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1. Review the claim and determine if there is missing medical information that is required to make a decision or manage the claim
Confirm 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. A signed consent is required for obtaining reporting from some health care professionals who practice outside of Alberta or for medical information that may not have a direct relationship to the injury but could be impacting the worker's recovery (for example, other medical conditions, pre-existing medical conditions). Every reasonable effort should be made to obtain the worker's signed consent. When the worker’s signed consent cannot be obtainedSection 36 of the Workers' Compensation Act allows the decision maker to withhold compensation payments until a signed consent is received., 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). Release of medical information (C-463) form Section 36 of the WCA
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2. Contact the provider to request the missing report(s)
Once the consent is on file (when needed), 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. 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, the 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 Report of Injury or Occupational Disease form or the Release of Medical Information form with the request letter. Notes: - Administrative assistants cannot request medical reports pertaining to VSC (visiting specialist clinic) appointments, IME (independent medical exams) reporting or opioid management requests. For these requests send the appropriate request letter. For VSC appointment reports, contact the surgical coordinator or the health care consultant.
- X-ray films should only be obtained if a medical consultant has requested them. Refer to the 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 the 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. Release of medical information (C-463) form Send the appropriate SP002 or SP006 series for requests. Send a task (Medical), to the records clerk in medical services to request x-ray films.
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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 requested information is not on file 10 business days after the original request, proceed to the next step.
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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. Follow the Internal consultant referrals procedure.
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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 appropriate 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 Request When 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. Fourth request If the requested medical reporting is not received within 10 business days of the third request, contact the appropriate manager or consultant: - When a contracted provider's report 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 only (for example, VSC, return to work centres, etc.).
- When a physician or medical facility report is not received, send a high-priority task to the medical services manager or designate.
The WCB health care consultant and medical services manager will determine the best course of action based on the claim circumstances.
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Administrative tasks
Follow the Internal consultant referrals procedure to request a medical consultant contact the facility or physician to obtain the report. Include the medical facility's name, address, telephone number, dates of previous requests, and other pertinent information. Call or send an email to the WCB health care consultant. Send a high-priority task to the medical manager with summary line “difficulty obtaining medical facility report” after 3 requests. Include the details: - The medical practitioner's or medical facility’s name
- Dates of previous requests
- Other pertinent information
Follow the Internal consultant referrals procedure to request assistance from a medical services manager.
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