1. Determine whether a claim entitlement investigation is needed
An investigation can be used to gather important missing information when it is needed to make an entitlement or other decision on a claim. Refer to Key Information for situations that may require an investigation. Consider all options before making a referral Determine what information is missing and whether that information is required to make the entitlement decision or whether there is sufficient information to make the decision. If the entitlement decision can be made without obtaining additional information, do not proceed further with this procedure. Before making the referral, confirm the following has been completed: - Worker information:
- A detailed statement from the worker is on file.
- The worker's statement has been reviewed, and the claim discussed to confirm or clarify concerns.
- Witness names and contact information have been provided by the worker.
- Allegations have been identified to determine if they meet policy criteria.
- Employer information:
- The file has been discussed with the employer, addressing their concerns.
- Witness names and contact information have been provided by the employer.
- If the employer is conducting their own investigation, confirm its status or completion timeline.
- Determine if the employer's investigation is relevant to the allegations being investigated.
- Confirm if the employer is willing to provide a copy of their investigation upon completion.
- Industry specialist referral has been made to gather required documents from employer after multiple requests were not successful.
- Medical information:
- Written requests for missing medical information have been sent.
- A referral was sent to the Medical Services Department to help obtain missing medical information after multiple unsuccessful requests to gather the medical reports.
- Media submissions:
- All media submissions (e.g., video and audio recordings, pictures, emails, social media information, etc.) has been reviewed to determine if can be used to make the entitlement decision or if further investigation is needed.
- If any media indicates possible abuse or misuse of the system, refer to Internal Library resources for guidance and initiate an investigation if necessary.
Once all attempts to gather the information have been exhausted: - Determine if the worker or employer have met their duty to cooperate in the claims process. Follow procedure 3-3 Duty to cooperate for more guidance, when necessary.
- Go to the next step to make a claim entitlement investigation referral.
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Administrative tasks
Note: Review the resource library for additional resources and information on investigations, including the types of investigations and the Supervisor Guide. Document discussions in a file note (Contact/Employer or Worker). Send the Request Info from Employer (IN004E) letter to the employer requesting more information and providing details about the possible referral and investigation process. Complete the Industry Specialist Referral Form (FM555J) from the eCO Create Referral screen, if appropriate. Media submission(s): - Requires further investigation, discuss with the supervisor and/or consult the internal Procedures Resource Library.
- Does not require further investigation, send the media to the claim file.
Refer to the following procedures if required:
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2. Make the referral
Make the claim investigation entitlement referral and include any relevant details for the investigation. Note: A supervisor's approval is not required to make a referral for a claim entitlement investigation. The Claims Investigations supervisor reviews the referral and contacts the decision maker if additional information is needed. When all information is available, the Claims Investigations supervisor completes their initial review and notifies the decision maker who confirms approval to proceed with the investigation. The referral is then assigned to a claims investigator to initiate the investigation. Continue to monitor the claim until the investigation has been completed. The claims investigator updates the decision maker every two weeks, or sooner if information is available. Obtain or provide any additional information when it is requested by a member of the Investigation Unit.
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Administrative tasks
To make the referral: - Add Investigation Referral option on the eCO Desktop.
- Select Claim investigation entitlement for the Investigation type.
Choose the reason for the referral from the Investigation Reason field and provide a brief summer in the Information Requested field. The Claims Investigations supervisor completes the Initial IU Review on the referral screen. Once completed, a notification email is sent to the decision maker. - Open the Investigation Review in the email notification which will open the case file search results page.
- Complete the reviewer decision section to confirm final validation to proceed with the investigation.
Note: The information included in the investigation referral may be released to external stakeholders in a FOIP request.
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3. Review the results and determine entitlement
Prior to concluding the claim entitlement investigation, the claims investigator contacts the decision maker to confirm no further investigation is required. Review the investigation memo and determine if the information addresses the concerns. Contact the investigator if there are any questions or if further investigation is required. Determine a plan of action or make the entitlement decision. Refer to the 1-1 Initial entitlement decisions or 1-10 additional entitlement decisions procedures
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Administrative tasks
When there has been a change to entitlement, send an updated Care Plan letter (CL041), as required.
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