Staff Review
Upon receipt of the completed AEHB 3487 HBEC Request for a Health Benefit Exception, a worker or supervisor conducts an informal review of the request. This is the first step in the HBEC process.

If the client is unable to complete the Request for a Health Benefit Exception, a worker or supervisor can complete it.  In this case, staff should obtain verbal consent from the client for HBEC staff to contact the client's health care practitioner if necessary.  Staff should not sign this form on behalf of the client.

Staff should ideally discuss the issue with the client and suggest alternatives, e.g. ABC Special Authorization for prescription drugs listed on the DBL or DBS (if the drug is available by Special Authorization), local resources such as university dental programs for low cost orthodontic procedures, or alternative treatments/medications, which are covered by the drug benefit lists.

To assist the HBEC in making timely and fair decisions, delivery staff are responsible to ensure the completeness and accuracy of the information on the AEHB 3487 HBEC Request for a Health Benefit Exception form and that the necessary accompanying documentation is provided before sending the request to HBEC.

For prescription and non-prescription drugs the AEHB 3810 HBEC Drug Request, completed by the prescriber, is to be included with the Request for a Health Benefit Exception.

For optical benefits, the AEHB 4001 Optical Request completed by the optical services provider, is to be included with the Request for a Health Benefit Exception.

For dental/denturist benefits, delivery staff should request a copy of the Standard Dental Claim form the dentist/denturist uses to request preauthorization from ADSC, so that the HBEC can determine which dental/denture procedure codes were denied by ADSC.

Note
The HBEC Request for a Health Benefit Exception form, the HBEC Drug Request form, and the HBEC Request for Optical Services can now be completed on-line then printed, signed and submitted to the delivery office. Completing the forms on-line improves readability. If necessary, blank forms can be printed, then completed by hand and submitted.

As soon as possible, staff forward the Request for a Health Benefit Exception form and all documentation submitted by the client, vendors, benefit administrator and medical practitioners to the HBEC, unless the client withdraws their request for HBEC review verbally or in writing.

The package can be faxed to the Health Benefits Exception Committee at 780-422-3646 , or scanned and emailed to AH.HealthBenefitsExceptions@gov.ab.ca or mailed to:

Health Benefits Exception Committee
Pharmaceutical and Supplementary Health Benefits Branch

Alberta Health 
11th Floor ATB Place
10025 Jasper Avenue
Edmonton AB T1J 1S6

Note
If in doubt regarding documentation requirements, contact the Health Benefits Planner responsible for the HBEC at 780-415-9432

HBEC Decision
In making their decision, the HBEC reviews all documentation submitted with the Request for a Health Benefit Exception. The HBEC may contact clients health care providers for additional information regarding their health needs. The HBEC may also make a request to the worksite to gather more information from the client.

The HBEC considers the following criteria in making their decision:

• Is the medical documentation sufficient to establish a medical need?
  
• Have other options for authorization (e.g. Special Authorization for a drug) been exhausted?
  
• For drug requests:
  • Have other drugs listed on the Drug Benefit List been tried and proven ineffective?
  • Is the drug approved by Health Canada for the use intended by the prescriber?
  • Has the client tried the drug, and has it proven effective?

• For requests for replacement eyeglasses, will the client be eligible for new eyeglasses in the next four months?

The health benefits under review are not issued pending the HBEC decision. In emergencies the Manager, Health Benefits Unit or another member of the HBEC, can make a decision regarding the request.

The decision of the HBEC is final; however, the HBEC may review the request again if new and compelling information is submitted.

The HBEC records their decision and rationale in a written letter to the client. The format provides the following information:

• good/service requested
• the ruling of the HBEC regarding the benefit requested about the benefit decision the client has requested the HBEC review,
• rationale for the ruling.