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1. Determine if there is missing medical information that is required to make a decision or manage the claim
Review the claim and confirm the required reports are missing from the claim file. If necessary, call the worker and confirm the following details: - Facility or provider name and address
- The date and type of test or treatment
Request the worker’s signed consent to access medical records (when it is not already on file) when the medical provider is out of province or the medical information is not directly related to the work injury but may be impacting the worker's recovery (for example, other medical conditions, pre-existing medical conditions, etc.). Every reasonable effort should be made to obtain the worker's signed consent. When the worker’s signed consentSection 36 of the Workers' Compensation Act allows the decision maker to withhold compensation payments until a signed consent is received. cannot be obtained, the signed consent section of the Worker's Report of Accident form can be used as a signed release. Ensure any non-relevant information is severed from the document.
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Administrative tasks
Document the details of the discussion in a file note (Contact/Worker). Section 36 of the Workers' Compensation Act Refer to the internal Procedure 21.11 - Requesting Alberta Health Cost Benefit Statements. Release of medical information (C-463) form
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2. Contact the provider to request the missing report(s)
Call the provider’s office to confirm they have the required information. Verbally request the report(s) and advise a written request will be sent outlining the specific information needed. Note: The written request for a Return to Work (RTW) Centre should be emailed directly to the clinician if the contractual reporting guidelines have not been met. The decision maker can either request the report themselves or forward the request to the administrative assistant to request the reports. Provide specific information regarding the request (e.g., date of the appointment, type of treatment, type of report(s), reports related to a specific condition or part of body treated, etc.). Reporting requests may not be processed by the provider without all required information. Request the report directly from the facility where the treatment was provided, as the report provided by the facility is part of the “facility fee” that is paid. If the report is requested directly from the physician, WCB may be required to pay an additional report fee to the physician in addition to the fee paid to the facility. For out-of-province requests, include the signed Worker's Report of Injury or Occupational Disease form or the Release of Medical Information form (from step 1) with the request letter. Notes: - Administrative assistants cannot request medical reports such as visiting specialist clinic (VSC) appointments or opioid management requests. For these requests, the decision maker will send the appropriate request letter.
- X-ray films should only be obtained if a medical consultant has requested them. Refer to the 11-2 Internal consultant referrals procedure.
- Medical information gathered for the purpose of litigation should not be requested. It is subject to solicitor-client privilegeSolicitor-client privilege extends to all communications, verbal or written, of a confidential character, between the injured worker and their legal advisor directly relating to the litigation. and may also not be suitable for making claim decisions. This includes an independent medical exam (IME) arranged by a law firm or the WCB legal department. Arrange medical assessments through WCB to ensure the information is appropriate.
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Administrative tasks
Document the details of the discussion in a file note (Contact/Treatment Provider). Add the treatment provider to the participant list, if not already added. Send a file note (Medical/Details) Request Medical Reports to AA Medical Requests Team Desk and include the following information: - The name and address of the treatment provider
- Part of body, specific injury or condition
- Date of appointment
- Type of treatment
- Type of report(s), such as imaging reports, chart notes, etc.
Requests to Calgary hospitals must be faxed to the appropriate health records department. Refer to the Procedure Resource Library for hospital contact information. Send the appropriate letter in the SP000 series based on the medical reporting needed. Send a task (Medical) to the records clerk in Medical Services to request x-ray films, if needed.
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3. Confirm the missing report(s) is received
When the medical report has been received on the claim, ensure it is related and relevant to the condition or injury. If the received information is not relevant to the request or the claim, request the reporting be removed or modified, severing non-claim related information. When the medical report is received, but illegible, request assistance from a clinical or medical consultant. When the required information has been received, end this procedure. If the information is not on file: - 10 business days after the original request, proceed to the next step, or
- within the timeframe outlined in the contract for a RTW Centre, send an email to the appropriate health care consultant or performance specialist to request assistance.
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Administrative tasks
Send a file note to the Access to Information, Team Desk to review and redact non-relevant personal, third-party or confidential information. Send a file note to the Document Modification, Team Desk to remove non-relevant personal, third-party or confidential reports.
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4. Send a second request when the information is not received
If the report is not received after 10 business days of the original request, call provider to confirm they received the original request. Send a second letter and attach a copy of the initial request letter. The administrative assistant will refer the claim back to the decision maker if no report is received within 10 business days of the second request.
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Administrative tasks
Confirm the name and phone number of the facility or physician is correct. Send the Trace - 2nd Request for Reply - Service Provider (SP006D) letter with the original request letter attached.
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5. Request assistance to obtain the report(s)
When reasonable efforts have been made to obtain the missing information, the decision maker will seek assistance from an internal consultant. The internal consultant will determine the best course of action. Third requestWhen the requested medical reporting is not received within 10 business days of the second request, refer to the appropriate internal consultant to assist in obtaining the missing report. When a contracted provider's report (other than a RTW Centre) is not received, contact a WCB health care consultant.WCB health care consultants are able to assist with obtaining reports not received from contracted providers. Fourth requestIf the requested medical reporting is not received within 10 business days of the third request, send a task to the Medical Services manager designate or contact the health care consultant. The Medical Services manager designate or health care consultant will determine the best course of action based on the claim circumstances. In the rare circumstance when the decision maker or internal consultant is not successful in obtaining the reporting, the Medical Services manager or internal consultant may involve the governing bodies or professional associations to assist the decision maker with accessing the information when a physician or medical facility continually refuses to respond to the requests. The WCB investigations unit may also subpoena the physician or medical facility for the requested information if necessary.
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Administrative tasks
Request a medical consultant contact the facility or physician to obtain the report (via Case Conference with Outside Provider (CCOP) – FM555D form). Include the medical facility's name, address, telephone number, dates of previous requests, and other pertinent information. Follow the 11-2 Internal consultant referrals procedure Call or send an email to the appropriate WCB health care consultant. Send a high-priority task to the Medical Services manager designate with summary line “difficulty obtaining medical facility report” after three requests. Include the medical practitioner's or medical facility’s name, the dates of previous requests and any other pertinent information. Refer to the Medical issues handled by Medical Services managers document in the Procedure Resource Library.
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