Medical Assessment Team (MAT) 008-20102224

MAT:

• checks and assesses all scanned medical evidence
• actions a Medical Assessment Recommendation Fast Note
• completes a Medical Assessment Recommendation form (SA479) where appropriate, and
• uploads this to the customer's scanned documents to support the Disability Support Pension (DSP) Service Officer's decision

If required, the MAT will contact the customer, their Treating Health Professional/s (THP) and/or the Health Professional Advisory Unit (HPAU) to obtain more information.

MAT assess the medical evidence to determine if:

• manifest medical eligibility criteria is met
• the customer is manifestly medically ineligible
• insufficient medical evidence prevents assessment of the customer's medical condition/s and functional impacts
• there are doubts about the medical evidence authenticity. Note: MAT or HPAU must investigate further by contacting health professionals listed in the evidence to confirm the diagnosis and prognosis
• a current and valid assessment can be used for the claim determination, or
• a Job Capacity Assessment (JCA) referral is required to determine medical eligibility

A report titled 'DSP Medical Assessment Recommendation' may be completed by an Assessor and uploaded to the customer's record (UNSSPOC/SA479) clearly documenting:

• the recommendation
• evidence taken into account, and
• if applicable, supporting evidence from the customer, their THP/s and/or HPAU

A work item is allocated to a DSP Officer to assess non-medical eligibility.

A Job Capacity Assessment (JCA) referral is not required where it is clear from available medical evidence the customer is manifestly medically eligible for DSP.

Manifest grants can be made if medical evidence confirms 1 of the following applies where the customer:

• is permanently blind
• is terminally ill, and the:
• condition is terminal with life expectancy less than 2 years, or
• average life expectancy for a person with the same condition is less than 2 years
• has a diagnosed intellectual disability with a valid Full Scale IQ below 70
• requires nursing home level care. Note: the customer does not have to be in a nursing home to be manifestly granted DSP. It is sufficient that they require the same level of care (usually provided by a carer/s)
• has Category 4 HIV/AIDS. Refer all potential manifest cases to the HPAU for consideration
• is receiving a Department of Veterans' Affairs Disability Compensation Payment at Special Rate (Totally and Permanently Incapacitated), paid under the Veterans’ Entitlements Act 1986

List 1 and 2 conditions include medical conditions that may meet the criteria above.

Claims that cannot be manifestly granted or rejected, as recommended by a MAT assessment, need a JCA to assess medical eligibility for DSP, including:

• if the customer's conditions are diagnosed, reasonably treated and stabilised (DTS)
• if applicable, the impairment rating for DTS conditions, and
• if the customer has Continuing Inability to Work (CITW)

A customer is manifestly ineligible where medical evidence shows:

• the customer's medical condition/s are clearly likely to persist for less than 2 years and the functional impacts are expected to resolve within the next 2 years
• the medical evidence provided does not support assessment against the Impairment Tables (the condition/s are not diagnosed, reasonably treated and stabilised), or
• there is clear evidence the customer can work at least 15 hours a week in open employment that is sustained and not in jeopardy

Where a MAT recommendation is rejected on medical grounds, finalise the claim without further assessment of non-medical eligibility.

As part of the MAT assessment, the Assessor may determine that insufficient medical evidence has been provided to assess medical eligibility. This assessment will consider all available evidence, including relevant information previously provided by the customer, such as older medical evidence and indications that they may be manifestly eligible. The Assessor will also consider the impact of barriers to obtaining medical evidence before recommending that insufficient medical evidence has been provided with the claim.

If limited or no evidence has been provided, the MAT Assessor may try to gather additional information. This may include contacting the customer or their THP.

Assessor will complete a recommendation report indicating that insufficient evidence was provided to assess medical eligibility.

See Managing suspected fraudulent medical evidence for the action an Assessor must take when they suspect medical evidence is fraudulent.

From 1 April 2023, a new version of Impairment Tables was introduced. The new Tables are used to assess a customer’s medical eligibility for all DSP claims lodged on or after this date. See The Impairment Tables.