Statement by claimant (SBC) - Medicare Compensation Recovery 011-15030060

When a Notice to claimant (NTC) is completed and returned to Services Australia it becomes an SBC.

An SBC is made up of the:

• complete services statement, containing the list of medical services that the injured person has used between the date of injury (DOI) to the date of statement issue or between the DOI and the date of judgment or settlement (DOJS) or date of reimbursement arrangement, and
• completed care services statement, and
• completed, signed and dated declaration

The services statement will not be included if the injured person did not receive Medicare benefits between the DOI and date of issue. In this instance the NTC will only consist of the care services statement and declaration.

The claim’s status determines the issue of either a:

• Notice of past benefits (NOPB), or
• Notice of charge (NOC), or
• Notice of past benefits - advance payment (NOBP-AP)

If a completed SBC is not returned by the due date (inclusive of a granted extension), all items on the NTC may be taken as relating to the injury/illness. This is referred to as an all services included notice.

MCRS will create an SBC work item when the SBC has not been returned by the due date. The system will also create an SBC work item when the SBC has been returned but not processed before the due date.

If a statement is returned late, the Agency may elect to process it as if it was received on time, provided processing of an all services included NOPB has not occurred.

If the SBC is incomplete, it will be assessed as not substantially correct and a Statement not substantially correct letter (Z2805) may be issued with a new due date.

A response to a previously issued Statement not substantially correct (Z2805) letter may include only a partial component or components of an SBC. These must be assessed in conjunction with existing documents on the claim and not automatically rejected. See the Resources page for scenarios where a decision on whether to accept a subsequent partially returned SBC is required. Go to Notice of past benefits (NOPB) and Notice of charge (NOC) for more details.

Each request for an extension to return an SBC must be:

• received on or before the due date on the statement
• assessed independently as the claim status determines whether an extension can be granted

See Extensions, decisions and reviews - Medicare Compensation Recovery for more details.

To be considered complete, the SBC must include:

• all pages of the services statement, care services statement and the declaration
• Yes or No indicated in the tick box for the care services statement
• the full name of the person making the declaration
• a tick in the relevant box to indicate who is making the declaration
• the business name (if applicable)
• the address of the person making the declaration
• the signature of the person making the declaration
• the date the declaration is made

Note: the declaration can be accepted as complete when the:

• tick in the relevant box to indicate who is making the declaration is not completed, but:
• the name provided is the injured person, or
• a supporting document has been used to confirm the identity of the signatory on the form

If the injured person/claimant has identified services by selecting at least one Yes or No box on the services statement, the agency will assume the only services that relate are the ones which are selected Yes. Any blank box is to be considered as No.

The agency will:

• assume that only previously identified services (if applicable) or no services are relating if the:
• injured person/claimant has not ticked any boxes on the services statement, and
• the declaration has been completed in full
• treat the statement as incomplete if:
• all pages of the services statement are not provided (this does not include the instructional letter as Page 1 of the Z2801 or the Z2800 NTC cover letter)
• one of the care services statement boxes (yes or no) has not been selected, or
• the declaration has not been completed

Note: if the final page of the services statement has not been provided but contains no services, the SBC may be accepted as valid.

Advanced Payment (AP) claims and pre-settlement

If the SBC is incomplete:

• a Statement not substantially correct (Z2805) letter will be sent asking the injured person/claimant to submit a new or amended statement, and
• the injured person/claimant will be granted an additional 28 days from the date on the letter to return the completed statement

For valid AP claims the extension to the due date applied by the issuing of the Z2805 letter may result in an extension applying to the S33D date.

See Extensions, decisions and reviews - Medicare Compensation Recovery.

All services will be considered as relating and an all services included notice will be issued if:

• no response to the Z2805 letter is received, or
• the returned amended SBC is still assessed as incomplete

No further Z2805 letters will be issued unless an administrative error has occurred, for example, the initial Z2805 letter was issued to an incorrect address.

Failed AP and Notice of charge (NOC) claims

There are no extensions granted or not substantially correct decisions issued on claims that do not meet the advance payment criteria, the due dates under section 24(4) are never extended. If the SBC is incomplete an all services included notice must be issued along with the Z2805 letter.

Removing services

If a subsequent SBC indicates that previously verified services do not relate to the injury/illness, Service Officers can process as requested unless:

• there is a Notice of past benefits (NOPB) that is current and valid
• the claim has reached judgment/settlement, or
• the injured person/claimant is seeking to remove care costs (this will need evidence and/or approval from a Service Support Officer (APS5) or Program Management or above)

Go to:

• Extensions, decisions and reviews – Medicare Compensation Recovery for amending a valid NOPB or if the claim has reached judgment or settlement
• the Process page for how to process an SBC

The injured person may have multiple claims for the same or similar injury/illness, but the agency can only recover the benefit or subsidy paid for a provided service once. The process of checking whether services have previously been recovered is called cross-referencing, which makes sure that indicated services have not already been recovered by the agency in relation to another compensation claim.

When services indicated on an SBC have been previously recovered the service cannot be included in any new:

• Notice of past benefits (NOPB), or
• Notice of past benefits - advance payment (NOPB-AP), or
• Notice of charge (NOC)

Where services are listed the system will present a Validate button. Matched services must be checked and confirmed as previously recovered (including checking for manual amendments) before the Validate button is selected.

MCRS will review selected services (including all services included and verified) against any other existing closed claim for the injured person and alert the Service Officer of services that may have been included on any closed claim NOC/NOPB-AP.

If matching services are found during the alert process MCRS will:

• de-select any previously verified matching service(s) listed
• display a message stating Highlighted services appear on the final notice for another closed claim for this injured person. Cross reference to ensure service is not recovered twice and re-select if necessary
• highlight each matching service row in a shaded blue colour box
• accept the selection and display the Submit button if any previously matched service is re-selected
• display the Submit button only when validation is completed for all selected services. Validation occurs once only, unless a Service Officer selects additional services after initial validation
• display the WIN for each identified service

Note: this is an alert only and is intended to highlight the potential for a previously recovered service/s.

Cross referencing is required when there is a previously closed claim for the same injured person which has:

• an overlapping period of liability, and
• a verified NOPB-AP or NOC and payment has been made, or
• an all services NOPB-AP or NOC and more than 2 years has passed from the date of judgment or settlement

Cross referencing is required when there is a previously closed claim for the same injured person which has:

• an overlapping period of liability, and
• a verified NOPB-AP or NOC and payment has been made, or
• an all services NOPB-AP or NOC and more than 2 years has passed from the date of judgement or settlement

Cross referencing is not needed when:

• the current SBC has no services indicated
• an all services included notice is being issued due to an incomplete or not returned SBC
• the other claim(s) has not settled
• the other claim(s) does not have overlapping periods of liability
• the other claim(s) NOPB-AP or NOC is for a $nil recovery
• the other claim(s) has an outstanding debt
• the other claim(s) has an all services included NOPB-AP or NOC and it has not reached the 2 year amendment-limit time frame since the date of judgement or settlement

Note: Service Officers must not solely rely on the most recent system issued NOC or NOPB-AP. A manual amendment may have previously been completed. Case notes and documents on the claim must be assessed to determine the latest NOC.

Go to Claim management - Medicare Compensation Recovery for details about case notes.

A NOPB provides the total Medicare and care cost recoverable amount for a compensation claim. The notice is then sent to the notifiable person and a copy to the claimant.

Go to Notice of past benefits (NOPB) and Notice of charge (NOC) for more details.

If an injured person received nursing home, residential or home care services because of their compensable injury or illness, there may be recoverable care costs.

• Go to the Process page for how to request a care costs check.
• See Care costs - Medicare Compensation Recovery.