Complex Claim Triage Tool: When to Escalate a File

Identify whether the file may require targeted clarification or a more coordinated assessment approach.

Under 90 seconds No patient identifiers required Informational only

Complete the fields to see a tailored guidance summary.

1 File complexity indicators 0 selected

Toggle all that apply to this file

Multiple providers involved More than one treating provider or specialist

Conflicting opinions or reports Providers or assessors disagree on key issues

Pre-existing conditions / co-morbidities Prior conditions complicate the current picture

Delayed recovery beyond expectations Progress slower than typical for this condition

Cognitive complaints present Memory, concentration, or processing concerns

Psychological symptoms present Mood, anxiety, trauma, or behavioural factors

Functional capacity remains unclear Work tolerances or restrictions not objectively defined

Failed RTW attempt Prior return-to-work did not succeed

Dispute about restrictions or capacity Parties disagree on work capability or limits

Significant documentation / litigation context Legal proceedings or heavy documentation burden

2 Dominant impact areas

Select all that apply

3 Current objective data

Select one

This tool is intended to support internal triage, referral planning, and return-to-work discussions. It does not provide a diagnosis, legal opinion, or formal FAE/IME. Please do not enter patient names, claim numbers, or other direct identifiers. Province-specific processes vary. Use this tool to support internal triage only.

Toggle complexity indicators above to see the escalation screen result.

Escalation level

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Complexity indicators 0 / 10

Standard (0–2) Targeted (3–5) Coordinated (6+)

What is driving this result

Both conflicting reports and multiple overlapping domains are present — file escalated to coordinated review.

Failed RTW attempt combined with unclear functional capacity — targeted work-capacity clarification is recommended.

Dominant impact areas identified

This tool is intended to support internal triage. It does not provide a diagnosis, legal opinion, or formal assessment. Do not enter patient names or claim numbers.

0 indicators —

An interactive, no-PHI screening tool that helps disability/claims professionals (adjusters, case managers, RTW coordinators, employers, legal) decide in under 90 seconds whether a file needs escalation…to an IME, multidisciplinary assessment, or coordinated review.

It collects complexity indicators (multiple providers, conflicting reports, comorbidities, delayed recovery, cognitive/psych symptoms, unclear functional capacity, failed RTW, disputes, litigation context), dominant impact areas, and current objective data, then returns tailored guidance.