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9th Floor, 10611 - 98 Avenue NW Suite 900, 9925 - 109 Street NW
EDMONTON AB T5K 2P7 EDMONTON AB T5K 2J8
JOINT COMMUNICATION
Multi-Employer/UNA Collective Agreement
Appeal Process for Drug Claim Denials
April, 2006
This communication is to assist employees, union representatives and employers in
utilizing the jointly agreed upon process for appealing denied claims for prescribed
medications. Attachments include:
Medication Claim Denial Appeal Process Flow Chart;
Medication Claim Denial Appeal Form; and
Listing of Employer Designates.
The Appeal Process
1. Initial Appeal Decision - If the employee decides to appeal a claim for a
prescribed medication denied by the insurance company, then the employee
needs to complete the Medication Claim Denial Appeal Form (copy attached).
These forms are available from the Employer Designates, and/or UNA
representatives (Note: The Appeal Form should be submitted to the Employer
Designate within 30 days from the date that the medication claim was originally
denied by the insurance company. If this is not possible, the employee or the
employee’s union representative should advise the Employer Designate that they
will be filing an appeal and are in the process of gathering the necessary
supporting information).
2. Submission to Employer Designate for Review - Once completed, the Appeal
Form is submitted to the appropriate Employer Designate (listing of Employer
Designates attached). The employee can either submit the Appeal Form directly
to the Employer’s Designate, or they can request that their UNA representative
submit the Appeal Form to the Employer Designate for them.
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A p p e a l P r o c e s s f o r D r u g C l a i m D e n i a l s
3. Employer Designate Review - The Employer Designate will review the
employee’s Medication Claim Appeal within 14 days of receiving the Appeal
Form.
(a) If the Employer Designate determines that the claimed medication meets
the agreed upon criteria, the employer will make arrangements for the
insurer to pay the claim to the employee. The Appeal Form will be signed
by the Employer Designate as “Approved” and returned to the employee
with a description of any conditions being placed upon the approval of the
claim.
(b) If the Employer Designate does not believe that the claim meets the agreed
upon criteria, they will advise the employee that the appeal is being
denied by indicating “Denied” on the Appeal Form, signing the form and
returning it to the employee.
4. Submission to Joint Appeal Panel for Review - Within 14 days of the Employer
Designate advising the employee that the appeal is being denied, the employee
should decide if they will appeal this decision further. If the employee decides to
pursue further appeal, the employee should contact their UNA representative
and give them a copy of the Appeal Form. The UNA representative will forward
the form to the UNA and HBA Services Secretariat representatives (David
Harrigan, Director of Labour Relations for UNA and Cory Galway, Senior
Negotiator, for HBA Services, respectively). The Secretariat representatives will
summarize the information from the Appeal Form to ensure that the employee’s
identity remains confidential, and will forward the information to the Joint
Appeal Panel for review.
5. Joint Appeal Panel Decision - Beginning in June, 2006, the Joint Appeal Panel
will meet monthly or as required and will review received Appeals at the first
Joint Appeal Panel meeting following receipt of the Appeal by the Secretariat
representatives.
(a) If the Joint Appeal Panel determines that the claimed medication meets the
agreed upon criteria, the Joint Appeal Panel instruct the employers’
Secretariat representative to recommend that the employer make
arrangements for the insurer to pay the claim.
(b) If the Joint Appeal Panel does not believe that the claim meets the agreed
upon criteria, they will instruct the UNA Secretariat representative to
advise the employee that the appeal is being denied.
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A p p e a l P r o c e s s f o r D r u g C l a i m D e n i a l s
6. Joint Appeal Panel Approval - If the Joint Appeal Panel has recommended that
the employer make arrangements for the insurer to pay the claim, and the
employer chooses not to implement the recommendation, the UNA and HBA
Services Secretariat representatives will make arrangements for the Appeal to be
reviewed by the Umpire for a final decision.
7. Joint Appeal Panel Denial - If the Joint Appeal Panel denies the claim, the UNA
Secretariat representative contact the employee to determine if the claim should
be appealed to the Umpire. If the decision is made to appeal to the Umpire, the
UNA and HBA Services Secretariat representatives will make arrangements for
the Appeal to be reviewed by the Umpire for a final decision.
8. Final Decision of Umpire - The Umpire, Mr. Jay Spark of Spark Consulting
Services, will review the Appeal and make a final decision regarding payment or
denial of the claim. The UNA and HBA Services Secretariat representatives will
advise the employee and employer of the Umpire’s decision.
A flow chart summarizing the steps and decisions of the Medication Claim Denial
Appeal process is attached for your reference
UNA Joint Communication - Drug Claim Denials Appeal Process
Page 3
Medication Claim Denial Appeal Process Flow Chart
Employee/Union
files initial appeal
(30 days)
Employer
Designate reviews
Approves appeal (14 days) Denies
Insurer is instructed to
pay claim
Employee decision
to advance appeal
Yes (14 days)
No
Employee provides
Appeal Form to UNA Appeal abandoned
representative
UNA representative forwards
appeal to UNA and HBA Services
Secretariat representatives
Joint Appeal
Panel reviews
appeal
Supports Denies
HBA Services Secretariat communicates Joint Appeal Panel communicates
Appeal Panel decision to employer decision to employee
Employer receives Employee receives
Appeal Panel Appeal Panel
recommendation recommendation
Rejects Accepts
Accepts Rejects
Insurer instructed to Employer/employee decision Appeal abandoned
pay claim communicated to applicable
Secretariat representative
Umpire
reviews
Appeal
Supports
Denies
HBA Services Secretariat UNA Secretariat representative
representative advises Employer advises Employee of Umpire
of Umpire decision decision
Claim paid - process completed Appeal denied - process completed
Medication Claim Denial Appeal Flowchart
9th Floor, 10611 - 98 Avenue NW Suite 900, 9925 - 109 Street NW
EDMONTON AB T5K 2P7 EDMONTON AB T5K 2J8
C O N F I D E N T I A L
Medication Claim Denial Appeal Form
Employees covered by the Provincial Collective Agreement who have had claims denied may submit them for
review and possible reimbursement.
Please fill out this form, attach necessary documents, and provide the complete form and supporting
documentation to the individual designated by the employer to handle medication claim appeals or to your
UNA representative within 30 days of the denial of your medication claim.*
* If all supporting documentation is not available within 30 days of the claim denial, please advise your designated
employer representative or your union representative that you are filing an appeal and are in the process of gathering
necessary supporting information.
PART A: To be completed by the employee:
Name: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________
City: ________________________________________________ Postal code: ______________________________
Telephone: ____________________________ Email: _________________________________________________
Employer: ___________________________________ Worksite: _____________________ Local #: __________
Please supply all the following information:
Date the claim was denied: ________________________________________
Copy of claim denial attached
Claim receipts attached, including pharmacy prescription #
Note: Copies of the receipt and/or the claim denial must be attached.
Does the claim meet the following conditions for coverage?
1. Was this medication prescribed by a physician or a dentist? Yes No
2. Was this medication dispensed by a pharmacist? Yes No
M e d i c a t i o n C l a i m D e n i a l
A p p e a l F o r m
3. Is this medication administered either orally, by injection, Yes No
absorption or inhalation?
4. Was this medication prescribed to correct or treat a medical Yes No
condition based on a diagnosis made by the physician or dentist?
If answer to #4 is yes, please provide additional information (Note: although the specific diagnosis is
not required, any information or explanation either written or oral that confirms that the medication
was prescribed to treat a medical condition will assist in resolving your appeal). Any information
provided to support this appeal will be kept in the strictest of confidence:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
You may be contacted if further information is required. Please provide your contact information:
Preferred telephone number:________________________________________________________________________
Email address: ____________________________________________________________________________________
I declare that I have examined all the information on this form, and on any accompanying statements or
receipts, and it is true and correct to the best of my knowledge.
_____________________________________________________________ ________________________________
Employee's Signature Date
PART B: To be completed by the Employer's Designate:
Appeal Result: Approved ________________ ______________________________
(Date) (Employer Designates Signature)
Conditions (if any) __________________________________________________
Denied ________________
(Date)
If your Appeal has been denied by the Employer, please contact your United Nurses of Alberta representative
for advice on appealing your claim to the Joint Appeals Panel
Medication Claim Denial Appeal Form
Multi-Employer/United Nurses of Alberta - Medication Claim Denial Appeal Process
Listing of Employer Designates
Region/Employer Designate Title Address Phone/Fax Email
Chinook Health Cheryll Hall HR/Benefits c/o Lethbridge Regional Ph (403) 388-6347 chall@chr.ab.ca
Region Technician Hospital Fax (403) 388-6016
960 - 19 Street South
LETHBRIDGE AB T1J 1W6
Palliser Health Ms. Debbie Shields Regional Manager, 666 – 5th Street SW Ph (403) 529-8028 dshields@palliserhealth.ca
Region Finance MEDICINE HAT AB Fax (403) 528-8148
T1A 4H6
Calgary Health Diane Pollo Director, Total 10101 Southport Road SW Ph (403) 943-1311 Diane.pollo@
Region Compensation CALGARY AB T2W 3N2 calgaryhealthregion.ca
David Thompson Linda Brooke Benefits Service Centre, Ph 1-877-361-4242 lbrooke@dthr.ab.ca
Health Region Wetaskiwin Hospital Fax (780) 361-4289
East Central Health Don Rudzcki Human Resources 4703 - 53 Street Ph (780) 608-8816 don.rudzcki@ech.ab.ca
Manager CAMROSE AB T4V 1Y8 Fax (780) 608-8850
Capital Health Susan Smith Administrative Capital Health Centre Ph (780) 735-0572 slsmith@cha.ab.ca
Coordinator/Senior 7th Floor North Tower Fax (780) 735-0597
Benefits Consultant 10030 – 107 Street NW
EDMONTON AB T5J 3E4
Aspen Regional Lena Workman Senior Benefits Aspen Benefits Office Ph (780)349-8511 Lena.Workman@
Health Administrator 10403 – 100 Avenue ext 224 aspenrha.ab.ca
WESTLOCK AB T7P 2J2 Fax (780) 349-8215
Peace Country Health Arlene MacLellan Manager, Human 2101, 10320 – 99 Street Ph (780) 538-5321 arlene.maclellan@pchr.ca
Resources Consulting GRANDE PRAIRIE AB Fax (780) 538-6156
T8V 6J4
Region/Employer Designate Title Address Phone/Fax Email
Northern Lights Carolyn Adams HR Advisor 7 Hospital Street Ph (780)791-6206 cadams@nlhr.ca
Health Region FORT MCMURRAY AB Fax (780) 791-6281
Caritas Health Group Bonnie Pasnak Benefit Coordinator Caritas Health Group Ph (780) 482-8257 bpasnak@cha.ab.ca
11111 Jasper Avenue NW Fax (780) 482-8258
EDMONTON AB T5K 0L4
Mineral Springs Linda Laing HR and Payroll PO Box 1050 Ph (403) 760 7203 linda.laing@
Hospital Consultant BANFF AB T1L 1H7 Fax (403) 760 7221 calgaryhealthregion.ca
Dr. Cooke Extended Tina Bauer Human Resources 3820 – 43 Avenue, Ph (306) 820-6166 tina.b@pnrha.ca
Care Centre Consultant LLOYDMINSTER SK Fax (306) 825-9880
S9V 1Y5
Our Lady of the Jacky Shipman Finance Manager Box 329 Ph (403) 882-3434 jshipton@dthr.ab.ca
Rosary Hospital, CASTOR AB T0C 0X0 Fax (403) 882-2751
Castor
Killam Health Care Wayne Button C.E.O Box 40 Ph (780) 385-3741 wayne.button@ech.ab.ca
Centre KILLAM AB T0B 1A0 Fax (780) 385-3904
Lamont Health Care Mr. Paul Hardy Director of Nursing Lamont Health Care Centre, Ph (780)895-2211 paul.hardy@ech.ab.ca
Centre Services LAMONT AB T0B 2R0 Fax (780)895-7305
St. Mary’s Hospital Donna Johanson Payroll and Benefits Human Resources – Ph (780)679-6125 donnajo@stmarys
(Camrose) Officer Administration Suite Fax (780)679-6196 camrose.com
4607 - 53 Street
CAMROSE AB T4V 1Y5
St. Joseph General Rick Schindel Chief Executive PO Bag 490 Ph (780)632-2811 rick.schindel@ech.ab.ca
Hospital, Vegreville Officer 5241 - 43 Street Fax (780)603-4402
VEGREVILLE AB T9C 1R5
Bonnyville Health Ms. Laura-Lee Heartt Director of Finance 4601 – 50 Street Ph (780) 826-3311 laura-lee.heartt@
Care Centre BONNYVILLE AB T9N 2J7 Fax (780) 826-6187 aspenrha.ab.ca
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