to successful completion of the rehabilitation plan exist? If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form. Employee Signature Date Claim Representative Signature QRC Signature Date Date

MN RP01 (8/05)

cc: Employee, Insurer, Attorney(s) or other parties

Instructions to QRC Proposed plan amendment without a change of QRC: The QRC or other parties may propose amendments to current rehabilitation plans. It is the QRC’s responsibility to facilitate discussion of proposed amendments and file the Rehabilitation Plan Amendment (R-3) form when appropriate. Once an amendment has been proposed, the QRC shall provide copies of the R-3 to the employee, insurer, and any attorneys representing the employee or insurer. The QRC shall also send a copy of the R-3 to the date of injury employer if the goal is to return the employee to work with that employer. Proposed plan amendment including a change of QRC: 1. If the employee has the right to change QRC’s without approval per Minn. Rule 5220.0710, subpart 1, the new QRC must file an R-3 with the Department of Labor and Industry within 15 calendar days of receipt of the information transferred by the former QRC. However, it is not necessary to circulate for signatures. Copies must be sent to the parties listed on the form. 2. If approval of a change of QRC is required per Minn. Rule 5220.0710 and the insurer has approved the change, the new QRC must circulate the R-3 for signatures and file with the Department of Labor and Industry within 15 days of obtaining the signatures. 3. If approval of a change of QRC is required and the insurer objects to the change, the insurer should file a Rehabilitation Request form with the Department of Labor and Industry within 15 days of the receipt of the R-3. Proposed plan amendment for withdrawal of QRC when insurer has denied further liability for the injury for which rehabilitation services are being provided: If a claim petition, objection to discontinuance, request for administrative conference, or any other document initiating litigation has been filed on the liability issue, a QRC who elects to withdraw must file the R-3 with the Department of Labor and Industry and send copies to the parties, including a separate copy to the Department’s Vocational Rehabilitation Unit. If no litigation is pending on the liability issue, the QRC may withdraw by filing an R-8 Plan Closure form if permitted by Minn. Rule 5220.0510, subp. 7. Instructions to Other Parties Within 15 days of receiving a proposed amendment: 1. If you agree with the amendment, sign the R-3 and return to the QRC; or 2. If you disagree with the amendment, notify the QRC of your objections and try to work with the QRC to resolve them. If the issues are not resolved, the objecting party must file a Rehabilitation Request with the Department of Labor and Industry within 15 days of the receipt of the R-3. NOTE: If a party fails to sign or object to a proposed amendment within 15 days of receiving the R-3, the amendment is deemed approved.

This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Plan Progress Report
Enter dates in MM/DD/YYYY format.
P R 0 1

DO NOT USE THIS SPACE

1. DATE OF THIS REPORT 2. SOCIAL SECURITY NUMBER 4. EMPLOYEE NAME 5. EMPLOYEE ADDRESS CITY 6. EMPLOYER NAME 9. INSURER CLAIM NUMBER 10. INSURER/SELF-INSURER/TPA 11. INSURER ADDRESS CITY 12. CLAIM REPRESENTATIVE STATE ZIP CODE STATE ZIP CODE 7. EMPLOYER CONTACT PERSON 14. QRC NAME 15. QRC FIRM 16. ADDRESS CITY 18. QRC FIRM # STATE ZIP CODE 8. PHONE NUMBER 3. DATE OF INJURY

13. PHONE NUMBER 17. QRC #

19. PHONE NUMBER

20. Is the employee released to return to work? 21. Current work status: 22. Is the plan still current? Not working Yes

Yes, Part time No

with restrictions

Yes, restrictions Seasonal layoff

without

Medical report date No If working, is this a temporary job? Yes No

Full time

Plan costs to date 23. Costs 24. Plan duration from plan filing date (in weeks) Duration to date + +

Other costs necessary to complete plan = Expected additional duration to plan completion = Yes No

Estimated total cost

Estimated total duration

25. Do barriers to successful completion of the rehabilitation plan exist?

If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form.

This form is required to be filed 6 months after filing the R-2 (unless an R-3 is filed 15 days before or after 6 months have passed since the R-2 filing date). See Minn. Rules 5220.0450, subp. 3 A. Send copies to the employee, insurer, and attorney(s). Send to the date-of-injury employer if the goal of the rehabilitation plan is to return to work with that employer.
This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

MN PR01 (6/05)

Rehabilitation Benefits

Kinds of Rehabilitation Services
Rehabilitation services refers to a program of vocational rehabilitation that is designed to return a person to work consistent with Minnesota Statutes §176.102, Subd. 1(b). The program consists of the delivery and coordination of services (some of which are discussed below) by rehabilitation providers under a plan.

Vocational Evaluation
Vocational evaluation is the comprehensive assessment of vocational aptitudes and potential. This brings together a qualified employee’s past history, medical and psychological status, and vocational testing results.

Medical Management
Medical management by a QRC is the provision of rehabilitation services that assist communication of information among parties about the employee’s medical condition and treatment. Medical management also consists of rehabilitation services that coordinate the employee’s medical treatment with the employee’s vocational rehabilitation services. Medical management refers only to those rehabilitation services necessary to facilitate the employee’s return to work.

Counseling
Counseling is professional guidance provided by the QRC to assist the employee in making a suitable return to work.

Job Analysis
Job analysis is a systematic study that reports work activity as follows: • • • • • What the employee does in the job is analyzed in relation to data, people, and things. What methods and techniques are employed by the employee? What machines, tools, equipment, and work aids are used? What materials, products, subject matter, or services are the result? What traits are required of the employee?

Job Modification
Job modification is altering the work environment to accommodate physical or mental limitations by making changes in equipment, in the methods of completing tasks, or in job duties.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 4-9

Rehabilitation Benefits

Job Development
Job development is systematic contact with prospective employers resulting in opportunities for interviews and employment that might not otherwise have existed. Job development facilitates a prospective employer’s consideration of a qualified employee for employment.

Job Placement
Job placement is activity that supports a qualified employee’s search for work, including; the identification of job leads, arranging for job interviews, the preparation of an employee to conduct an effective job search, and communication of information about the labor market, programs, or laws offering employment incentives, and the qualified employee’s physical limitations and capabilities as permitted by data privacy laws, among others.

Vocational Testing
Vocational testing is the measurement of vocational interests, aptitudes, and abilities using standardized, professionally accepted psychometric procedures.

Transferable Skills Analysis
Transferable skills analysis is the identification and comparison of skills learned in previous vocational or a vocational activities with those required by occupations which are within the qualified employee’s physical and mental capabilities.

Job Seeking Skills Training
Job seeking skills training is the formal teaching of independent work search skills including, but not limited to, the completion of applications, preparation of resumes, effectiveness in job interviews, and techniques for obtaining job leads.

Work Adjustment
Work adjustment is the use of real or simulated work activity under close supervision at a rehabilitation facility or other work setting to develop appropriate work behaviors, attitudes, or personal characteristics.

Labor Market Survey
Labor market survey is contacting employers in a given locale regarding the availability of employment opportunities for a graduate of a specific training program, job responsibilities, employers’ past and anticipated future hiring, physical requirements and salary.

July 2007 4-10

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Rehabilitation Benefits

On-the-Job Training
On-the-job training means training while employed at a workplace where the employee receives instruction from an experienced worker and which is likely to result in employment with the on-the-job training employer upon its completion. When an on-the-job training plan is submitted to the department, the department reviews the proposed plan within 30 days of its submission and notifies the parties of plan approval or rejection. The plan approval process is subject to the procedures under Minnesota Rules Part 5220.0410, Subp. 6. The commissioner may make a determination or pursue resolution of disputes regarding the plan consistent with Minnesota Rules Part 5220.0950, Subp. 3.

Retraining
Retraining is training for a new occupation and obtaining the necessary skills to obtain work which produces an economic status as close as possible to what the employee would have enjoyed without disability. Retraining is to be given equal consideration with other rehabilitation services and may be proposed for approval if other considered services are not likely to lead to suitable gainful employment. When the QRC determines retraining to be appropriate, the QRC completes a Retraining Plan describing the recommended course of study and circulates it to the employee, employer, and insurer for their signatures. When the QRC submits a Retraining Plan to the department with all three signatures, the department reviews the plan within a day or two of its submission, notifies the parties of its approval or denial and mails the Proof of Service to all parties with a signed copy of the Retraining Plan. For injuries from October 1, 1995 through September 30, 2000, a request for retraining of an employee must be filed with the department before the insurer has paid 104 weeks of temporary total and/or temporary partial disability benefits. For injuries on or after October 1, 2000, any request for retraining must be filed with the department before 156 weeks of temporary total and/or temporary partial disability benefits have been paid. The insurer must notify the employee in writing of this requirement, and this notice must be given before 80 weeks of temporary total and/or temporary partial benefits have been paid.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 4-11

Rehabilitation Benefits

July 2007 4-12

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

On the Job Training Plan
Enter dates in MM/DD/YYYY format.
J A 0 4

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

SOCIAL SECURITY NUMBER EMPLOYEE NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER OJT EMPLOYER NAME OJT EMPLOYER ADDRESS CITY

DATE OF INJURY

OJT JOB TITLE OJT BEGINNING DATE OJT ENDING DATE STATE ZIP CODE OJT PLAN PROGRESS EVALUATION DATE(S)

Does this OJT employer intend to hire the employee upon completion of the OJT?

Yes

No

JOB DESCRIPTION (attach a job analysis, or describe the nature of the work, giving examples of duties)

Job must be within the employee’s physical restrictions. ATTACH MEDICAL REPORT. List the skills the employee will acquire through this training:

List supplies and tools needed during training (itemize costs):

TOTAL COSTS

WEEKLY WAGES AND WORKERS’ COMPENSATION BENEFITS Weekly wages paid by OJT Employer Weekly workers’ compensation benefits paid by Insurer

Start of OJT

End of OJT

MN JA04 (12/05)

(over)

cc: Employee, Insurer, OJT Employer

RATIONALE FOR OJT: see Minn. Rule 5220.0850, subp. 2(N) [NOTE: Justification is required for plans EXCEEDING 6 months: see Minn. Rule 5220.0850, subp. 3]

ACCEPTED PLAN: If all parties are in agreement with (and have signed) this OJT Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0850, subp. 4).
Employee Signature Insurer Representative Signature OJT Employer Signature OJT Trainer Signature QRC Signature QRC Number Print or type name Print or type name Print or type name Print or type name Print or type name Phone number Phone number Phone number Phone number Phone number Date Date Date Date Date

INSTRUCTIONS TO QRC DISPUTED PLAN: To resolve a disputed OJT Plan, call the Department’s Benefit Management and Resolution Unit at (651) 284-5032, and/or file a Rehabilitation Request (see Minn. Rule 5220.0850, subp. 5). DO NOT SUBMIT A DISPUTED PLAN to the Department without attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. For Department Use Only Approved DLI Representative Signature Reason for denial: Denied Print or type name Phone number Date

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

Retraining Plan
Enter dates in MM/DD/YYYY format.
E P 0 4

DO NOT USE THIS SPACE

Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics.

SOCIAL SECURITY NUMBER EMPLOYEE NAME EMPLOYER NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER

DATE OF INJURY

CLAIM REPRESENTATIVE

PHONE NUMBER

Pre-injury job title Occupational goal(s) Certificate/Degree program title School name Program length (weeks)

Pre-injury wage

Current compensation rate

Anticipated wage (from Labor Market Survey) Program start date City, State to Program completion date

ITEMIZED COSTS: * Explain (for example, tutoring, board and lodging) Tuition/Lab/Activity fees Books/Tools Special/Unique costs* Custodial Day Care Travel/Parking Total retraining costs (excluding wage benefits) REQUIRED ATTACHMENTS: Pursuant to Minn. Rule 5220.0750, subp. 2(H), the following items MUST BE ATTACHED. a. Course syllabus/class titles. b. Physical requirements of the job for which the employee is being trained. (On-site job analysis is preferred.) c. Medical information that the training and the occupational goals are within the employee’s restrictions. d. Test results which support course choice. e. Recent labor market survey.
MN EP04 (12/05) (over) cc: Employee, Insurer

RETRAINING RATIONALE: see Minn. Rule 5220.0750, subp. 2(F)

ACCEPTED PLAN: If all parties are in agreement with (and have signed) this Retraining Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0750, subp. 5).
Employee Signature Insurer Representative Signature QRC Signature QRC Number Print or type name Print or type name Print or type name Phone number Phone number Phone number Date Date Date

INSTRUCTIONS TO QRC NOTE: Retraining is limited to 156 weeks. DISPUTED PLAN: To resolve a disputed Retraining Plan, call the Department’s Benefit Management and Resolution Unit at (651) 284-5032 and/or file a Rehabilitation Request (see Minn. Rule 5220.0950). DO NOT SUBMIT A DISPUTED PLAN to the Department without attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. For Department Use Only Approved DLI Representative Signature Reason for denial: Denied Print or type name Phone number Date

Rehabilitation Benefits

R-8 Notice of Rehabilitation Plan Closure
When an employee’s rehabilitation plan is completed and closure of rehabilitation services is not disputed, the QRC must file a Notice of Rehabilitation Plan Closure along with a Closure Report summarizing services provided. When the reason for the closure is a return to work, the QRC may not complete and file the closure report until the employee has continued working for at least 30 calendar days following the return to work. This form must be filed with the department, with copies sent to the employee and the insurer. At any time, the insurer or employee may request the closure or suspension of rehabilitation services by filing a “Rehabilitation Request” form. The commissioner or a compensation judge may close rehabilitation services for good cause, including, but not limited to the following reasons: • • • • denial of primary liability lack of medical causation employee is not cooperating with the plan employee is not likely to benefit from further rehabilitation services

Note: An insurer intending to discontinue rehabilitation benefits as well as TTD or TPD benefits must file a “Rehabilitation Request” form in addition to the NOID form.

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 4-13

Rehabilitation Benefits

July 2007 4-14

Basic Adjusters’ Training Guide MN Department of Labor and Industry

Mail completed copy to: Department of Labor and Industry 443 Lafayette Road North St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

R-8 Notice of Rehabilitation Plan Closure
Enter dates in MM/DD/YYYY format.

N R 0 1

DO NOT USE THIS SPACE

1. DATE OF REHABILITATION CONSULTATION: (#27 on R-2)

2. SOCIAL SECURITY NUMBER

3. DATE OF INJURY

8. QRC NAME

4. EMPLOYEE NAME 5. DATE-OF-INJURY EMPLOYER

9. ADDRESS CITY STATE ZIP CODE

6. INSURER/SELF-INSURER/TPA

10. QRC NUMBER

11. QRC FIRM #

12. QRC PHONE #

7. INSURER CLAIM NUMBER

13. NAME OF LAST REGISTERED REHAB VENDOR

14. VENDOR #

15. EMPLOYMENT STATUS AT PLAN CLOSURE (check one) a. Employee RTW with DOI employer b. Employee RTW with different employer c. Employee not employed (Skip to item 21) COMPLETE #16-20 IF EMPLOYEE RETURNED TO WORK 16. EMPLOYER AT PLAN CLOSURE

21. REASON FOR REHABILITATION PLAN CLOSURE (check one) (see instructions on back) a. Plan completed (employee returned to suitable gainful employment) b. Award on Stipulation/Mediation c. Commissioner or Compensation Judge Order d. Employee and insurer have agreed to close the plan

17. JOB TITLE AT PLAN CLOSURE

e. Unable to locate employee f. Death of employee g. QRC withdrawal

18. Gross weekly wage at RTW

19. RTW DATE

22. Did employee have an attorney? Yes No

23. PLAN CLOSURE DATE

20. RETURN TO WORK JOB: Same job Modified job Different job

24. Check if services provided: On-the-job training Retraining $ $ $ $ $ $ $

25. Cost of prior QRC Firm services other than placement 26. Cost of current QRC Firm services other than placement 27. Cost of any job placement and job development provided by prior QRC Firm 28. Cost of any job placement and job development provided by current QRC Firm 29. Cost of job placement and job development by Registered Rehabilitation Vendor(s) (including CARF accredited) 30. Cost of other rehabilitation services (retraining, on-the-job training, relocation, testing, etc.) 31. Total cost of rehabilitation services (add 25-30)

By signing this form, I certify that copies of this form and attachments are being sent to the insurer, any attorney(s), the Department of Labor and Industry , and if required to the VRU, and to the employee at the following address: 32. QRC signature 33. Date form completed

EMPLOYEE: IF YOU HAVE QUESTIONS ABOUT THE CLOSURE OF THIS REHABILITATION PLAN, CALL THE DEPARTMENT OF LABOR AND INDUSTRY AT 651-284-5032 OR 1-800-342-5354
MN NR01 (6/05)

Instructions to QRC

The Notice of Rehabilitation Plan Closure (R-8) form must be filed with the Department of Labor and Industry within 30 calendar days of knowledge that: (see Minn. Rules 5220.0510, subps. 7 and 7a) a. the employee has been steadily working at suitable gainful employment for 30 days or more, or the time period provided for in the plan b. the employee’s rehabilitation benefits have been closed out by an award on stipulation or award on mediation c. the commissioner or a compensation judge has ordered that the rehabilitation plan be closed and there has been no timely appeal of that order d. the employee and insurer have agreed to close the rehabilitation plan e. the QRC has been unable to locate the employee following a good faith effort to do so f. the employee has died g. the QRC decides to withdraw after the insurer has provided written notice to the employee, the employee’s attorney, the commissioner, and the QRC that the insurer is denying further liability for the injury for which rehabilitation services are being provided. In this situation, the QRC must file the R-8 and attach a copy of the insurer’s notice of denial, copying appropriate parties, including a separate copy to the Department’s Vocational Rehabilitation Unit. NOTE: This does not apply if a claim petition, objection to discontinuance, request for an administrative conference, or other document initiating litigation has been filed on the liability issue. If one of these documents has been filed and the QRC decides to withdraw, the QRC shall document the withdrawal by filing a Rehabilitation Plan Amendment (R-3). ATTACH A CLOSURE REPORT SUMMARIZING SERVICES PROVIDED. (see Minn. Rule 5220.0510, subp. 7(4)) Send copies of the R-8 to the employee, insurer, and attorney(s). If the insurer is denying further liability, send a separate copy addressed to the Department’s Vocational Rehabilitation Unit.
This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198.

Rehabilitation Benefits

Disputes about Rehabilitation
Disputes about rehabilitation can happen at any point during a claim involving one or more of the following issues: • • • • • • • • • an employee’s eligibility for a rehabilitation consultation eligibility for rehabilitation services the rehabilitation plan rehabilitation plan amendments retraining on-the-job training change of QRC rehabilitation plan closure QRC fees

According to Minnesota Rules Part 5220.0950, Subp. 1, where issues exist about an employee’s entitlement to rehabilitation services, the appropriateness of a proposed plan, or any other dispute about rehabilitation, a party may request assistance to resolve the dispute by filing a Rehabilitation Request form with the department. A Rehabilitation Response form is filed in response to this request, and the department decides how best to handle the dispute. The department may issue a Decision and Order resolving a rehabilitation dispute based on the written submissions of the parties. Alternatively, the department may order all parties to attend an administrative conference. This is a meeting during which a department representative listens to all parties’ perspectives regarding the dispute and attempts to assist them in reaching an agreement. If no agreement is reached, a Decision and Order will be issued. All rehabilitation administrative conferences are expedited according to the needs and availability of the parties. A party that disagrees with a decision of the department may request a formal hearing at the Office of Administrative Hearings. Parties sometimes use the Independent Vocational Evaluation (IVE) to clarify an employee’s job duties in relation to any physical limitations imposed by the injury. Minnesota Rules Part 5220.1801, Subp. 5 permits an IVE to be performed by a registered rehabilitation provider other than the assigned QRC when litigation is pending at the Office of Administrative Hearings or when retraining has been recommended. In other rare circumstances, a request for an IVE is sent to the department by a party on a Rehabilitation Request form. When requesting an IVE, the requesting party should be specific in the narrative portion of the form as to the

Basic Adjusters’ Training Guide MN Department of Labor and Industry

July 2007 4-15

Rehabilitation Benefits

nature of the request, why the evaluation is necessary and how this relates to the rehabilitation plan.

July 2007 4-16

Basic Adjusters’ Training Guide MN Department of Labor and Industry

CHECK BOX IF THIS REQUEST ADDS REHABILITATION ISSUES TO A PENDING REHABILITATION REQUEST SOCIAL SECURITY NUMBER

Rehabilitation Request
Enter dates in MM/DD/YYYY format.

NOTE: Before filing this form, call the workers’ compensation insurer. If that does not resolve the issue, call Workers’ Compensation Benefit Management and Resolution Unit at (651) 284-5032 (or 1-800-342-5354).

R Q

0 3

DO NOT USE THIS SPACE

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • This form must be filled out completely; otherwise, it may be returned to you. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • This form may not be used to request wage loss, medical, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee’s Employee Attorney YES NO

Employer

Insurer/TPA Self-insured

Insurer’s Attorney

QRC/ Vendor

2.

REHABILITATION ISSUES (check only those that apply) I request: a. b. that rehabilitation services/consultation be provided. Attach medical report which lists restrictions. a change of QRC (qualified rehabilitation consultant): NAME FIRM NAME T O ADDRESS PHONE # (include area code)

NAME F FIRM NAME R O ADDRESS M PHONE # (include area code) c. d. e. f. g. h. i. that the rehabilitation plan be changed. retraining or exploration of retraining. that the rehabilitation plan be terminated. that the rehabilitation plan be suspended.

that the employee’s rehabilitation expenses be reimbursed. Attach itemized bills and supporting documentation. that QRC/vendor bills be paid. Attach supporting QRC/vendor reports and itemized bills. other (explain)

MN RQ03 (11/05)

(over)

3.

Explain the details of your request. Attach all documents, such as medical reports and rehabilitation reports/bills, which support your request. A decision may be based solely on these documents, the Workers’ Compensation Division file, and the response to this form.

4.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Rehabilitation Response
Enter dates in MM/DD/YYYY format.

THIS FORM RESPONDS TO ISSUES RAISED ON THE REHABILITATION REQUEST FORM WHICH WAS SIGNED ON

R R 0 3

(date)

DO NOT USE THIS SPACE

SOCIAL SECURITY NUMBER

DATE OF INJURY

EMPLOYEE NAME

PHONE # (include area code)

EMPLOYEE ADDRESS

INSURER/SELF-INSURER/TPA

CITY

STATE

ZIP CODE

INSURER ADDRESS

EMPLOYER NAME

CITY

STATE

ZIP CODE

EMPLOYER ADDRESS

CLAIM REPRESENTATIVE NAME

CITY

STATE

ZIP CODE

INSURER CLAIM #

INSURER PHONE #

EXT

INSTRUCTIONS: • All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. • This form must be filled out completely. • The injured worker’s name, social security number, and date of injury must be written on all attached documents. • Insurers must file this form with the Department of Labor and Industry, and serve this form on the other parties, within 10 days after service of the Rehabilitation Request. All others should file this form with the Department of Labor and Industry, and serve it on all parties, within 20 days after service of the Rehabilitation Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS RESPONSE IS BEING COMPLETED BY: Employee’s Insurer/TPA Employee Employer Attorney Self-insured RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I agree disagree with the request for rehabilitation consultation/services. YES NO

Insurer’s Attorney

QRC/ Vendor

2.

IF A QRC IS BEING ASSIGNED, GIVEN NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC. NAME FIRM NAME ADDRESS SELECTED BY

b. c. d. e. f. g. h. i.

I I I I I I I

agree agree agree agree agree agree agree

disagree disagree disagree disagree disagree refuse refuse

with the request to change QRCs. that the rehabilitation plan should be changed. with the request for retraining/exploration of retraining. that the rehabilitation plan should be terminated. that the rehabilitation plan should be suspended. to reimburse the employee for rehabilitation expenses. to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for dispute.

Response to “Other”:

MN RR03 (11/05)

(over)

YOU MUST COMPLETE # 3 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 3. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely upon review of this form, its attachments, the Workers’ Compensation Division file, and the Rehabilitation Request form.

4.

Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE

NAME

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

NAME

ADDRESS

CITY, STATE, ZIP CODE

I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE

(date)

ADDRESS

ATTORNEY REGISTRATION #

CITY

STATE

ZIP CODE

PHONE # (include area code)

EXT

DATE SIGNED

WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers’ Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 Private or confidential data which you supply on this form will be used to process your workers’ compensation claim. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers’ Compensation Reinsurance Association. It may also be used in workers’ compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.

Rehabilitation Benefits

Roles of Registered Rehabilitation Providers
The department registers individuals to provide rehabilitation services, either as a registered rehabilitation vendor or as a QRC. The roles of vendor and QRC are distinct. A registered vendor provides job development and job placement under an approved rehabilitation plan. A QRC provides rehabilitation consultations and develops and implements rehabilitation plans for employees who are entitled to rehabilitation services. A QRC firm, and its employees, may provide job development and job placement services only in cases for which a QRC or QRC intern employed by that firm is the assigned QRC (see Minnesota Rules Part 5220.1250). A QRC is committed to moving the rehabilitation plan forward. The effective QRC is skilled in getting employees back to work as soon as possible while keeping the employee’s safety in mind. Good communication is at the heart of what a QRC is and does.

What to Expect from a QRC
A QRC determines whether or not an employee is a qualified employee (therefore entitled to rehabilitation services), develops a rehabilitation plan with the goal of returning the employee to suitable gainful employment, coordinates and monitors back to work efforts, and effectively communicates to keep the parties informed regarding progress of the rehabilitation plan.

Forbidden Conduct by a QRC
Minnesota Rules Part 5220.1801, Subp. 8 and 9 specify prohibited conduct by a QRC. For example, a QRC may not: • • • • • • • • engage in claims adjustment, claims investigation, or related activities. make recommendations regarding workers’ compensation monetary benefits. speak to the reasonableness of medical charges. arrange for independent medical examinations. do surveillance. provide opinions on settlement. give recommendations regarding retirement. engage in conduct likely to deceive, defraud or harm the public.

No party should ask a QRC to do any of the above activities. The rules require a QRC to be objective, and the department disciplines those who do not remain
Basic Adjusters’ Training Guide MN Department of Labor and Industry July 2007 4-17

Rehabilitation Benefits

professionally objective in conduct and in recommendations on all cases. Therefore, insurers should not pressure a QRC to do anything that suggests bias on a QRC’s part.

Professional Conduct and Accountability
Anyone may register a complaint with the department about a rehabilitation provider. Complaints about activities or services of rehabilitation providers relating to noncompliance with laws, rules, or orders should be made in writing to the department. Each complaint is investigated. The rules require cooperation by the rehabilitation provider who is the subject of the complaint. If an investigation indicates a violation of the rehabilitation rules or statute, the department may initiate a contested case hearing at the Office of Administrative Hearings under Minnesota Statutes §176.102, Subd. 3a. After the hearing, the administrative law judge of the Office of Administrative Hearings issues a report and the Rehabilitation Review Panel (RRP) makes the final decision on discipline. See Minnesota Statutes §176.102, Subd. 3 regarding the role of the RRP in matters of QRC discipline. The Panel reviews and makes a determination with respect to appeals from orders of the department regarding certification approval of QRCs and vendors. Under Minnesota Statutes §176.102, Subd. 3a, the panel has authority to discipline QRCs and vendors and may impose a penalty of up to $3,000.00 per violation, payable to the Assigned Risk Safety Account, and may suspend or revoke certification. In lieu of initiating contested case proceedings, the department may elect to enter into stipulated consent agreements regarding discipline with the subject of a complaint. Disciplinary action can consist of a fine as provided by statute, or suspension and/or revocation of registration. These outcomes are considered public information. Following the investigation of a complaint, if discipline is not warranted the department may issue a letter of instruction, or possibly dismiss a complaint as unsubstantiated. The department notifies the complainant as to the disposition of the case.

Disability Case Managers
In cases where statutory rehabilitation services are not required, the insurer may assign a Disability Case Manager (DCM) to the file. DCMs are often used for medical management issues and for return to work situations with date-of-injury employers. DCMs may be QRCs, but this is not required. DCMs can not represent themselves as QRCs or perform statutory rehabilitation services.

July 2007 4-18

Basic Adjusters’ Training Guide MN Department of Labor and Industry