Extensions, decisions and reviews - Medicare Compensation Recovery 011-15030070

An extension of time to return the Statement by claimant (SBC) may be granted if received on or before the due date provided on the statement. Requests received after the due date must be rejected.

An extension request must be made in writing or through telephone by the:

• injured person or claimant
• authorised legal representative appointed to act on the injured person’s behalf (such as by a Court Order, as a Power of Attorney or Executor), or
• authorised third party (including a solicitor or an individual who is authorised to act on behalf of the injured person, claimant or legal representative)

Services Australia will issue an 'Extension of period to give a statement request granted/refused' (Z2804) letter when a decision has been made or when a decision is internally reviewed.

Generally, no more than 2 extensions of time will be granted. This practice makes sure that no more than 3 months of services after the date of injury can be excluded when a Notice of past benefits (NOPB) is issued. Each case is assessed independently.

See:

• Process for information on granting an extension
• Escalations - Medicare Compensation Recovery for information on escalating claims to APS5 (SS05) or Program Management

An extension may be granted when a claim has:

• not reached judgment or settlement
• the agency may grant an additional 28 days from the date the SBC was due if the request is received on or before the original due date
• reached judgment or settlement and the:
• notifiable person has made a valid Advance Payment (AP)
• request is received on or before the due date of the SBC
• agency may grant an extension for a period of up to 12 months. The requestor must advise of extension period, otherwise it will default to 28 days
• reached a reimbursement arrangement
• the agency may grant an additional 28 days to return the completed SBC, if the request is received on or before the original due date

An extension cannot be granted if:

• the due date provided on the Notice to Claimant (NTC) has passed
• a claim has settled but AP criteria were not met
• supporting documents are missing, such as a Last Will and Testament or probate document, or
• the claim has reached judgment or settlement and the Section 33D date has passed

For how to grant or refuse an extension request see the Process page.

Note: requests for second or subsequent extensions received on or before the current due date, can be assessed by Service Delivery APS4 level or above and be granted in limited circumstances. For scenarios in which this may occur, see Table 5 on the Resources page.

A granted extension of time to return the SBC may change the date under s33D. This determines when the Notice of past benefits - advance payment (NOPB-AP) is required to be issued by the agency.

If the extension due date is before the original s33D date there is no impact. However, if the extension due date falls outside of the original s33D time frame, the agency has 28 days from the new due date, or 28 days from the date the completed SBC is returned to produce the NOPB-AP, whichever is earlier.

See Notice of past benefits (NOPB) and Notice of charge (NOC) - Medicare Compensation Recovery for calculation information.

See Notice of reimbursement arrangement (NORA) - Medicare Compensation Recovery

Refusal to issue a new NOPB, NOC or NOPB-AP is referred to in sections 18 and 21 of the Health and Other Services (Compensation) Act 1995. The delegation to make the decision is held at a Service Delivery APS3 level and above.

A 'Notice of refusal' (Z2806) letter is issued when:

• a request to issue a NOPB is received while there is a valid NOPB on the claim
• an SBC is returned late and there is a valid ‘all services included’ NOPB on the claim
• the injured person/claimant has submitted an SBC to amend the NOC, NOPB or NOBP-AP without sufficient evidence. This may apply to previously verified Medicare services or care costs, or
• a request to amend an 'all services included' NOC was received outside of 2 years from the date of judgment or settlement (DOJS)

The Resources page contains information about reasons for issuing a notice of refusal.

In some circumstances the injured person, claimant or authorised third party (ATP) may apply for an internal review of a decision. A valid review request must be made:

• within 28 days of notification of the decision, and
• in writing

The agency must review the decision and decide to affirm or vary the original decision within 28 days of receiving the application.

Review of decision - extensions

The injured person, claimant or ATP can request an internal review of decisions related to extensions. The application for an internal review may be because the:

• agency is denying an extension, or
• claimant is not satisfied with the length of the extension period

An internal review of a decision must be completed by an APS4 (or above) and must not be made by the Service Officer who made the initial decision. The reviewer will consider if processes and policies were correctly applied in the original decision and:

• affirm the original decision, or
• vary the original decision with a longer due date

When a decision has been made, the reviewer will process accordingly in MCRS and issue an Extension - Review of decision (Z2804) letter.

The Process page contains steps on how to review an extension decision.

Review of decision - Notice of refusal

The only notice of refusal decision that includes the right to review is a refusal to amend a Notice of charge - all services included. This may happen when the injured person, claimant or their ATP did not lodge a request to amend an ‘all services included’ NOC within 2 years from the date of judgment or settlement.

The decision to refuse is reviewable under the Health and Other Services (Compensation) Act 1995.

An injured person or claimant asking for a review of the decision to refuse an amendment of a Notice of charge - all services included must make an application in writing within 28 days of notification of the original refusal.

The due date for the review application will be given on the original refusal notice. It allows an extra 9 days for postage.

As 2 years is the maximum time frame under the Health and Other Services (Compensation) Act 1995, the decision to refuse to give notice will not be overturned on review unless the details of the claim led to an incorrect decision being made. Consider other circumstances if the injured person/claimant makes contact asking to amend an all services included notice more than 2 years from the date of judgment or settlement. Escalate the claim to Program Management and give reasons for why they should review the case.

An APS5 (or above) must complete the review of the original decision to refuse to issue a notice (known as a reconsideration). This:

• must be done within 28 days from receipt of the application, and
• must not be completed by the Service Officer who made the initial refusal decision

A 'Reconsideration of decision to refuse to issue a notice (Z2806) letter will be issued when all relevant evidence has been considered and an outcome reached. If the decision is made to accept the evidence and vary the original decision an APS5 (or above) needs to re-process the SBC.

If the injured person/claimant is unsatisfied with the outcome of the reconsideration, they have the right to apply to the Administrative Review Tribunal (ART) for a review. They will be told this through the Reconsideration of decision to refuse to issue a notice (Z2806) letter.

Note: the Administrative Appeals Tribunal (AAT) was superseded by the Administrative Review Tribunal (ART) on 14 October 2024.

Role of the ART

The ART provides an independent review on a range of administrative decisions made by:

• government departments
• agencies, and
• some non-government bodies

The ART will only review a decision after the agency has completed an internal review.

When an injured person or claimant disagrees with a decision

An injured person, claimant or their ATP may disagree with a decision about the reconsideration of refusal to issue a notice under section 18.

In these cases, they may apply to the ART to review the decision. In line with Section 27A of the Administrative Review Tribunal Act 1975, notice of a person’s right to have the decision reviewed is included in the relevant letters.

Note: ART reviews may incur an application fee.

Receiving notification of an ART appeal

If a request received is about an ART appeal:

• escalate notification of an ART appeal to Program Management
• all relevant documentation and previous decisions made about the disputed claim will be available on the claim for Program Management assessment

Program Management will send the required documents to the ART. See Escalations.

Formal ART decisions

When an ART decision is in favour of the:

• agency, the compensation claim will proceed and money will be recovered in line with the decision details
• injured person or claimant, the agency is bound by the terms of the decision and will proceed accordingly

Charges for lodging an application

The ART will inform the injured person or claimant:

• of any fees associated with lodging an application, or
• if they are exempt from paying any such fees

Contacting the ART

The ART website has the contact details for each State and Territory.

The Resources page contains a link to the ART website.

If an administrative error is identified, a call must be made to the notifiable person and the injured person/ claimant/ATP, to advise a new notice will be issued.

This makes sure:

• correct information is available when negotiating the settlement or judgment amount
• less future rework and enquiries
• claims are closed accurately
• that the agency recovers the correct amount

For further details see Table 2 and Table 3 on Resources page.

An amendment to an NOPB, NOC, or NOPB-AP may be considered in certain circumstances. Criteria for review will depend on if the:

• claim is pre or post judgment or settlement
• notice is verified or all services included
• notice was valid or expired at the date of:
• review request, or
• date of judgment or settlement (DOJS)

General circumstances for review of a notice include a:

• processing error being identified and services or costs have been incorrectly included
• request from an injured person/claimant/ATP to remove previously verified services from an expired NOPB (pre-settlement) is received. No further evidence (for example, letter from a treating medical practitioner or statutory declaration) is required. A subsequent SBC will need to be completed with previously verified services crossed out or ticked no.
• request from an injured person/claimant/ATP to remove previously verified services from a NOC or NOPB-AP (post-settlement) is received. Evidence is required and must be either a:
• letter from a treating medical practitioner confirming the services do not relate to the compensable injury, or
• statutory declaration completed by the injured person/claimant providing thorough rationale supporting the removal
• request is received for review of a care cost amount (in full or in part), stating that the cost does not relate to the compensable injury or illness. Medical evidence is required to remove previously identified care costs and must be escalated to Program Management.

Note: an amendment of care services must be approved and completed by a Program Management APS5 (or above) when the appropriate evidence is submitted.

For more information on escalating these cases to Program Management see Escalations - Medicare Compensation Recovery.

The Resources page contains more information about circumstances, evidence and delegations to approve amendments.

Where a request is received to amend an NOPB, NOC or NOPB-AP and remove previously verified services, the complete SBC must clearly indicate which services are to be removed by:

• being ticked no, crossed out or having a line drawn through them, or
• including a comment beside the service indicating it is unrelated

Note: initials are not needed when services are to be removed.

Delegation to amend notices vary by classification level:

• Service Delivery APS5 staff hold a higher level of delegation and may amend notices across a broader range of scenarios
• Service Delivery APS3 and APS4 staff are limited to amending notices prior to settlement, and only where an identified processing error has occurred that resulted in the incorrect inclusion of services or costs
• Escalation to Program Management is not required except where a request to amend care costs has been received or the request for amendment has been received outside of 2 years since the date of judgment or settlement

The Resources page contains more information about circumstances, evidence and delegation to approve amendments.