Archived - Additional entitlement decision procedure

Detailed business procedure

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1. Review the claim to determine if additional entitlement needs to be addressed Before contacting the worker, take the time to fully review and understand the information on the claim file, and get an understanding of the worker’s injury, their workplace environment and what they may need to assist in determining additional injury entitlement. Determine what information is required to make the entitlement decision and anticipate questions that may arise during the conversations with the worker and employer. When reviewing the documents on the claim file, confirm: The type of additional injury or illness that is being reported and whether the medical reporting confirms a diagnosis. If the worker has any previous claims and if the injury or illness is a pre-existing condition. This information helps to set a pre-accident baseline and determine the impact of the work injury to the pre-existing condition. If the injury or illness results in time off work. Any possible third-party action claims. Any consideration indicated in the Additional diagnoses section.	Administrative tasks Refer to Policy 03-02, Part II, Application 1 and the 1-6 Aggravation of a pre-existing condition procedure.
2. Contact the worker, employer and treatment providers This is an important step in the additional entitlement decision process, as it involves all parties sharing information about the injury, the worker’s and employer’s needs, possibilities for modified work and details about the claims process and what to expect along the way. Contact the worker, employer and/or treatment provider(s) to obtain any outstanding information required to make an entitlement decision on the additional injury or illness. If the diagnosis is unclear, discuss any referrals or assessments needed to confirm the diagnosis and its relationship to the work injury. When speaking to the worker ask: How did the additional injury or illness occur (mechanism of injury [MOI])? How does the additional injury or illness relate to the work accident or injury? Where did treatment take place? Is the information already on file? Do you have any pre-existing conditions? When speaking to the employer: Discuss the accident and injury/illness and clarify any information that is inconsistent or missing. Confirm whether the employer agrees with the additional injury or illness as reported by the worker? Educate the employer about the nature of the worker’s additional injury and the important role the employer plays in the worker’s recovery. Discuss what modified work is available to the worker. Determine if the employer is facing any challenges while their worker is hurt and away from work. Encourage them to stay connected with their worker and keep the worker engaged in the workplace while they recover. When communicating with the health care provider via telephone or letter, confirm: Diagnosis for the additional injury or illness and treatment recommendations. The degree of the disability. The worker’s fitness for work and opportunities for safe modified work.	Administrative tasks Document the discussion in a file note (Contact/Worker Contact/Employer Contact/Treatment Provider Contact). Send the Claimant Custom (CL000A) letter outlining the plan for making the entitlement decision if appropriate.
3. Gather missing information and make referrals, if appropriate Request any missing medical information from the treatment provider if required. Once outstanding reports are on file and if entitlement is not clear, request a review from the appropriate internal consultant. If medical evidence confirms that the worker has a pre-existing condition, consider if the compensable accident worsened the pre-existing condition. Refer to Policy 03-02, Part II, Application 1Application 1, Aggravation of a Pre-existing condition.. When the diagnosis is not confirmed or is uncertain, consider if a referral or assessment is needed to verify the diagnosis and the relationship to the work injury. Referrals or assessments may include: Medical or psychological opinion when there are questions about the relationship of the injury to the work accident, Medical status exams, Independent medical exams, Psychological assessment, Hearing assessment, Vision assessment, Investigation Unit referral when all attempt to gather information (e.g., reporting from the worker, employer, witness statements, etc.) have been unsuccessful.	Administrative tasks To request outstanding medical reports, refer to the Additional diagnoses and specific circumstances section for the letter type. Follow the appropriate procedure: 1-6 Aggravation of a pre-existing condition 4-1 Medical testing, referrals and program support 11-1 Requesting medical reports 11-2 Internal consultant referral
4. Review and make an entitlement decision Review all information on the file and determine if the medical information supports the additional injury or illness entitlement. The additional entitlement decision has three outcomes: Accepted It is confirmed that the additional injury is work-related. Medical investigation Further medical investigation is required to determine additional entitlement. In some cases, workers may qualify for wage replacement benefits during the medical investigation. Refer to the 1-4 Benefits during a medical investigation procedure and return to this step when a decision can be made. Not accepted/inactive It is determined that the additional injury is not related to the work incident or injury. The decision maker was unsuccessful in making contact with either the worker or employer and there is missing information.	Administrative tasks Complete/Update the appropriate eCO screens: Injury Details Treatment Details Return to Work Work Restriction Employment
5. Communicate the decision and the next steps Call the worker and employer to discuss the decision to accept or not accept the additional diagnosis. When speaking with the employer, only information related to the accepted additional diagnosis should be discussed. Information related to additional diagnoses not accepted should not be disclosed. Clearly explain the information considered to make the decision (referencing policy, medical information, and any important background information) during the discussion. Communicate the decision in writing. If the additional injury or illness is not accepted, continue to manage the claim for the accepted injury. If the worker agrees, consider a referral to WCB’s Community Support Program. This program can connect workers with various agencies and organizations across the province for additional support outside of the workers’ compensation system. If the additional injury or illness is accepted, emphasize that the worker’s recovery is the top priority. Discuss the next steps in the care plan including treatment, benefits (e.g., wage replacement benefits, travel, expenses, etc.), return-to-work-details and plans for follow-up conversations. Offer additional services if eligible. When no further care planning is required, advise the worker and employer that the file will be closed and ensure all benefits have been paid. Let the worker know that their file can be reopened at any time in the future if there are any concerns or additional information related to their claim. If a permanent clinical impairment is anticipated, explain that the impairment may be assessed based on the reporting on the claim file, or the worker may undergo a medical review with an independent medical examiner 24 months after the date of accident or most recent surgery. Send the file to the case assistant with a detailed file note on what is to be monitored.	Administrative tasks Document the discussion in a file note (Contact/Worker Contact or Employer Contact). Send the appropriate decision letter. Refer to the additional diagnosis section below for the correct letter type. Or modify the Cl041K to outline the decision requiring communication. Refer to the Community Support Program site on the internal Electronic Workplace. Follow the appropriate procedure: 3-1 Modified Work 3-2 Collaborative care planning
6. Monitor the claim for any ongoing needs Continue to keep in contact with the worker every two weeks and the employer every six weeks, or as soon as the worker has achieved the ability to return to either modified or full work in order to assist with facilitating their return to work. Together, discuss the worker’s progress, evaluate their fitness for work, and discuss modified work opportunities. Also, issue the appropriate benefits and arrange services as required. If a permanent clinical impairment is suspected, the impairment may be assessed on the reporting on the claim file, or the worker may undergo a medical review with an independent medical examiner 24 months after the date of accident or most recent surgery.	Administrative tasks Follow the appropriate procedure: 3-1 Modified work 3-2 Collaborative care planning Document any new entitlement decision made in a file note (Entitlement Decision). Document discussions in a file note (Contact/Claimant or Employer or Modified Work/Employer or Claimant). Once the worker's fitness for work has been determined, send the appropriate fit for work letter in the CL041 series. Otherwise, send a Care Plan Conclusion (CL041E) letter as required.

Additional diagnoses and specific circumstances

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Second Injury A second injury is a new and distinct impairment or disease occurring as a consequence or complication of a compensable injury. The decision maker reviews entitlement for a second injury in accordance with Policy 03-01, Part II, Application 2. When a second injury is reported, either by the worker, treatment provider or medical reporting, determine if the injury occurred as a direct result of: A WCB approved medical or rehabilitation treatment for a compensable injury, or A weakened limb or failure of a prosthesis or appliance related to a compensable injury. If the above criteria do not apply, it is not a second injury. If it is not a second injury, consider whether the injury is a separate concurrent conditionA concurrent condition is a non-compensable condition that exists at the same time as the compensable disability.. For more information on concurrent conditions, refer to the Policy 04-02, Part II, Application 1, Question 11. If a worker reports that an incident occurred on a WCB owned or leased property (e.g., Millard Health), document the details, refer the worker back to that property to report the incident, and report it to Finance. When the injury is not accepted as a second injury, treatment for the second injury is not authorized. Continue to manage the claim for the compensable injury. If the injury occurred on property not leased or owned by the WCB, the worker may have a claim against the occupier or owner of the facility. The WCB does not have any involvement in the process. When the injury is accepted as a second injury, continue to manage the second injury on the same claim and update the care plan, as needed. The worker is eligible for the same benefits and services as for the work-related injury. If there is a possibility of third-party action, notify the WCB Legal Department of the injury that has been accepted and the circumstances of the incident. Third-party actionFor WCB purposes, a third party is a person not covered under the WCA who causes or contributes to an accident. may be considered where the second injury occurred as a result of the fault of a third party not covered by the Act (e.g., medical malpractice, defective prosthesis, etc.). Refer to Policy 07-02, Part II - Application 6 - Third party recoveries and the Third-party claims section in the 1-1 Initial entitlement decision procedure. Review the claim for cost transfer if the second injury is accepted. Refer to Procedure 12-1 Cost relief, cost transfer and cost allocation .	Administrative tasks Document the discussion in a file note (Contact/ Claimant Contact) including the details of the incident. Send the appropriate letter depending on the claim circumstances. When a detailed explanation of the entitlement decision is required, modify the template of the CL041K letter. The letter must clearly explain what second injuries and medical treatment have been accepted and not accepted. Update the secondary codes tab in the claim folder as well as the injury details screen.
Sexual dysfunction- paraplegic, quadriplegic and severe injury When sexual dysfunction is reported, either by the worker, treatment provider or medical reporting, determine if the dysfunction occurred as a direct result of the compensable accident. Identification of a work-related sexual dysfunction may come from: Family physician Hospital staff Canadian Paraplegic Association (CPA) counsellor CPA Registered Nurse Worker Spouse/adult interdependent partner Medical Consultant Counsellor Other sources When there is no confirmed diagnosis, ask the worker to speak with their treating physician for a referral to a specialist (e.g., urologist or gynecologist). Consult with a medical consultant, if assistance is needed to confirm the cause or severity of the sexual dysfunction, health implications, pre-existing conditions, non-organicNon-organic means there is no physical cause. based sexual dysfunction and permanent clinical impairment (PCI). If accepted, the decision-maker assists the worker and spouse/adult interdependent partner in coping with sexual dysfunction by providing counselling, medical treatment, and aids for sexual function and reproduction. Treatment/Counselling Once the issue has been identified, the decision maker can refer the worker for counselling specializing in sexual dysfunction which can provide education on conservative and invasive treatments. Authorize the purchase of an appliance(s) or medication prescribed for sexual dysfunction. Medications are authorized if prescribed by a physician. For worker/spouse/adult interdependent partner appliance purchases, a report from the service provider or prescription from the treating physician is required. Family Planning Under Policy 04-07, Part II Application 3, we may provide assistance for family planning to severely injured workers if the worker has a functional disability resulting from their compensable injury. Encourage the worker to speak with the treating physician for a referral to a facility for family planning. Discuss the WCB responsibility for family planning assistance and explain the authorization process. Contact the Health Care Consultant for fertility clinic service providers. The treating physician will make the referral. Notify the fertility clinic of pending WCB responsibility for family planning assistance and request a report on the treatment plan and estimated costs. Review the fertility treatment plan and estimated costs. Consult with the medical consultant for clarification of the treatment plan, if needed. Authorization of the treatment plan and costs is based on an appropriate treatment facility nearest to the worker's place of residence. If the worker requests to change to a different facility, the difference in cost may be the responsibility of the worker. Review and action recommendations from the supervisor as appropriate. Communicate the decision verbally and in writing including the rationale to approve or not approve the treatment. Be sensitive to the circumstances of the injury and treatment. Send a copy of the letter to the treating physician and the fertility clinic. Include the following information: All accepted costs for treatment. The level of entitlement for treatment. When further WCB approval is required (e.g., repeat treatment, change in treatment, etc.). That the worker is responsible for any medical complications of conception, pregnancy, and delivery, pre-natal and post-natal care for mother and child, the child's health or medical treatment, custody issues and other child rearing or medical costs. Review and appeal information. Monitor the treatment and review and action requests for repeat treatment and/or cost overruns. Obtain approval from the appropriate level of authority when additional costs for treatment are identified.	Administrative tasks Contact the Health Care Consultant for sexual health and education service providers. Issue payment for the appliance and/or medication. Request payment using TOP/NOP code MS02 (appliances), MS05 (dressings), or MS13 (medications). For fertility treatment, send a file note (Line) with the description “Fertility treatment plan” to the supervisor for approval and attach to the appropriate lines (e.g. Authorized Medication, Severe Injury, etc.) Submit a proposal to the supervisor requesting approval to proceed with the fertility treatment plan. Include details related to the recommended treatment, estimated costs including other applicable costs (e.g., travel and subsistence allowance), and any identified concerns. Send the Claimant Custom (CL000A) letter. Prepare two originals of the letter to the worker. In the letter, request that one original be signed by the worker and spouse/adult interdependent partner and returned to the WCB. Signatures are obtained in an effort to confirm understanding of the terms and agreement.
Temporomandibular Joint Disorders (TMJ) The decision maker determines additional entitlement to benefits and services for TMJ disorders in consultation with a dental consultant, and if required, the medical consultant. When investigating entitlement for TMJ, request the following: A report of the dental damage. A detailed dental history, including any pre-existing TMJ concerns and x-rays. A report with an outline of the proposed treatment. Complete medical (if appropriate) and dental history (work related and non-work related). List of medication prescribed as a result of the work-related injury. Information about the worker's future oral hygiene needs (e.g., will the worker need an electric toothbrush, special appliance or required aid). A report of anticipated TMJ disorder/dental damage, if any and its causes. A report of anticipated repairs, TMJ treatment and/or maintenance. Once the information has been gathered, refer the claim for a dental medical review requesting an opinion to confirm: If a causal relationship exists between the work injury or activity and the TMJ problems, If the work injury or activity aggravated a pre-existing condition and whether the aggravation is temporary or permanent, and The recommended treatment. The dental consultant provides a dental opinion in response to the questions outlined in the file note. If a dental opinion cannot be provided based on the claim information, the dental consultant refers the claim back to the decision maker to request the necessary information. The decision maker reviews the dental consultant's opinion and makes a decision to accept or not accept the TMJ disorder as an additional injury/illness and recommended treatment.	Administrative tasks Send the Request Initial Dental Assessment (SP001A) letter to request missing dental reports. Add the Dental Treatment line and complete the Benefit Details screen. Attach dental reports to the Relevant Documents screen. Note: When dental x-rays and photos are received, the exam document coordinator sends a file note to notify the decision maker. The decision maker confirms that all x-rays / photos are received before sending a dental consultant referral. Dental x-rays/photos can be mailed or emailed. Follow the 11-2 Internal consultant referrals procedure Send the appropriate letter to the treatment provider: Dental Treatment Approved (SP001B) letter Dental Treatment Not Approved (SP001C) letter Send the appropriate letter communicating the decision. An entitlement decision letter or care plan update (CL041 series).
Psychological injuries on compensable physical injury claims When a worker has a compensable physical injury and develops a psychological injury as a result of the compensable physical injury, the worker may be eligible for additional entitlement in the following circumstances: Traumatic onset psychological injury on a physical injury claim. A worker may suffer a traumatic onset psychological injury on an already accepted claim when the circumstances that led to the physical injury meet the criteria to be considered a traumatic incident under Policy 03-01, Part II, Application 6. For additional information, refer to the Traumatic onset psychological injury on a physical injury claim section below. Emotional reaction to compensable physical injury or treatment on a physical injury claim. A worker may develop a psychological condition due to difficulty adjusting to the physical injury and/or its treatment. For additional information, refer to the emotional reaction to compensable physical injury or treatment on a physical injury claim section below.
Traumatic onset psychological injury on a physical injury claim A worker may suffer a traumatic onset psychological injury on an already accepted claim for a physical injury when the date of accident mechanism of injury (MOI) for that compensable physical injury meets the criteria to be considered a traumatic incident under Policy 03-01, Part II, Application 6, Question #5. Under Policy 03-01, Part II, Application 6, traumatic onset psychological injury is compensable when it is an emotional reaction in response to a single traumatic work-related event or a cumulative series of traumatic work-related events experienced by the worker. A traumatic event(s) is defined as a direct personal experience of an event or directly witnessing an event that, reasonably and objectively assessed, is: sudden/unexpected, frightening or shocking, having a specific time and place, and involving actual or threatened death or serious injury to oneself or others or threat to one’s physical integrity (i.e., assault). Call the worker to discuss the psychological issues or stressors they are experiencing. Explain that a questionnaire and release of medical information form will be sent to them. Ask that they complete and return these documents. Questions to ask the worker: How are you feeling? How are you sleeping? What is going well? What is not going well? Do you have any concerns about return to work? What does a typical day look like for you? When the accepted MOI for the compensable physical injury was: Not a traumatic incident, review the claim to determine if the psychological/psychiatric condition may be a reaction to the worker's injury or compensable treatment. Refer to the Emotional reaction to compensable injury/treatment on a physical injury claim. A traumatic incident, the worker may be offered 5 counselling sessions. Notes: When there will be a delay in making an entitlement decision for a psychological injury, five counselling sessions are offered to gather information. When a significant psychological barrier is clearly not related to work, but it hinders the worker's recovery from a compensable injury, up to five sessions of counseling may be offered. This is applicable if the worker cannot obtain suitable treatment due to financial constraints or limited community resources. These sessions aim to address the barrier and facilitate progress in the care plan for the compensable injury. If the worker accepts the offer of counseling, approve treatment with an authorized provider. Should they decline, continue to monitor and consider repeating the offer in two weeks if symptoms persist or do not improve. If the worker has completed five counselling sessions, determine if an extension is required or if the symptoms are resolving/resolved. An entitlement decision for psychological injury should be completed after no more than ten counselling sessions. Review the claim to determine if medical information/evidence supports: A confirmed DSMDSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders. DSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders.psychiatric or psychological diagnosis. A DSM psychological diagnosis is required to determine entitlement for a psychological injury. A pre-existing psychiatric/psychological diagnosis If presumptive coverageWCB recognizes that certain occupations (i.e., first responders, emergency dispatch, correctional officers) routinely expose workers to traumatic events. Presumptive coverage means that the Workers' Compensation Board (WCB) presumes that a confirmed DSM psychological or psychiatric injury occurred due to an incident at work or work exposures. WCB recognizes that certain occupations (i.e., first responders, emergency dispatch, correctional officers) routinely expose workers to traumatic events. Presumptive coverage means that the Workers' Compensation Board (WCB) presumes that a confirmed DSM psychological or psychiatric injury occurred due to an incident at work or work exposures. applies. Refer to the Policy 03-01, Part II, Application 6 and the 1-1 Initial entitlement decision procedure, psychological injury section for information on presumptive coverage. Request clarification or additional information from the treating physician, psychiatrist or psychologist if the diagnosis is unclear or there is evidence of a pre-existing condition. Note: A psychiatric or psychological condition can be diagnosed by a physician (including psychiatrists), psychologist, a clinical social worker or a nurse practitioner. Psychiatric diagnoses are made by psychiatristsPsychiatrists are medical doctos who can prescribe medications as a course of treatment.. Psychological diagnoses are made by psychologistsPsychologists are not medical doctors and cannot prescribe medications. Their focus is on treating emotional and mental suffering in patients with therapy and behavioral intervention.. Both psychologists and psychiatrists use the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose conditions. Policy 03-01 Part II - Addendum A provides the current DSM version for WCB use. Once all the medical and psychological information has been gathered, determine entitlement for the DSM psychiatric/psychological diagnosis. If assistance is required in determining entitlement, consider: A referral to a medical consultant when the majority of the available reporting is from a physician (including psychiatrists) or there is a combination of physician, psychiatric and psychological reporting. A referral to a psychological consultant when the majority of the available reporting is from a psychologist. Whether further psychological assessment is needed to confirm a DSM diagnosis and relationship to the work injury. Refer to the Psychological/Psychiatric Assessments section below. Psychological/Psychiatric Assessments Assessments to consider may include: A comprehensive psychological assessment (CPA), A psychiatric independent medical examination (IME) or Both, a CPA followed by a psychiatric IME. WCB uses the “but for” test to determine if a worker has developed a traumatic onset psychological injury on a compensable physical claim. A CPA is not always required to confirm the physical injury/treatment was necessary for the development of the psychological/psychiatric condition (i.e., A CPA may or may not be necessary to confirm the "but for" standard of causation is met). Refer to the 4-1 Medical testing, referrals and program support procedure. When referring for both a CPA and an IME the CPA should be completed first, so the IME examiner has the information available. Consider a CPA when: There is no DSM diagnosis, or the diagnosis is unclear. There is a delayed onset of the psychiatric or psychological condition. Causation must be confirmed. The worker's symptoms are not resolving with treatment. There are concerns about validity issues. Consider a psychiatric IME when: There is no DSM diagnosis, or the diagnosis is unclear. There is a significant pre-existing or concurrent psychiatric condition. There are medical factors that may be contributing to the psychiatric presentation. It has been recommended by a CPA, medical consultant or psychological consultant. Review all the information including psychological assessment results, medical or psychological consultant's opinion, and make a decision to accept or not accept the psychological/psychiatric diagnosis. Upon confirmation of a DSM psychological diagnosis, review all pertinent information, including the results of the psychological assessment and the medical or psychological consultant's opinion. Make a decision to accept or not accept the psychological diagnosis. Call the worker to discuss the decision including additional recommendations for treatment and the next steps in their care plan. When speaking with the employer, only information related to the accepted psychological injury should be discussed. Information related to non-compensable psychological issues should not be disclosed. Communicate the decision in writing. If the psychological or psychiatric diagnosis is not accepted, recommend the worker consult with their treating or family physician to organize support and treatment. Additionally, if the worker consents, consider a referral to Community Support Services.	Administrative tasks Document the discussion in a file note (Contact/Claimant). Send the: Claimant custom letter (CL000A) General information questionnaire for emotional injuries (C844) Release of medical information (C463) Follow the 4-3 Psychological counselling procedure. Send the appropriate letter: DSM Confirmation Physician (SP026J) DSM Confirmation Psychologist (SP026K) Request Medical Physician (SP006A) Request Medical Psychiatrist (SP006H) Psychological Report Request (SP021D) From the eCO create a referral screen complete the appropriate referral: The Medical Consultant Review (FM555C) form The Psych Entitlement, Care Plan & Fitness for Work Referral (FM555M) form Refer to the CPA tool to assist in determining whether a CPA is required to make the entitlement decision: internal Electronic workplace (EW) > Business Tools > Psychological Injury Management > Home/Overview > CPA tool. Send the appropriate letter outlining the decision: Care plan update (CL041F) Entitlement Update (CL041K) Insured Custom Letter (IN000A) Note: If the letter includes confidential information that is not to be disclosed to the employer, refrain from sending a copy of this letter. Add the Mental Health Line and complete the Benefit Details tab authorizing treatment, if required. Refer to the Community Support Program site on the internal Electronic Workplace.
Emotional reaction to compensable physical injury or treatment on a physical injury claim An emotional reaction to a compensable physical injury or its treatment occurs when a worker develops a psychological or psychiatric condition due to difficulty adjusting to the compensable physical injury and/or its treatment. This includes situations involving re-employment services when a career change is necessary or when the worker is engaged in complex, long-term planning. Review the information that indicates a worker is experiencing stress or psychological barriers. Indicators of stress or psychological barriers may include: Reports from the treating physician, return-to-work provider, other treatment providers (e.g., medical status examination (MSE), functional capacity evaluations (FCE), psychological counselling reports or other medical assessments). Observations from the re-employment provider, family members, the employer, co-workers etc. Reports from review/appeal bodies who recommend investigations into a psychological disability. Requests to approve payment for new prescriptions, anti-anxiety medication or sleep disturbances. Call the worker to discuss the psychological issues or stressors they are experiencing. Ask: How are you feeling? How are you sleeping? What is going well? What is not going well? Do you have any concerns about return to work? What does a typical day look like for you? When the barriers are related to the compensable injury or it if is unclear if there is a relationship, offer up to five psychological counselling sessions. Five counselling sessions can be approved at a time when there will be a delay in making an entitlement decision for a psychological injury. An entitlement decision should be completed after no more than ten counselling sessions. Note: In rare circumstances, up to five sessions of psychological counselling can be offered where: There is a significant psychological barrier preventing recovery of the compensable physical injury, and The barrier is clearly unrelated to the compensable injury, and The worker is unable to access appropriate treatment due to financial issues or lack of community access. Monitor and determine entitlement for psychological injury Monitor the worker's progress in counselling to determine if the worker's symptoms are resolving. After completing five counselling sessions review the worker's status. If the worker's symptoms have resolved, do not continue with this procedure. Review any requests for an extension of treatment. Refer to the 4-3 Psychological counselling procedure to determine if an extension of treatment can be authorized. Whether a treatment extension is approved or not, if the worker's symptoms have not resolved after five counselling sessions, review the claim information to determine if the medical information supports a confirmed DSMDSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders. DSM refers to the Diagnostic and Statistical Manual of Mental Health Disorders. The manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose psychiatric disorders.psychological diagnosis. Notes: A DSM psychological diagnosis is required prior to determining entitlement for a psychological injury. This may include entitlement for an aggravation of a pre-existing psychological/psychiatric diagnosis. A psychiatric or psychological condition can be diagnosed by a physician (including psychiatrists), psychologist, a clinical social worker or a nurse practitioner. Psychiatric diagnoses are made by psychiatristsPsychiatrists are medical doctos who can prescribe medications as a course of treatment.. Psychological diagnoses are made by psychologiPsychologists are not medical doctors and cannot prescribe medications. Their focus is on treating emotional and mental suffering in patients with therapy and behavioral intervention.sts Both psychologists and psychiatrists use the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose conditions. Policy 03-01, Part II, Addendum A provides the current DSM version for WCB use. When the information is unclear or does not provide a DSM diagnosis, call the physician or psychologist to obtain additional information or clarification and send the appropriate letter. If assistance is required to determine entitlement or whether further psychological assessment is needed, consider: A referral to a medical consultant when the majority of the available reporting is from a physician (including psychiatrists) or there is a combination of physician, psychiatric and psychological reporting. A referral to a psychological consultant when the majority of the available reporting is from a psychologist. Psychological assessments can help confirm the DSM diagnosis and relationship to the work injury. Assessments to consider include: A comprehensive psychological assessment (CPA), A psychiatric independent medical examination (IME) or Both a CPA followed by a psychiatric IME. WCB uses the “but for” test to determine if a worker has developed a psychological condition due to their compensable physical injury or treatment of their compensable physical injury claim. A CPA is not always required to confirm that the physical injury/treatment was necessary for the development of the psychological/psychiatric condition (i.e., a CPA may or may not be necessary to confirm the “but for” standard of causation is met). Refer to the Policy 03-01, Part 2, Application 6, Question 2 and Policy 02-01, Part II, Application 7, Questions 5 and 7 When referring for both a CPA and an IME the CPA should be completed first, so the IME examiner has the CPA information available. Consider a CPA when: There is a delayed onset of the psychiatric or psychological condition. Causation must be confirmed. There are concerns about validity issues. Consider a psychiatric IME when: There is a significant pre-existing or concurrent psychiatric condition. There are medical factors that may be contributing to the psychiatric presentation. It has been recommended by a CPA, medical consultant or psychological consultant. Upon confirmation of a DSM psychological diagnosis, review all pertinent information, including the results of the psychological assessment and the medical or psychological consultant's opinion. Decide to accept or not accept the psychological diagnosis. Call the worker and the employer to discuss the decision including additional recommendations for treatment and the next steps in the care plan. When speaking with the employer, only information related to the accepted psychological injury should be discussed. Information related to non-compensable psychological issues should not be disclosed. Communicate the decision in writing. If the psychological or psychiatric diagnosis is not accepted, recommend the worker consult with their treating or family physician to organize support and treatment. Additionally, if the worker consents, consider a referral to Community Support Services.	Administrative tasks Document the discussion in a file note (Psychology) documenting the discussion. If the worker declines the offer of counselling, monitor and repeat the offer again in two weeks if symptoms are not subsiding. If the worker accepts the offer of counselling, initiate the referral to an authorized provider. Refer to the 4-3 Psychological counselling procedure. Document the discussion in a file note (Psychology) documenting the discussion. Send a letter to the appropriate letter: DSM Confirmation Physician (SP026J) letter DSM Confirmation psychologist (SP026K) letter Request Med Psychiatrist (SP006H) letter From the eCO create a referral screen complete the appropriate referral: The Medical Consultant Review (FM555C) form The Psych Entitlement, Care Plan & Fitness for Work Referral (FM555M) form Refer to the CPA tool to assist in determining whether a CPA is required to make the entitlement decision: EW > Business Tools > Psychological Injury Management > Home/Overview > CPA tool. Document the discussion in a file note (Psychology). Send the appropriate letter outlining the decision: Care plan update (CL041F) Entitlement Update (CL041K) Insured Custom Letter (IN000A) Note: If the letter includes confidential information that is not to be disclosed to the employer, refrain from sending a copy of this letter. Add the Mental Health Line and complete the Benefit Details tab authorizing treatment, if required. Refer to the Community Support Program site on the internal Electronic Workplace.

Supporting references

Policies

Workers’ Compensation Act

Applicable Sections

Section 1 (1-3)- Interpretations
Section 22 (1-7)- Action vests in the board
Section 24 (1-7)- Eligibility for compensation
Section 38 (1-4)- Medical examinations and investigations
Section 54- Reduction or suspension of compensation benefits
Section 56 (6)- Compensation for disability
Section 61 (1-2)- Recurrence of disability
Section 63- Determining impairment of earing capacity
Section 78 (1-3)- Provision of medical aid
Section 80 (1-2)- Amount of medical aid
Section 89 (1-3)- Board to provide vocational and rehabilitation services

WCB Procedures

Additional entitlement decision - Archived Nov 17, 2025

Procedure summary

Detailed business procedure

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Additional diagnoses and specific circumstances

Administrative tasks

Treatment/Counselling

Family Planning

Administrative tasks

Administrative tasks

Psychological/Psychiatric Assessments

Administrative tasks

Monitor and determine entitlement for psychological injury

Administrative tasks

Supporting references

Policies

Workers’ Compensation Act

Workers' Compensation Regulation

Related Legislation

Procedure history