Medicare Compensation Recovery 011-15000000

For Medicare Compensation Recovery purposes, compensation is:

• a payment of damages
• a payment under an insurance scheme, or compensation under law
• a payment (with or without admission of liability) resulting from judgment or settlement of a claim for damages or a claim under an insurance scheme
• any other compensation or damages payment, other than a payment under a scheme to where the recipient has contributed. For example, life insurance or superannuation

Note: a claim against a life insurance policy, or superannuation scheme where the injured person contributed is not notifiable under the HOSC Act.

Compensation does not include

• a payment by an individual who is not insured, is indemnified against any liability for the injury, and who is not required by law to be insured or indemnified
• a criminal injuries compensation payment
• a voluntary payment which (whether on its own or in conjunction with other such payments) has the effect of extinguishing by agreement a claim for compensation. Go to Ex-gratia payments
• a payment of a kind, or in circumstances prescribed by the regulations

An individual is taken to be insured or otherwise indemnified from liability if:

• the individual is a member of a representative organisation, and
• the representative organisation bears liability for paying on behalf of the individual member

The References page contains a link to legislation, section 4 of the HOSC Act.

Go to Notifiable and not notifiable claims.

The notifiable person must tell the agency in writing of an injury or illness to a person where:

• a compensation amount of more than $5,000 was fixed by judgment or settlement (including legal costs for settlements), or
• a reimbursement arrangement was made more than 6 months after a claim was lodged

The Australian Government pays benefits and subsidies on that person’s behalf to service providers, when:

• a person receives professional services for which a Medicare benefit is paid, and/or
• nursing home, residential care or home care services

When a person receives compensation for an injury or illness, this usually includes related medical costs.

This means that they may need to repay the Australian Government any of the below related benefits or subsidies before they can receive their money:

• Medicare benefits
• nursing home benefits
• residential care subsidies, and/or
• home care subsidies (collectively referred to as ‘care costs’)

Only related services between the date of injury or illness (DOI) and the date compensation fixed by a judgment, settlement, or a reimbursement arrangement made, are recoverable.

If an injury or illness was sustained before the Medicare program commenced on 1 February 1984, the Notice to claimant (NTC) will only list services received on or after that date.

The date and nature of an injury or illness must be provided in writing so a claim can be registered in the MCRS. Notice of a claim can be provided on a:

• Notice of past benefits request form (MO026)
• Notice of judgment or settlement form (MO022)
• Notice of reimbursement arrangement form (MO027), or
• supporting documents, provided they have all mandatory details

If the claimant or notifiable person is having difficulty specifying a date of injury or illness (DOI), go to Table 10 on the Resources page for help.

The nature of the injury or illness can be a basic description if it adequately describes it. For example:

• whiplash
• upper or lower extremity (left or right not required)
• psychiatric/ psychological
• broken arm/leg
• soft tissue injury

Due to the sensitive nature of some of the claims registered by the agency, Service Officers must check injury descriptions to make sure professional standards are adhered to on outgoing correspondence when:

• new claims are registered, or
• accessing a claim in MCRS

Updates required include:

• corrections to typing errors or abbreviations
• injury descriptions of a mental/psychological nature must be entered as psychological. These may include:
• abuse
• historical abuse
• psych
• psychiatric
• death of (another party)
• mental harm
• mistreatment in care, or
• mental sequelae

Note:

• a description of the accident is not acceptable as it does not provide information about the injury or illness sustained
• for example, the agency cannot accept ‘hit by car,’ ‘slip and fall’ or ‘fell off ladder’ as an injury description:
• the injury description does not need to list if it was left or right:
• for example, broken arm is sufficient. Service Officers must not use acronyms when entering injury descriptions into the data field on MCRS

Any change to a date of injury/illness (DOI) or description for a registered claim must be notified in writing.

The DOI or injury description may change over the life of a compensation claim for various reasons such as:

• the injury or illness was caused by an incident earlier than originally thought
• the parties agree that the injury or illness was due to the nature and conditions of the injured person’s employment and agree on an earlier date to encompass the whole period
• various injuries or incidents are added or removed from the scope of the claim (either by agreement or by determination of a tribunal or similar body), and/or
• the initial date notified to the agency was incorrect and the error has been identified

If the injury description has minor changes between notifications, go to the Updating an existing claim from an enquiry case table.

MCRS will not automatically send a new Notice to claimant (NTC) following a change to DOI or injury description . If a new Identify related Medicare history and/or care services letter Z2800 and Medicare history and care services statement letter Z2801 are required, information must be submitted on a:

• Notice of judgment or settlement form (MO022)
• Notice of reimbursement arrangement form (MO027) or
• Notice of past benefits request (MO026)

If notification is received on a MO022, MO026 or an MO027 advising of a change to the DOI, Service Officers must issue a new NTC.

If a new NTC is not required, select document type Other – all other documents to update the date of injury illness without issuing the new NTC.

Go to Notice of past benefits request and notice to claimant > Notice to claimant > When Services Australia will not issue a notice to claimant for more details.

If there is a current Notice of past benefits (NOPB) based on the previous date of injury or description, it will:

• remain current until expiry if the claim does not settle, or
• automatically expire when the new NTC is issued following receipt of a MO022, MO026 or MO027

If the current notice lists services before the DOI, they will be removed once a MO022, MO026 or MO027 is processed.

Go to:

• Authority to access a claim, and
• Document Assessment

The date of the injury or illness depends on the type of compensation claim being made by the injured person and the nature of the injury, illness, disease or condition reported. Compensation claims lodged against compensation payers can include claims for:

• workers compensation
• motor vehicle accidents
• public liability
• product liability
• common law
• medical negligence
• school accidents
• sporting injuries
• wrongful deaths (including malpractice)

If a compensation payer contacts the agency to clarify the agency's position about a notifiable date of injury or illness, go to the Resources page for details about giving advice about the notifiable date of injury or illness.

If a Service Officer needs further support to help the compensation payer, refer the case to the Programme Support Officers (PSO) hotline.

Medicare was introduced to eligible Australian residents on 1 February 1984. If the date of injury or illness is before 1 February 1984, a compensation case must be registered with the actual date of injury or illness, for example, 10 February 1970.

However, the Notice to claimant (NTC) (composed of the Medicare history statement, care cost statement and declaration form) will only list services for which a Medicare benefit has been paid since 1 February 1984.

While a specific date of injury or illness should be provided to the agency, for certain cases this may not be possible due to the length of time involved (for example, historic abuse or psychological claims). The date of injury or illness provided will often be only a year or a month and year, an approximate date or a date range.

If a form or notice is received by the agency to register a case for a historic claim without a specific date of injury or illness, go to the Resources page for how to register the date.

The program uses letters to make contact when:

• there is a legislative requirement to provide a written notice, or
• a form or request cannot be processed due to missing information

This includes when:

• making a decision
• sending a formal notice

Always use a system generated letter, except when sending copies of legacy Compensation Case Management System (CCMS) letters.

Standard letter template manual letters are used in these 2 instances only:

• We need more information to process a payment (Z2277)
• Tells the payer that money has been received but the agency has not received advice to inform who/what the payment is for
• Compensation claim document enclosed (Z2451)
• This is the manual version of the system Compensation claim document enclosed letter (Z2803). Tells the recipient that compensation claim documents are enclosed. Only use this letter when sending copies of a document from a legacy claim that are not available on the correspondence list in MCRS

MCRS will show one of the following statuses for each system issued letter (correspondence):

• requested - has gone to print (next business day) - it can only be previewed before being submitted
• sent - has been printed and sent by Australia Post
• consolidated - multiple letters of the same type and to the same recipient were triggered within a claim on the same day - only the latest will be sent, and all others will be marked as consolidated
• For example, if a Z2806 letter was issued for an incorrect reason and a corrected Z2806 letter is issued on the same day only the later version is sent. Any system issued letter except the Z2803 letter can be consolidated
• error - an error has occurred and the letter has not been sent. Program Management create a regular report for these errors. Do not notify Program Management when a letter error is identified

If an error occurs, Service Officers must investigate to determine the cause and update the information. The process step must be redone as MCRS will not automatically send the letter once an issue is fixed. Errors can be caused for a number of reasons. For example:

• no full stop in the state field of an overseas address
• a claim not properly migrated
• a missing address

The Resources page contains a list of manual and system generated letters.

Case notes must be entered every time a claim is:

• viewed
• accessed, or
• processed

For more details about why and how to add case notes, and to access the case notes template, go to Escalations and case notes.