What the 55087 is for
Group critical illness coverage pays a one-time lump sum when the plan member, their spouse or a dependent child is diagnosed with a covered condition and survives the plan’s survival period. Alberta Blue Cross compares what you report against the list of critical illnesses and conditions in the patient’s group plan. It is a different claim from short-term or long-term disability, which pays income while the patient can’t work. The same patient may need both forms.
Who completes it
The plan member completes Section 1: their identification, employer, group and section numbers, the claimant’s details if the claim is for a dependant, and the consent to release health information. The attending physician, a consulting specialist or another treating provider completes Section 2, the Attending Physician Statement, and signs the notice to physician.
Patients usually print the form from their employer or the Blue Cross site, fill in Section 1 at home and drop it off with a request to finish the rest. Pages go missing, or the consent comes back unsigned and the whole package stalls. In Medulla, you send Section 1 to the patient over a secure link. They fill it in on the form from their phone or computer, and their answers land on the same PDF you complete Section 2 on, so Blue Cross receives one form with both parts.
How to fill in the Attending Physician Statement
Diagnosis
Give the primary diagnosis, any secondary diagnosis and any complications. Name the condition the way the plan defines it where you can, for example the cancer type and stage, or the infarct confirmed by troponin and ECG. Record the date symptoms first appeared, the date the patient first sought treatment or consultation, and the dates of first and last treatment. Say whether the patient has had the same or a similar illness before. Check them against the chart and the specialist’s letters.
Hospitalization
Say whether the patient was in hospital, where, and the admission and discharge dates. List any surgery with its date and a short description. Attach the discharge summary or operative report rather than paraphrasing it.
Other information
Name other physicians who treated this illness, and say whether you believe the patient is competent to endorse cheques and direct the proceeds. Summarize the medical history and list objective findings separately from subjective ones. Attach the tests that confirm the diagnosis: pathology, imaging, stress tests or angiograms. The form asks how eating, dressing, bathing, ambulation and toileting are affected, and for a cardiac claim it asks for the Canadian Cardiovascular Society functional class.
Prognosis
Outline the prognosis with reference to the plan’s list of critical illnesses and conditions. A short statement of expected course and residual impairment is enough when the attached records carry the detail.
Common reasons the claim stalls
- Section 1 missing, or the consent unsigned or undated.
- A working diagnosis with no confirming pathology, imaging or specialist report attached.
- Dates that don’t match the chart or the specialist’s letter.
- Objective and subjective findings mixed together, or no objective findings at all.
- The cardiac functional class left blank on a heart-related claim.
Submitting and who pays
The plan member is responsible for submitting the employee statement and this statement to Alberta Blue Cross Life and Disability Services. Blue Cross accepts claim documents through its secure member site and app, by mail or by fax, and doesn’t accept them by email. The plan member pays any charge for completing the form, so the clinic bills them directly.