Request for review (RFR)

This step is completed by the CS supervisor, who does an initial review of the RFR to understand the issue and decide how the RFR should be action. This may include assigning tasks to the decision maker; however, the supervisor remains accountable for reviewing the decision and participating in the resolution process. Claim assignment is not required if the only action is contacting the requester.

An RFR may not always be ready to proceed. Even if it cannot move forward (e.g., outside timelines), the decision under dispute may still be reviewed based on questions or concerns outlined in the RFR. For example, if an RFR is outside the one-year time limit, it cannot proceed to DRDRB without an extension. However, if new information suggests the decision may be incorrect, the decision can still be reviewed or reconsidered the same as any other decision that does not have a pending RFR. 

Verify the RFR meets the submission standards

Review the Request for Review (G040) form for completeness

Ensure the RFR relates to a Customer Service (CS) decision and clearly identifies the issue(s) to be reviewed, the decision being challenged, the date of the decision letter and the reason for the disagreement.

If the issue relates solely employer premiums or account mattersThis may include issues related to cost transfers due to negligence, removing costs from an employer's experience rating, industry classification or combinations., refer the RFR to Underwriting / Employer Account Services (EAS) that an RFR has been received and requires action. EAS will notify the requester and proceed with RFR review process. Do not continue with this procedure.

If the issue relates to a third-party decision, notify Legal Services. Legal Services will notify the requester and proceed with the RFR process.

Review the timeline requirements

Confirm the RFR has been submitted within the one-year time limit from the date of the decision letter. If the RFR is outside the one-year time limit and the reasons for the delay are:

• Submitted: Call the requester and explain that the issue will be forwarded to the DRDRB to review for an extension of the time limit.
• Not submitted: Call the requester to advise that they must submit reasons for the delay to the DRDRB Chair (or delegate) within four weeks. Explain that the RFR will be placed on hold for four weeks pending their submission. Refer the requester to the WCB website - Review and appeal page. 

Proceed to the RFR outside the one-year time limit section.

Confirm submission standards

Assess whether the RFR meets the submission standards.

If the submission standards are not met, call the requester to explain why the RFR cannot proceed until it is completed with the required information. Ensure they understand that the RFR must be clear, specific and actionable so the reviewer understands the issue(s) and the specific decision being challenged and why. Refer them to the WCB website page where they can access a form or submit their RFR online. 

If the submission standards are met, continue the RFR review process.

Complete preliminary review of the RFR

Review the RFR and claim information to confirm:

• A CS decision exists for the issue under dispute.
• The issue is reviewable.
• The decision was clearly communicated.

Discuss the claim with the decision maker if clarification is needed. 

Determine next steps

Based on the claim circumstances, determine the appropriate action and contact the requester to explain next steps.

This step is completed by the case manager. 

Review the details on the RFR to identify the issue(s) they are requesting to be reviewed. Reassess each issue individually along with the information used to make the decision. Action any recommendations from the supervisor's preliminary review and consult with them, if needed.

In reviewing the decision, consider the following:

The rationale for the decision

• What evidence was relied on (e.g., medical reports, opinions, assessments).
• How that evidence was interpreted.
• Which policies or guidelines were applied.

Completeness of information

• Confirm all relevant information was considered at the time.
• Identify if anything may have been missed or is newly available.

Alignment with policy

Ensure each decision aligns with the available evidence, policy and legislation. 

Decision maker resolution discussion

Call the requester to discuss the RFR issue(s) and any concerns. Clearly explain the how and why the decision was made including the evidence considered and the applicable policy. Clarify any misunderstandings about the evidence or policy. Listen to the requester’s concerns, address points of disagreement and any identified gaps, and work collaboratively to explore solutions to resolve the issues. 

When:

• Further investigation is needed, discuss the next steps including referrals (e.g., medical assessments or internal consultant referrals) and the expected timeline to complete the investigation. Explain that once the investigation is complete, they will be contacted to discuss the outcome and whether it resolves the RFR.
• New information is available, that it will be reviewed for reconsideration of the decision and they will be contacted to discuss the outcome and whether it resolves the RFR.
• No further action needed and the decision remains unchanged, confirm if the requester has clarified understanding of how and why the decision was made.

When the issue(s) is resolved: Confirm the outcome with the requester to ensure their concerns were addressed. Summarize any agreed-upon actions or next steps, if applicable. Notify the supervisor and proceed with implementing any changes or follow-up, if required. Do not continue this procedure.

When the issue(s) is not resolved: Confirm that the requester remains unsatisfied after the discussion. Ensure all relevant information has been considered or identified. Ask if they are ready to proceed with a formal review and explain that the RFR will be forwarded to the CS supervisor for review. Notify the supervisor that the decision remains unchanged and the RFR will proceed. Send the appropriate letter.

This step is completed by the CS supervisor. 

Review the decision maker's resolution efforts

Review the outcome of the decision maker's review, including all actions taken to attempt resolution of the RFR issues(s).

Assess whether:

• the concerns raised in the RFR were addressed;
• appropriate resolution attempts were made;
• relevant evidence was considered;
• applicable policy was applied; and
• any follow-up actions remain outstanding.

If a new Customer Service decision was made, review the decision to confirm it is supported by the evidence and aligns with policy. Confirm if the new decision resolved the RFR issue (s).

When the decision maker:

• resolved the RFR, continue to step 5 to communicate the decision.
• partially resolved, review the unresolved issue(s). Consider if additional investigation, information or action is required by the decision maker that may resolve the issue(s) if required. Discuss the recommendations with the decision maker.
• did not resolve the RFR and further information or investigation is:
  • required, discuss any recommendations or action required with the decision maker.
  • not required, continue with the resolution discussion outlined below.

Supervisor resolution discussion

Call the requester to discuss the RFR issue(s) and collaboratively review the steps taken to date to resolve them.

At least two call attempts are required to ensure resolution is attempted. If the first contact attempt is unsuccessful, send an email asking the requester to contact WCB to discuss their concerns and provide any needed clarification. If there is no response, make a second call attempt. If the second call attempt is also unsuccessful, send a final email or letter advising that the review will either proceed based on the information available (if appropriate), remain on hold until clarification is provided or be withdrawn. In these circumstances, continue to step 5 to send the appropriate letter and action the RFR as appropriate based on the outcome of CS RFR review.

If the requestor is reached, continue the discussion as outlined below.

Discuss the RFR issue(s) with the requester 

• Confirm the issue(s) under review and ensure they are clearly defined.
• Listen to understand the requester's concerns and perspective.
• Explain the information considered in making the decision (e.g., objective medical informationObjective medical information means the data can be measured through physical examination findings, medical tests and/or reports from diagnostic procedures., medical opinions, assessments) that were considered in making the decision including related evidence and policies.

Address multiple issues separately

• When the RFR involves multiple issues related to additional responsibility (for example, different injuries, treatments or medications), address each issue separately.
• Identify each item as its own issue under review. For example, if a request includes physiotherapy, chiropractic treatment and acupuncture, address each one on its own.
• Clearly explain the rationale and outcome for each issue, even when the same policy applies.

Explore resolution options

• Explore possible solutions and work collaboratively to develop a plan to resolve the issue(s), where possible.
• Find out if there is any additional information to be considered, such as whether they are seeking another opinion, having further consultations or waiting on another report.  
• When further investigation or review is required, advise the requester that the decision maker will be assigned to the claim to action the recommendation.

Action the outcome of the resolution discussion as follows:

This step is completed by the decision maker. 

Follow up on the recommendations from the supervisor (or DRDRB if returned as premature) and work with the supervisor to resolve the RFR or move it to DRDRB, as required. This could include making a new decision on an issue where no decision was previously made, completing necessary investigation, reviewing new information to determine if it is new evidence and the decision should be reconsidered or confirmed as correct. Once the required action is complete, discuss the outcome or decision with the supervisor. 

Review and follow-up on the recommendations from the supervisor (or DRDRB if returned as premature) to complete further actions for the RFR. Work with the supervisor to resolve the RFR or move it to DRDRB, as required. 

Note: A clarification of the original decision is not a new decision. The letter to the requester should clearly indicate that a clarification was requested, and no new decision is being made. 

This step is completed by the CS supervisor.  

Call the requester to discuss the steps that have been completed including the outcome of any investigations, if not previously discussed in step 3. Explain what information was considered, how it impacted the original decision and the confirmed outcome as noted below. Note: In some cases, the decision maker may have already communicated a decision under the procedure they followed.

Update the file based on the claim circumstances. 

When the decision is:

• Changed, discuss the steps that will be taken to implement the new decision. Confirm if the changed decision resolves the RFR or if they still want to proceed to DRDRB. Continue to the next step.
• Unchanged and the:
  • Requester wants to proceed with a DRDRB review, explain that the RFR will move to the DRDRB level for review. The DRDRB will be notified of the RFR when the eCO screens are updated. Continue to step 7 to monitor for the DRDRB decision.
  • Requester does not want to proceed with a DRDRB review, explain that the RFR will be considered resolved. Do not continue with this procedure.
  • Unchanged and the requester is not ready to proceed with the RFR, or the worker is waiting for assistance from a representative, explain that the RFR will be postponed. Agree on a follow-up date and clarify expectations for what may be required from the requester for the next discussion. Refer to RFR postponed at the Customer Service level by the requester section.
• A new decision for an issue that was not previously decided on, confirm if the RFR issue is resolved. If it is, do not continue with this procedure. If it is not and the requester wants to proceed with the RFR, explain that it will move to the DRDRB level for review. The DRDRB is notified of the RFR when the eCO screens are updated. Continue to step 7 to monitor for the DRDRB decision.
• A reconsideration of a previously made decision, the decision may have already been communicated verbally and in writing under the 1-7 Reconsider a previous decision (new evidence) procedure. Complete the remainder of the RFR process as noted above based on the outcome (i.e., whether the decision is changed, unchanged and whether the RFR will proceed).

Communicate the outcome of the review in writing (to all stakeholders) confirming whether the original decision has been changed, remains unchanged or to explain a new decision. Clearly outline the rationale (referencing policy, medical information and any important background information) for the decision and indicate whether the RFR will proceed to the DRDRB level. 

This step is completed by the decision maker and supervisor.

Decision maker

Complete the required action to implement the changed decision. Determine if the outcome of the review impacts the worker's benefits. Notify the supervisor once the decision has been implemented including information related to benefits or services changes.

Note: For RFR's that involved reconsideration of a previously made decision, the changed decision may have already been partially or fully implemented under the 1-7 Reconsider a previous decision (new evidence) procedure.

Supervisor 

Review the decision maker's file note and confirm the decision has been fully implemented. If the changed decision resolves the RFR, update the file as appropriate and do not continue with this procedure.

The decision is fully implemented once all benefits have been issued to the requester, referrals for any required services have been completed and a letter has been sent explaining the decision. 

Note: Consider whether there was a service concern that has impacted the worker's rights under the WCB Code of Rights and Conduct. If so, acknowledge and address the service concern, and have a follow-up discussion with the decision maker, if appropriate, on future opportunities to improve service delivery. 

This step is completed by the decision maker. 

Monitor the claim and issue interim relief payments, if directed by DRDRB

Monitor for direction or a decision from the DRDRB. 

If the DRDRB returns the RFR to CS as being premature because they have determined the RFR is not ready for their review, continue to the next step. 

When the worker or employer has been approved for interim relief benefits by DRDRB, arrange for the benefits to be issued as per their direction. They will advise the decision maker of any changes to the benefits. Refer to the Interim Relief (IR) benefits section.

Do not share details and documents about a worker's or employer's request for IR with third parties. Any questions about this information should be directed to the resolution specialist handling the case.

When the DRDRB or AC decision memo is received, refer to the 13-3 Implement a DRDRB or AC decision implementation procedure.

Decision maker

Within five (5) business days of receiving notification that the issue is premature, review the DRDRB file note and DRDRB premature letter issued to understand the reasons the RFR issue(s) is being returned as premature.

Determine what needs to be done to address why the RFR issue is considered premature. This could include making a decision on something that has not been decided yet, completing necessary investigation, or reviewing new information to decide if it is new evidence and the decision should be reconsidered, etc. Then, assess whether this action can be taken and completed right away, or if it will take more time—meaning a plan should be created and communicated.

If the required action can be addressed right away (e.g., make a decision based on existing information), follow the appropriate procedure to complete it. Contact the requester and explain how the outcome of the additional action impacts their RFR issue(s): does it resolve it or do they want to proceed to DRDRB? Notify the supervisor of the discussion and whether the requester wants to proceed to DRDRB. Confirm in writing the completed action, discussion and whether the RFR is resolved or will be returned to the DRDRB for further review. 

If the required action cannot be addressed right away (e.g., further assessment is required), contact the requester to outline the plan for completing the action, including an estimated completion date. Notify the supervisor of the discussion with the requester and the action plan including the estimated completion date. Include details on how the resolution will likely impact the worker's benefits. Confirm the agreed-upon plan in writing. Return to step 4 to implement the plan.

Supervisor

Review the file note from the decision maker, and discuss the outcome of their review, if needed.

When it will take more than five (5) business days to address the issue(s), notify the resolution specialist of the expected timeline and reason for the delay. The action plan must be actively monitored to prevent delays. Premature review matters remain a priority until the required actions are completed, the issue is resolved or the matter is referred back to the DRDRB. 

When no further action is required (e.g., the decision maker revised the decision), continue to the next step. 

Decision maker

Once any further action or investigation has been completed (under the appropriate procedure), contact the requester to discuss the results of the review (if not already done) and the impact to the decision. Ask the requester if they want to proceed with a DRDRB review. 

Notify the supervisor of the outcome (i.e., impact to decision and whether benefits increased, decreased or remained unchanged as a result).

Supervisor

Review the claim and any new file note from the decision maker. Update the file to clearly indicate whether the original decision changed or remains the same, along with the date of the decision letter. 

When there is no change to the original decision, notify the requester that one or more issues have been returned to the DRDRB. Return to step 7 to monitor for a DRDRB decision.