Division 3
Diagnostic and Treatment Protocol for WAD Injuries
14 Protocols established
15 Developing the
diagnosis
Diagnostic Criteria
and Treatment of WAD I Injuries
16 Diagnostic criteria:
WAD I injuries
17 Treatment protocols:
WAD I injuries
18 Diagnostic and
treatment authorization
Diagnostic Criteria
and Treatment of WAD II Injuries
19 Diagnostic criteria:
WAD II injuries
20 Treatment protocols:
WAD II injuries
21 Diagnostic and treatment authorization
Division 4
Treatment Limits and Referrals
22 Aggregate limits on visits
23 Assessment of non‑protocol injuries
24 Referral to injury management consultant
25 Injuries unresolved after 90 days
Part 3
Injury Management Consultants Register
26 Register established
27 Eligibility requirements
28 Ceasing to be an injury management consultant
29 Transitional
Part 4
Claims and Payment of Claims
30 Definitions
31 Priority of this Part
32 Claims
33 Decision by
insurer
34 Failure of
insurer to respond
35 Subsequent
denial of liability
36 Making and
paying claims
37 Sending notices
38 Multiple claims
Part 5
Review and Coming Into Force
39 Review
40 Coming into
force
Definitions
1(1) In
this Regulation,
(a) “client”
means an insured person as defined in the Automobile Accident Insurance
Benefits Regulations (AR 352/72);
(b) “evidence‑based practice” means the
conscientious, explicit and judicious use of current best practice in making
decisions about the care of a client, integrating individual clinical expertise
with the best available external clinical evidence from systematic research;
(c) “health care practitioner” means
(i) a physician,
(ii) a registered member as defined in the Chiropractic Profession Act, or
(iii) a physical therapist as defined in the Physical Therapy Profession Act,
who is entitled to practise their profession
in Alberta;
(d) “IMC
register” means the register of injury management consultants established under
section 26;
(e) “injury
management consultant” means a health care practitioner who is entered on the
IMC register in accordance with Part 3;
(f) “insurer” has the same meaning as it has in
the Automobile Accident Insurance Benefits Regulations (AR 352/72);
(g) “International Classification of Diseases”
means the most recent edition of the publication titled the International Statistical Classification of
Diseases and Related Health Problems, Canada, published by the Canadian
Institute of Health Information, based on a publication issued from time to
time titled the International Statistical
Classification of Diseases and Related Health Problems, published by the
World Health Organization;
(h) “prescribed claim form” means the form
established by the Minister under section 803 of the Insurance Act;
(i) “protocols” means the diagnostic and
treatment protocols established by this Regulation;
(j) “sprain” means an injury to one or more of
the tendons or ligaments, or to both;
(k) “strain” means an injury to one or more
muscles;
(l) “Superintendent” means the Superintendent of
Insurance appointed under the Insurance
Act;
(m) “WAD injury” means a whiplash associated
disorder other than one that exhibits one or both of the following:
(i) objective, demonstrable, definable and
clinically relevant neurological signs;
(ii) a fracture to or a dislocation of the spine.
(2) For the purpose of
section 629 of the Act, “assessment” includes diagnosis.
Part
1
Application and Operation
Application
of this Regulation
2 This Regulation applies only in cases
where
(a) a client wishes to be diagnosed and treated
in accordance with the protocols for a sprain, strain or WAD injury caused by
an accident arising from the use or operation of an automobile, and
(b) a health care practitioner chooses to
diagnose and treat the client’s sprain, strain or WAD injury in accordance with
the protocols.
Authorization for
additional services or supplies
3 Nothing in this Regulation prevents or limits a
client or a health care practitioner from applying to an insurer for an
authorization for a service or supply in addition to the limits specified by
this Regulation, and the insurer may, in accordance with the Automobile Accident Insurance Benefits
Regulations (AR 352/72),
approve the additional service or supply.
Interpretative
bulletins and information circulars
4 The Superintendent may issue
interpretative bulletins and information circulars
(a) describing the anticipated roles and general
expectations of those persons affected by or who have an interest in the
implementation, application and administration of the protocols;
(b) respecting the administration, implementation
and operation of the protocols;
(c) respecting any other matter the
Superintendent considers appropriate.
Prescribed fees
5(1) The Superintendent may
prescribe the fees and disbursements or the maximum fees and disbursements to
be paid for any service, diagnostic imaging, laboratory testing, specialized
testing, supply, treatment, visit, therapy, assessment or making a report under
this Regulation, or any other activity or function necessitated by, described
in or referred to in this Regulation.
(2) The fees and
disbursements or maximum fees and disbursements prescribed under subsection (1)
must be published in The Alberta
Gazette.
Part 2
Diagnosis and Treatment Protocols
Division 1
Diagnosis and Treatment
Protocol for Strains
Protocols established
6 Sections 7 to 9 are established as
protocols for the diagnosis and treatment of strains.
Developing the
diagnosis
7(1) With
reference to the International Classification of Diseases and using evidence‑based
practice, a diagnosis of a strain is to be established by a health care
practitioner using the following process:
(a) taking a history of the client, including
(i) how the injury occurred,
(ii) the current symptoms the client is
experiencing,
(iii) the client=s relevant past history, including physical,
psychological, emotional, cognitive and social history, and
(iv) how the client’s physical functions have
been affected by the injury;
(b) examining the client, including
(i) a general examination,
(ii) a relevant regional examination, including
(A) an examination of the neurological system,
and
(B) an examination of the musculoskeletal
system,
and
(iii) assessing the pain associated with the
injury;
(c) making an ancillary investigation,
including, as required,
(i) diagnostic imaging,
(ii) laboratory testing, and
(iii) specialized testing;
(d) identifying the muscle or muscle groups
injured.
(2) If a strain is diagnosed, the diagnostic criteria to be used
to determine the degree of severity of the strain are set out in the following
table, extracted from Orthopaedic Physical Assessment by David J. Magee,
(3rd), (1997), pg 19, with permission from Elsevier Inc.:
|
|
1st degree
strain
|
2nd degree
strain
|
3rd degree
strain
|
|
Definition
of the degree of strain
|
Few
fibres of muscle torn
|
About
half of muscle fibres torn
|
All
muscle fibres torn (rupture)
|
|
Mechanism
of injury
|
Overstretch
Overload
|
Overstretch
Overload Crushing
|
Overstretch
Overload Crushing
|
|
Onset
|
Acute
|
Acute
|
Acute
|
|
Weakness
|
Minor
|
Moderate
to major (reflex inhibition)
|
Moderate
to major
|
|
Disability
|
Minor
|
Moderate
|
Major
|
|
Muscle
spasm
|
Minor
|
Moderate
to major
|
Major
|
|
Swelling
|
Minor
|
Moderate
to major
|
Moderate
to major
|
|
Loss of
function
|
Minor
|
Moderate
to major
|
Major
(reflex inhibition)
|
|
Pain on
isometric contraction
|
Minor
|
Moderate
to major
|
None to
minor
|
|
Pain on stretch
|
Yes
|
Yes
|
Not if
it is the only tissue injured; however, other structures may suffer 1st
degree or 2nd degree injuries and be painful
|
|
Joint
play
|
Normal
|
Normal
|
Normal
|
|
Palpable
defect
|
No
|
No
|
Yes (if
detected early)
|
|
Range of
motion
|
Decreased
|
Decreased
|
May
increase or decrease depending on swelling
|
Treatment protocols
8 A strain is to be treated by
(a) educating the client with respect to at
least the following matters:
(i) the desirability of an early return to
normal activities and to work, if applicable;
(ii) an estimate of the probable length of time
that symptoms will last;
(b) managing inflammation and pain, as
required,
(i) by the protected use of ice;
(ii) by elevating the injured area;
(iii) by compression;
(c) teaching the client about maintaining
flexibility, balance, strength and the functions of the injured area;
(d) giving advice about self‑care and the disadvantage of extended dependence
on health care providers;
(e) subject
to section 9(3), providing treatment that is appropriate and within the scope
of practice of the person providing it under
(i) the Medical Profession Act,
(ii) the Chiropractic Profession
Act, or
(iii) the Physical Therapy
Profession Act,
as the case may be, and
that is necessary, in the opinion of the health care practitioner, for the
treatment or rehabilitation of the injury;
(f) any
other adjunct therapy that, in the opinion of the health care practitioner, is
necessary for the treatment or rehabilitation of the injury and that is linked
to the continued clinical improvement of the client.
Diagnostic and
treatment authorization
9(1) Within the practitioner’s scope of practice, a health
care practitioner may authorize, for a 1st degree strain, a 2nd degree strain
or a 3rd degree strain,
(a) one visit to a health care practitioner for
an assessment of the injury, including the preparation of a treatment plan and
prescribed claim form, if required, which is in addition to the visits that may
be authorized under subsection (2);
(b) necessary diagnostic imaging, laboratory
testing and specialized testing;
(c) necessary medication to manage the
inflammation or pain, or both;
(d) acquisition of necessary supplies to assist
in the treatment or rehabilitation of the injury.
(2) Subject to the limits described in
section 22, within the practitioner’s scope of practice, a health care
practitioner may authorize, for the treatment of a 1st degree
strain or a 2nd degree strain, not more than a combined total of 10 medical, physical
therapy, chiropractic and adjunct therapy visits to provide the treatment
described in section 8.
(3) Under these protocols,
a health care practitioner may not use a visit to treat a 1st degree strain or
a 2nd degree strain by a deliberate, brief, fast thrust to move the joints of the spine
beyond the normal range but within the anatomical range of motion, which
generally results in an audible click or pop.
(4) Within the practitioner’s scope of practice, a health care
practitioner may authorize, for a 3rd degree strain,
(a) necessary diagnostic imaging, laboratory
testing and specialized testing;
(b) necessary medication;
(c) acquisition of necessary supplies to assist
in the treatment or rehabilitation of the injury.
(5) Subject to the limits
described in section 22, within the practitioner’s scope of practice, a health
care practitioner may authorize, for the treatment of a 3rd degree strain, a
combined total of 21 medical, physical therapy, chiropractic and adjunct
therapy visits to provide the treatment described in section 8, and in
particular definitive care of specific muscles or muscle groups at specific
anatomical sites, including, as required,
(a) immobilization,
(b) strengthening exercises,
(c) surgery, and
(d) if surgery is required, post‑operative
rehabilitation therapy.
Division 2
Diagnosis and Treatment
Protocol for Sprains
Protocols established
10 Sections 11 to 13 are established as
protocols for the diagnosis and treatment of sprains.
Developing the
diagnosis
11(1) With
reference to the International Classification of Diseases and using evidence‑based
practice, a diagnosis of a sprain is to be established by a health care
practitioner using the following process:
(a) taking a history of the client, including
(i) how the injury occurred,
(ii) the current symptoms the client is
experiencing,
(iii) the client=s relevant past history, including
physical, psychological, emotional, cognitive and social history, and
(iv) how the client’s physical functions have
been affected by the injury;
(b) examining the client, including
(i) a general examination,
(ii) a relevant regional examination, including
(A) an examination of the neurological system,
and
(B) an examination of the musculoskeletal
system,
and
(iii) assessing the pain associated with the
injury;
(c) making an ancillary investigation,
including, as required,
(i) diagnostic imaging,
(ii) laboratory testing, and
(iii) specialized testing;
(d) identifying the tendons or ligaments, or
both, that are involved and the specific anatomical site of the injury.
(2) If
a sprain is diagnosed, the diagnostic criteria to be used to determine the
degree of severity of the sprain are set out in the following table, extracted
from Orthopaedic Physical Assessment by David J. Magee, (3rd), (1997),
pg 19, with permission from Elsevier Inc.:
|
|
1st degree sprain
|
2nd degree sprain
|
3rd degree sprain
|
|
Definition
of the degree of sprain
|
Few
fibres of ligament torn (partial tear, no instability or opening of the
joint)
|
About
half of ligament torn (partial tear with some instability indicated by
partial opening of the joint on stress manoeuvres)
|
All
fibres of ligament torn (complete tear with complete opening of the joint on
stress manoeuvres)
|
|
Mechanism
of injury
|
Overstretch
Overload
|
Overstretch
Overload
|
Overstretch
Overload
|
|
Onset
|
Acute
|
Acute
|
Acute
|
|
Weakness
|
Minor
|
Minor to
moderate
|
Minor to
moderate
|
|
Disability
|
Minor
|
Moderate
|
Moderate
to major
|
|
Muscle spasm
|
Minor
|
Minor
|
Minor
|
|
Swelling
|
Minor
|
Moderate
|
Moderate
to major
|
|
Loss of function
|
Minor
|
Moderate
to major
|
Moderate
to major (instability)
|
|
Pain on
isometric contraction
|
None
|
None
|
None
|
|
Pain on
stretch
|
Yes
|
Yes
|
Not if
it is the only tissue injured; however, other structures may suffer 1st
degree or 2nd degree injuries and be painful
|
|
Joint
play
|
Normal
|
Normal
|
Normal
to excessive
|
|
Palpable
defect
|
No
|
No
|
Yes
|
|
Range of
Motion
|
Decreased
|
Decreased
|
May
increase or decrease depending on swelling Dislocation or subluxation
possible
|
Treatment protocols
12 A sprain is to be treated by
(a) educating the client with respect to at
least the following matters:
(i) the desirability of an early return to
normal activities and to work, if applicable;
(ii) an estimate of the probable length of time
that symptoms will last;
(b) managing inflammation and pain, as
required,
(i) by the protected use of ice;
(ii) by elevating the injured area;
(iii) by compression;
(c) teaching the client about maintaining
flexibility, balance, strength and the functions of the injured area;
(d) giving advice about self‑care and the
disadvantage of extended dependence on health care providers;
(e) subject to section 13(3), providing
treatment that is appropriate and within the scope of practice of the person
providing it under
(i) the Medical
Profession Act,
(ii) the Chiropractic
Profession Act, or
(iii) the Physical
Therapy Profession Act,
as the
case may be, and that is necessary, in the opinion of the health care
practitioner, for the treatment or rehabilitation of the injury;
(f) any other adjunct therapy that, in the
opinion of the health care practitioner, is necessary for the treatment or
rehabilitation of the injury and
that is linked to the continued clinical improvement of the client.
Diagnostic and
treatment authorization
13(1) Within the practitioner’s
scope of practice, a health care practitioner may authorize, for a 1st degree
sprain, a 2nd degree sprain or a 3rd degree sprain,
(a) one visit to a health care practitioner for
an assessment of the injury, including the preparation of a treatment plan and
prescribed claim form, if required, which is in addition to the visits that may
be authorized under subsection (2);
(b) necessary diagnostic imaging, laboratory
testing and specialized testing;
(c) necessary medication to manage the
inflammation or pain, or both;
(d) acquisition of necessary supplies to assist
in the treatment or rehabilitation of the injury.
(2) Subject to the limits described in
section 22, within the practitioner’s scope of
practice, a health care practitioner may authorize,
for the treatment of a 1st degree sprain or a 2nd degree, sprain not more than a combined
total of 10 medical, physical therapy, chiropractic and adjunct therapy visits
to provide the treatment described in section 12.
(3) Under these
protocols, a health care practitioner may not use a visit to treat a 1st degree
sprain or a 2nd degree sprain by a deliberate, brief, fast thrust
to move the joints of the spine beyond the normal range but within the
anatomical range of motion, which generally results in an audible click or pop.
(4) Within the practitioner’s scope of practice, a health care
practitioner may authorize, for a 3rd degree sprain,
(a) necessary diagnostic imaging, laboratory
testing and specialized testing;
(b) necessary medication;
(c) acquisition of necessary supplies to assist
in the treatment or rehabilitation of the injury.
(5) Subject to the limits
described in section 22, within the practitioner’s scope of practice, a health
care practitioner may authorize, for the treatment of a 3rd degree sprain, a
combined total of 21 medical, physical therapy, chiropractic and adjunct
therapy visits to provide the treatment described in section 12, and in
particular definitive care of specific tendons or ligaments at specific
anatomical sites, including, as required,
(a) immobilization,
(b) strengthening exercises,
(c) surgery, and
(d) if surgery is required, post‑operative
rehabilitation therapy.
Division 3
Diagnostic and Treatment Protocol
for WAD Injuries
Protocols established
14 Sections 15 to 21 are established as
protocols for the diagnosis and treatment of WAD injuries.
Developing the
diagnosis
15 With reference to the Scientific
Monograph of the Quebec Task Force on Whiplash Associated Disorders: Redefining
“Whiplash” and Its Management, published by Hagerstown, MD: J.B. Lippincott
Company, 1995, and using evidence‑based practice, a diagnosis of a WAD
injury is to be established by a health care practitioner using the following
process:
(a) taking a history of the client, including
(i) how the injury occurred,
(ii) the current symptoms the client is
experiencing,
(iii) the client’s relevant past history,
including physical, psychological, emotional, cognitive and social history,
(iv) inquiry into alerting factors that may
influence prognosis, and
(v) how the client’s physical functions have
been affected by the injury;
(b) examining the client, including
(i) a general examination,
(ii) a relevant regional examination, including
(A) an examination of the neurological system,
and
(B) an examination of the musculoskeletal
system,
and
(iii) assessing the pain associated with the
injury;
(c) making an ancillary investigation, including, as required,
(i) diagnostic imaging,
(ii) laboratory testing, and
(iii) specialized testing;
(d) identifying the anatomical sites.
Diagnostic Criteria and
Treatment
of WAD I Injuries
Diagnostic
criteria: WAD I injuries
16(1) If
a WAD injury is diagnosed, the criteria to be used to diagnose a WAD I injury
are
(a) complaints of spinal pain, stiffness or
tenderness;
(b) no demonstrable, definable and clinically
relevant physical signs of injury;
(c) no objective, demonstrable, definable and
clinically relevant neurological signs of injury;
(d) no fractures to or dislocation of the spine.
(2) If a WAD I injury is diagnosed, no further investigation of the injury is
warranted, unless there is cause to do so.
Treatment
protocols: WAD I injuries
17 A WAD I injury is to be treated, as
required, by
(a) educating the client with respect to at
least the following matters:
(i) the desirability of an early return to
normal activities and to work, if applicable;
(ii) an estimate of the probable length of time
that symptoms will last;
(iii) reassurance that there is likely no serious
currently detectable underlying cause of the pain;
(iv) the importance of postural and body
mechanics control;
(v) that the use of a soft collar is not
advised;
(vi) the probable factors that are responsible for other symptoms the
client may be experiencing that are temporary in nature and that are not
reflective of tissue damage, including
(A) disturbance of balance,
(B) disturbance or loss of hearing,
(C) limb pain or numbness,
(D) cognitive dysfunction, and
(E) jaw pain;
(b) giving advice about self‑care and the disadvantage
of extended dependence on health care providers;
(c) prescribing medication, including the
appropriate use of analgesics, which may include short‑term use of non‑opoid
analgesics or non‑steroidal anti‑inflammatory drugs, but muscle
relaxants and narcotics are not authorized under these protocols for treatment
of WAD I injuries;
(d) in the case of treatment of an injury,
(i) pain management, as required;
(ii) injury specific exercises;
(iii) early return to normal activities;
(iv) a home exercise program to improve range of
motion;
(v) thermal therapy by the client;
(vi) preparing the client for a return to work,
if appropriate;
(e) providing
treatment that is appropriate and within the scope of practice of the person
providing it under
(i) the Medical Profession Act,
(ii) the Chiropractic Profession
Act, or
(iii) the Physical Therapy
Profession Act,
as the case may be, and
that is necessary, in the opinion of the health care practitioner, for the
treatment or rehabilitation of the injury;
(f) any
other adjunct therapy that, in the opinion of the health care practitioner, is
necessary for the treatment or rehabilitation of the injury and that is linked
to the continued clinical improvement of the client.
Diagnostic and
treatment authorization
18(1) Within the
practitioner’s scope of practice, a health care practitioner may authorize, for
a WAD I injury,
(a) one visit to a health care practitioner for
an assessment of the injury, including the preparation of a treatment plan and
prescribed claim form, if required, which is in addition to the visits that may
be authorized under subsection (2);
(b) necessary diagnostic imaging, laboratory
testing and specialized testing;
(c) necessary medication to manage the
inflammation or pain, or both;
(d) acquisition of necessary supplies to assist
in the treatment or rehabilitation of the injury.
(2) Subject
to the limits described in section 22, within the practitioner’s scope
of practice, a health care practitioner may authorize, for the treatment of a WAD I
injury, not more than a combined total of
10 medical, physical therapy, chiropractic and adjunct therapy visits to
provide the treatment described in section 17.
Diagnostic Criteria and
Treatment
of WAD II Injuries
Diagnostic
criteria: WAD II injuries
19(1) If
a WAD injury is diagnosed, the criteria to be used to diagnose a WAD II injury
are
(a) complaints of spinal pain, stiffness or
tenderness;
(b) demonstrable, definable and clinically
relevant physical signs of injury, including
(i) musculoskeletal signs of decreased range of
motion of the spine, and
(ii) point tenderness of spinal structures
affected by the injury;
(c) no objective, demonstrable, definable and
clinically relevant neurological signs of injury;
(d) no fracture to or dislocation of the spine.
(2) An
investigation to determine a WAD II injury and to rule out a more severe
whiplash injury may include
(a) for cervical spine injuries, radiographic
series in accordance with The Canadian
C‑Spine Rule for Radiography in Alert and Stable Trauma Patients,
published in the Journal of the
American Medical Association, October 17, 2001 – Volume 286, No. 15;
(b) for thoracic, lumbar and lumbosacral spine
injuries, radiographic series appropriate to the region of the spine that is
injured, if the client has one or more of the following characteristics:
(i) an indication of bone injury;
(ii) an indication of significant degenerative
changes or instability;
(iii) an indication of rheumatoid arthritis;
(iv) an indication of osteoporosis;
(v) a history of cancer.
(3) The use of magnetic resonance imaging or computerized
tomography is not authorized under these protocols, unless 3 plain view films
are equivocal.
Treatment
protocols: WAD II injuries
20 A WAD II injury is to be treated, as
required, by
(a) educating the client with respect to at
least the following matters:
(i) the desirability of an early return to
normal activities and to work, if applicable;
(ii) an estimate of the probable length of time
that symptoms will last;
(iii) reassurance that there is likely no serious
currently detectable underlying cause of the pain;
(iv) the importance of postural and body
mechanics control;
(v) that the use of a soft collar is not
advised;
(vi) the probable factors that are responsible
for other symptoms the client may be experiencing that are temporary in nature
and that are not reflective of tissue damage, including
(A) disturbance of balance,
(B) disturbance or loss of hearing,
(C) limb pain or numbness,
(D) cognitive dysfunction, and
(E) jaw pain;
(b) giving advice about self‑care and the
disadvantage of extended dependence on health care providers;
(c) prescribing medication, including the
appropriate use of analgesics, which may include short‑term use of non‑opoid
analgesics or non‑steroidal anti‑inflammatory drugs, but muscle
relaxants and narcotics are not authorized under these protocols for treatment
of WAD II injuries;
(d) in the case of treatment of an injury,
(i) pain management, as required;
(ii) injury specific exercises;
(iii) early return to normal activities;
(iv) a home exercise program to improve range of
motion;
(v) initiation of manipulation, manual therapy
or mobilization, or any 2 or more of them, to improve function, if appropriate;
(vi) preparing the client for a return to work,
if appropriate;
(e) providing
treatment that is appropriate and within the scope of practice of the person
providing it under
(i) the Medical Profession Act,
(ii) the Chiropractic Profession
Act, or
(iii) the Physical Therapy
Profession Act,
as the case may be, and
that is necessary, in the opinion of the health care practitioner, for the
treatment or rehabilitation of the injury;
(f) any
other adjunct therapy that, in the opinion of the health care practitioner, is
necessary for the treatment or rehabilitation of the injury and that is linked to the continued clinical
improvement of the client.
Diagnostic and
treatment authorization
21(1) Within
the practitioner’s scope of practice, a health care practitioner may authorize,
for a WAD II injury,
(a) one visit to a health care practitioner for
an assessment of the injury, including the preparation of a treatment plan and
prescribed claim form, if required, which is in addition to the visits that may
be authorized under subsection (2);
(b) necessary diagnostic imaging, laboratory
testing and specialized testing;
(c) necessary medication to manage the
inflammation or pain, or both;
(d) acquisition of necessary supplies to assist
in the treatment or rehabilitation of the injury.
(2) Subject to the
limits described in section 22, within the practitioner’s scope of practice, a health care practitioner
may authorize, for the treatment of a WAD II injury, not more than a combined
total of 21 medical, physical therapy, chiropractic and adjunct therapy visits
to provide the treatment described in section 20.
Division 4
Treatment Limits and Referrals
Aggregate limits on
visits
22(1) Except
as otherwise specifically provided in this Regulation, if a client is diagnosed
and treated under these protocols for 2 or more injuries,
(a) only one visit for an assessment of the
injuries by a health care practitioner is authorized by these protocols;
(b) if the injuries are diagnosed as a 1st
degree strain, 2nd degree strain, 1st degree sprain or 2nd degree sprain, the
cumulative total of visits for the 2 or more injuries that may be authorized
under the protocols, without the approval of the insurer, may not exceed 10;
(c) if 2 or more of the injuries described in
clause (b) and one or more of
(i) a 3rd degree strain for which treatment is
authorized,
(ii) a 3rd degree sprain for which treatment is
authorized, or
(iii) a WAD II injury
are
diagnosed, the cumulative total of visits for the 2 or more injuries that may be
authorized under the protocols, without the approval of the insurer, may not
exceed 21;
(d) if 2 or more of
(i) a 3rd degree strain,
(ii) a 3rd degree sprain, or
(iii) a WAD II injury
are
diagnosed, the cumulative total of visits for the 2 or more injuries that may
be authorized under these protocols, without the approval of the insurer, may
not exceed 21.
(2) Despite anything in
this Regulation,
(a) an authorization by a health care
practitioner for anything permitted by these protocols must be in writing and
issued within 90 days of the date of the accident in which the client was
injured,
(b) an authorization under these protocols
expires 90 days after the date of the accident in which the client was injured,
unless the authorization is approved by an insurer for use after the 90 days,
and
(c) an authorization may be issued in respect of
the person who issues the authorization.
Assessment of non‑protocol
injuries
23 If, after an assessment, a physical
therapist as defined in the Physical Therapy Act or a registered member
as defined in the Chiropractic Profession Act diagnoses an injury as one
to which these protocols do not apply, these protocols authorize a claim under
Part 3 for the assessment.
Referral to injury
management consultant
24(1) A
health care practitioner may authorize a visit by a client to an injury
management consultant if the health care practitioner
(a) is uncertain about an injury to which the
protocols apply or the diagnosis or treatment of it;
(b) believes that the injury
(i) is not resolving appropriately, or
(ii) is not resolving within the time expected and the practitioner
requires another opinion or report.
(2) If a client is diagnosed with a WAD I or WAD II injury and
the client has any alerting factor that may influence prognosis, the health
care practitioner must seek to reassess the client within 21 days of the
accident and, if the injury is not resolving, authorize a visit by the client
to an injury management consultant for an assessment and report.
(3) The visit and the cost
and expenses related to an assessment and report by an injury management
consultant under subsection (2) are authorized to be claimed under Part 3 and
are in addition to the aggregate limit on visits referred to in section 22.
(4) Except for the visit, assessment and report described in
this section, no further visit, assessment or report by an injury management
consultant in respect of the same injury is authorized by these protocols,
unless the insurer approves of it.
Injuries unresolved
after 90 days
25(1) Subject
to subsection (3), if after 90 days from the date of the accident an injury has
not resolved or is not satisfactorily resolving, the health care practitioner
may refer the client to an injury management consultant.
(2) The
injury management consultant may
(a) provide advice and a report about the
diagnosis or treatment of the client, or
(b) recommend a further assessment or a multi‑disciplinary
assessment of the injury or an aspect of the injury and the persons who should
be included in that assessment.
(3) No examination, further assessment, multi‑disciplinary
assessment or any report referred to in subsection (2), and no visit or
treatment as a result, is authorized by these protocols, unless the insurer
approves it.
Part 3
Injury Management
Consultants Register
Register established
26(1) The
Superintendent must establish, maintain and administer a register of injury
management consultants.
(2) The Superintendent must ensure that the IMC register is
published in a form and manner so that the register is accessible to the
public.
Eligibility
requirements
27(1) A
health care practitioner is an injury management consultant under this
Regulation if, in accordance with this Part,
(a) the council of the College of Physicians and
Surgeons of the Province of Alberta notifies the Superintendent that a
physician meets the requirements set out in subsection (2) and the
Superintendent enters the name of that person on the IMC register;
(b) the Council of the College of Chiropractors
of Alberta notifies the Superintendent that a registered member as defined in
the Chiropractic Profession Act meets
the requirements set out in subsection (2) and the Superintendent enters the
name of that person on the IMC register;
(c) the Council of the College of Physical
Therapists of Alberta notifies the Superintendent that a physical therapist as
defined in the Physical Therapy
Profession Act meets the requirements set out in subsection (2) and the
Superintendent enters the name of that person on the IMC register.
(2) A
person is eligible to be an injury management consultant if the person
(a) is an active practising member of that
person’s profession,
(b) has demonstrated to the satisfaction of the
council of that person’s profession that he or she
(i) is knowledgeable with respect to the
biopsychosocial model,
(ii) is knowledgeable with respect to assessing
acute and chronic pain,
(iii) is experienced in rehabilitation and
disability management, and
(iv) uses evidence‑based decision‑making
in his or her practice,
and
(c) meets any additional qualifications
established by the Superintendent and approved by the councils of the colleges
concerned.
Ceasing
to be an injury management consultant
28 A person ceases to be an
injury management consultant if
(a) the
council of the profession concerned notifies the Superintendent that the
person’s name is to be removed from the IMC register, and
(b) the Superintendent removes the person’s name
from the IMC register.
Transitional
29(1) Notwithstanding section 27, the Superintendent may enter on the
IMC register the name of a physician, a registered member as defined in the Chiropractic
Profession Act or a physical therapist as defined in the Physical
Therapy Profession Act when the respective council of the profession concerned notifies the
Superintendent that the person
(a) is
an active practising member of the profession, and
(b) in
the opinion of the council, is able to perform the functions of an injury
management consultant.
(2) A
person whose name is entered on the IMC register under subsection (1) ceases to
be an injury management consultant
(a) on the date the practising member becomes an
injury management consultant under section 27,
(b) 2 years from the date this section comes
into force or such later date as the Superintendent determines, or
(c) on the date the member ceases to be an
injury management consultant under section 28,
whichever
occurs first.
Part 4
Claims and Payment of Claims
Definitions
30 In this Part,
(a) “applicant”
means a client or health care practitioner who sends a completed prescribed
claim form to the insurer under section 32;
(b) “business
days” means any day other than a Saturday, Sunday or other holiday as defined
in section 28(1)(x) of the Interpretation
Act;
(c) “prescribed
claim form” means the form established by the Minister under section 803 of the
Insurance Act.
Priority of this Part
31 If there is any inconsistency or conflict
between this Part and Section B ‑ Accident Benefits under the Automobile
Accident Insurance Benefits Regulations (AR 352/72), this Part prevails.
Claims
32 A client or health care practitioner who
wishes to make a claim under this Part must send to the insurer a completed
prescribed claim form, which must include
(a) details
of the injury, and
(b) details
of the accident that are within the personal knowledge of the client,
within 10 business
days of the date of an accident or, if that is not reasonable, as soon as
practicable after that.
Decision by insurer
33(1) An
insurer, within 5 business days of receiving a completed prescribed claim form,
must send to the applicant a decision notice
(a) approving
the claim, or
(b) refusing
the claim.
(2) A claim may only be refused by the
insurer giving reasons for refusing the claim, but those reasons are limited to
the following:
(a) the
person who suffered the injury is not an insured person under the Automobile Accident Insurance Benefits
Regulations (AR 352/72);
(b) the
insurer is not liable to pay as a result of an exclusion contained in the
Special Provisions, Definitions and Exclusions of Section B under the Automobile Accident Insurance Benefits
Regulations (AR 352/72);
(c) there
is no contract of insurance in existence that applies with respect to the person
who suffered the injury;
(d) the injury was not caused as a result of an
accident arising out of the use or operation of an automobile.
Failure
of insurer to respond
34 If an insurer does not send a decision notice back to the
applicant within 5 business days of receipt of the applicant’s completed
prescribed claim form, the insurer
(a) is
deemed to have approved the claim, and
(b) is
liable to pay the claim under section 36, unless the claim is denied under
section 35.
Subsequent denial of liability
35(1) If an insurer
(a) approves
a claim, or
(b) is
deemed to have approved a claim
under this Part, the
insurer may subsequently deny liability in accordance with subsection (2).
(2) Liability may only be denied if an
insurer sends notice in writing to the client and every person whom, under the
prescribed claim form, the insurer is notified the client is authorized to
visit, or who is authorized to provide services or supplies to the client,
giving reasons why liability is denied, but those reasons are limited to the
following:
(a) the
person who suffered the injury is not an insured person under the Automobile Accident Insurance Benefits
Regulations;
(b) the
insurer is not liable to pay as a result of an exclusion contained in the
Special Provisions, Definitions and Exclusions of Section B under the Automobile Accident Insurance Benefits
Regulations;
(c) there
is no contract of insurance in existence that applies with respect to the
person who suffered the injury;
(d) the
injury was not caused as a result of an accident arising out of the use or
operation of an automobile.
(3) A valid notice of denial under
subsection (2) takes effect on the date it is received by the person to whom it
is sent and, after receipt of the notice of denial by the client, the insurer
is not liable, under section 36, to pay any future claim by a person under this
Part.
Making
and paying claims
36(1) Where anything is authorized under this
Regulation, the authorization may be the subject of a claim under subsection
(2).
(2) The insurer must pay a claim that is authorized by this
Regulation or is authorized by a health care practitioner or injury management
consultant under this Regulation, that,
(a) in
the case of an invoice by a health care practitioner, injury management
consultant or provider of an adjunct therapy, is also verified by the client
concerned, or
(b) in
the case of a claim by the client, a receipt for the benefit is provided,
together with satisfactory evidence that the claim is authorized by this
Regulation or is authorized by a health care practitioner under this
Regulation.
Sending
notices
37 Where this Part requires or permits a
notice to be sent to a person, it may be
(a) delivered
personally,
(b) mailed,
(c) faxed,
or
(d) transmitted
by e‑mail if both parties have agreed to this method of sending and
receiving notices.
Multiple
claims
38 If a person has a claim under these
protocols and a claim for other benefits under provisions of Section B of the Automobile
Accident Insurance Benefits Regulations (AR 352/72), the claimant must
comply with this Regulation and the provisions of Section B, according to the
claim or claims made.
Part 5
Review and Coming into Force
Review
39 This Regulation must be reviewed
(a) not
less than every 2 years from the date this Regulation comes into force, and
(b) whenever
(i) the council of the College of Physicians and Surgeons of the
Province of Alberta,
(ii) the Council of the College of Chiropractors of Alberta, or
(iii) the Council of the College of Physical Therapists of Alberta
provides written notice to
the Superintendent that the protocols should be reviewed.
Coming into Force
40 This Regulation comes into force on
October 1, 2004.
