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

This document details information about granting or refusing extensions for the return of a Statement by claimant (SBC), Notice of refusals and review of decisions. It also explains how to amend a notice when an error has occurred or if the notice has been disputed by the injured person/ claimant, authorised third party or notifiable person.

Step	Action
1	Evaluate extension + Read more ... For requests by phone, go to Step 2 For written requests, go to Step 3
2	Evaluate – extension request received by phone + Read more ... For legacy claim, see Claim management - Medicare Compensation Recovery to migrate the claim first. Select Phone enquiry from the dropdown menu Select Have you authenticated the caller and selected the relevant claim? Select Is an extension being requested? Select Continue A message displays Have you entered a case note? Select yes if case note entered Select no if case note not entered. Enter case note and select Continue A message displays Have you entered a case note? Would you like to continue processing Statement by Claimant task or assign the task to the queue? If the Service Officer is: proficient: Select Keep assigned to me Select Ok, go to Step 4 not proficient: Select Cancel and add a case note to document actions taken Select Continue Select Assign to the queue Select Ok Procedure ends here
3	Evaluate - extension request received in writing + Read more ... For legacy claims, see Claim management - Medicare Compensation Recovery to migrate the claim first. Select Statement by claimant Select Does the claim selected match the details in the documents? Select Is an extension to be processed? Select Continue A message displays: Would you like to continue processing Statement by claimant task or assign to the queue? If the Service Officer is: proficient: Select Keep assigned to me Select Ok, go to Step 4 not proficient: Select Cancel and add a case note to document actions taken Select Continue Select Assign to the queue Select Ok Procedure ends here
4	Capture extension details + Read more ... Is the request a reconsideration of decision? Yes, APS4 and above Staff can complete the case, go to Table 3 APS3 Staff must transfer the case see Table 1 in Escalations - Medicare Compensation Recovery No, enter extension request received date the extension decision date will default to today's date go to Step 5
5	Criteria for refusal of extension + Read more ... Check if the claim meets any of the criteria for refusal of an extension. This includes, but is not limited to: the due date provided on the Notice to claimant (NTC) has passed the claim has settled but Advance payment (AP) criteria were not met supporting documents are missing, such as a Last Will & Testament or probate document the claim has reached judgment or settlement, but the Section 33D date has passed Does the claim meet any of the criteria for refusal of an extension? Yes, refuse the request, select Submit. Go to Step 7 No, grant the request. Select Do you grant the request? Go to Step 6
6	Grant the extension request + Read more ... New due date field displays and the new due date will auto populate to 28 days after the original date Select Submit. Go to Step 7 Note: the due date can be manually amended if granting an extension for more than 28 days extensions of more than 28 days can only be carried out when: a claim has settled, and it meets the valid AP criteria the requestor must specify the time frame (must be within 12 months of the original due date), otherwise it must default to 28 days For details about valid AP criteria see Payments, refunds and debts – Medicare Compensation Recovery.
7	Issue correspondence – Z2804 + Read more ... If the request is: Granted: Select the Notice type from the dropdown menu Select Extension from the Letter purpose dropdown menu Select the correct recipient and select Preview to review the correspondence add a case note to document actions taken Select Submit to issue the correspondence Refused: Select the Notice type from the dropdown menu Select Extension from the Letter purpose dropdown menu Select the relevant refusal reason Select the correct recipient and select Preview to review the correspondence add a case note to document actions taken Select Submit to issue the correspondence Procedure ends here.

Issue a Notice of refusal (Z2806)

Table 2: follow this process to issue a Notice of refusal (Z2806)

Step	Action
1	Evaluate - Statement by claimant (SBC) or Notice of past benefits request + Read more ... Select Statement by claimant or Notice of past benefits request from the dropdown menu Select Does the claim selected match the details in the documents? button Note: select the document type based on the document received, the options displayed will auto populate depending on the document type. Is a Notice of refusal (Z2806) letter needed? Yes, select Do you want to refuse to issue a NOPB? button select Continue a message displays Are you sure you want to refuse to issue a Notice of Past Benefits? or Are you sure you want to refuse to issue a Notice to claimant?, select Yes, go to Step 2 No, to issue a Notice of claimant (NTC), select Continue: to issue an NTC, see Notice of past benefits request and Notice to claimant (NTC) - Medicare Compensation Recovery to process SBC see Statement by claimant (SBC) - Medicare Compensation Recovery
2	Who sent the request for a new NOPB? + Read more ... Injured person, claimant or Authorised third party (ATP), go to Step 3 Notifiable person or their solicitor, go to Step 4
3	Issue correspondence - Z2806 + Read more ... Is the request for a reconsideration of decision? Yes, case is to be completed by APS5 (or above) if outside of Service Officer’s delegation, transfer the case see Escalations - Medicare Compensation Recovery go to Table 4 No, select Notice of refusal from the dropdown menu select the relevant refusal reason Note: if Failed to submit the statement within 2 years from DOJS reason is selected, additional fields appear. Key the Date request was received. Key the Settlement date the correct recipient will be pre-selected. Select Preview to view the letter content add a case note to document actions taken select Submit to issue the correspondence procedure ends here Note: where an NOPB is being requested by an Authorised third party (ATP) that has not previously received the Notice to claimant (NTC), or a valid NOPB has not been received by the sender, a copy may be issued through restricted claim actions. See Table 2 in Medicare Compensation Recovery.
4	Skip correspondence - Z2806 + Read more ... Select Skip Correspondence button Add a case note to document actions taken Select Submit Message displays, Are you sure you want to proceed skipping the correspondence? Select Yes Procedure ends here. Note: Skip Correspondence is used where a subsequent request is received from the notifiable person or their solicitor, after a previous request has been actioned. This is to reduce unnecessary requests for further information regarding the refusal letter.

Issue a Review of decision - Extensions (Z2804)

Table 3

Step	Action
1	Reconsideration of decision + Read more ... Only an APS4 (or above) can action a reconsideration of decision. Select the WIN hyperlink from the left-hand summary panel within the work item to assess the claim fully. Review all case notes, previous decisions made, correspondence issued and documents received to make a determination to: substitute, vary, or affirm
2	Evaluate - extension + Read more ... When reviewing an extension decision: Select Statement by claimant (SBC) from the dropdown menu Select Does the claim selected match the details in the document? button Select Is an extension to be processed? button Select Continue A message displays Have you entered a case note? Would you like to continue processing Statement by claimant task or assign to the queue? If the Service Officer is: proficient and has an APS4 (or above) delegation: select Keep assigned to me select Ok, go to Step 3 not proficient or has APS3 delegation select Assign to the queue select Ok add a case note to document actions taken procedure ends here
3	Capture extension details + Read more ... Extension request received date defaults to the original extension received date. If the reviewable decision is: substituted or varied: Select Do you grant the request? button Select Submit go to Step 4 affirmed: Do not select the Do you grant the request? button Select Submit Go to Step 4
4	Issue correspondence – Z2804 + Read more ... Select the form type (document received) from the dropdown menu Select Extension from the Letter purpose dropdown menu Select Review decision from the dropdown menu Select Original extension decision from the dropdown menu Select the relevant reason for the decision Select the correct recipient (the party requesting the extension) and select Preview to view the letter content Add a case note documenting the actions taken Select Submit to issue the correspondence Procedure ends here

Issue a Review of decision - Notice of refusal (Z2806)

Table 4: follow this process to action a reconsideration of decision

Step	Action
1	APS5 (or above) to action a reconsideration of decision + Read more ... Select the WIN hyperlink from the left hand summary panel within the work item and review: the documents received and correspondence issued the case notes, and other relevant resources See the Background page - Notice of refusal and Review of decision Assess the claim fully and make a determination: Affirm, or Vary
2	Evaluate - Statement of claimant (SBC) + Read more ... Select Statement by claimant or Notice of Past Benefits request from the dropdown menu Select Does the claim selected match the details in the document? button Note: select the document type based on the document received, the options displayed will auto populate depending on the document type. Is review of a decision needed? Yes, select Do you want to refuse to issue a NOPB? button select Continue a message displays Are you sure you want to refuse to issue a Notice of Past Benefits? or Are you sure you want to refuse to issue a Notice to claimant?, select Yes, go to Step 3 No, select Do you want to issue an NTC? button, select Continue to issue NTC see Notice of past benefits request and notice to claimant. To process SBC see Statement by claimant and care costs
3	Issue correspondence - Z2806 + Read more ... If the refusal to issue a notice is for a Notice of past benefits (NOPB), the NOPB will become the Notice of charge (NOC) if a valid Notice of judgment or Settlement (MO022) form is received. From the Heading dropdown menu select Review of decision. From the Decision type dropdown menu select either Affirmed or Varied: Affirmed (to uphold the original decision): Key the Date request was received and Settlement date Preview the correspondence Select Submit to issue the correspondence Varied (to accept presented reasoning or evidence to change original decision): Preview the correspondence Add a case note documenting the actions taken Select Submit to issue the correspondence Procedure ends here

Process an Amendment pre-settlement care costs

Table 5

Step

Action

Evaluate - request to amend care costs + Read more ...

Select Notice of Judgment or Settlement from the dropdown menu
Select Does the claim selected match the details in the document? button

Note: amendments to care costs can only be completed by an APS5 (or above).

Is the Service Officer proficient with an APS5 (or above) delegation?

Yes, see Care costs - Medicare Compensation Recovery
No,

select Save and close the enquiry using the X in the summary panel
add a case note documenting the information received and actions taken. Include what the customer is seeking and any evidence supplied
go to Step 2

Recategorise work item in Work Optimiser + Read more ...

In Work Optimiser:

Select the appropriate work item from Work Items
Select Actions
Select Reassign
Select Recategorised from the Reason box
Enter MCRS_SBC_CC_NOPB if SBC was the document received or MCRS_SBC_CC_NOJS if NOJS was the document received as the Work Type
Select Submit

Procedure ends here

Process an amendment post settlement - claim previously closed in MCRS

Table 6

Step	Action
1	Evaluate - request to amend NOC or NOPB-AP + Read more ... Different messages will display depending on how the original claim was closed: Claims that closed under S24(4), S25(4) or S33K will show: Claim closed under S24(4), S25(4) or S33K. Are you sure you want to reopen the claim? Claims that did not close under one of the above conditions will show: Selected WIN is closed. Are you sure you want to reopen and update the claim details? Select Yes to continue.
2	Capture details screen + Read more ... If NOJS was selected from the dropdown menu, the NOJS Capture screen will display See Table 1 in Notice of judgment or settlement (NOJS). Go to Step 3. If NORA was selected from the dropdown menu, the NORA Capture screen will display See Table 1 in Notice of reimbursement arrangement (NORA). Go to Step 4. Note: make sure all fields are updated as required. For example, if the button indicating a refund to the injured person was not selected in the initial capture of a failed advance payment (AP) as shown at Q38 on NOJS, it must be selected during re-capture to ensure correct refund recipient is recorded for amendment purposes.
3	Assess NOJS details + Read more ... The most recent NOPB will display. Complete SAP searches for any additional money that may have been received after the claim was initially closed. If an amount was: received previously and added to the claim, continue with this Step not received previously and not added to the claim, the Has any amount been received for this claim in SAP button will be deselected Was an additional payment located? Yes, select the Has any amount been received for this claim in SAP button. Do not add payment amounts to these fields add additional payment by selecting the Any additional payment received button, enter payment details into the additional payment fields select Continue on the review screen, check all details for accuracy select the Reprocess SBC details and issue NOC button select Submit Reprocess SBC details message displays presents. Select yes go to Step 5 No, go to Step 5
4	Assess NORA details + Read more ... Confirm that details on the Review screen are correct. Do services or care costs require amendment? Yes, select the Reprocess SBC detail and issue NOC button. Go to Step 5 No, select Submit. Go to Step 6
5	Capture SBC details + Read more ... Reprocess the SBC to match the amended SBC provided, or details as approved by an APS5 Service Officer or Program Management. See Statement by claimant (SBC) - Medicare Compensation Recovery to process the SBC. The claim does not need to be escalated for care cost checks if: care costs are shown on the care cost statement of the SBC being used to request an amendment, but the NOC being amended does not include a care cost charge Note: a valid NOC or NOPB-AP can only be increased following approval from Program Management and will be assessed on a case-by-case basis. If not sure, consult a Program Support Officer (PSO). Does the NOC/NOPB-AP need an amendment to decrease the care cost amount? Yes, select the Are care services involved or a care costs breakdown required? button for escalation to an APS 5 (or above) select Submit procedure ends here No, after finalising the SBC capture select Submit. Go to Step 6
6	S23A and payment details + Read more ... Complete SAP searches for any additional money that may have been received after the claim was initially closed. If an amount was: received previously and added to the claim, continue with this Step not received previously and not added to the claim, the Has any amount been received for this claim in SAP button will be deselected Was an additional payment located? Yes, select the Has any amount been received for this claim in SAP button. Do not add payment amounts to these fields add additional payment by selecting the Any additional payment received button, enter payment details into the additional payment fields confirm the information is correct select and turn on the Is S23A and Advance Payment details verified? button select Submit No, confirm the information is correct select and turn on the Is S23A and Advance Payment details verified? button select Submit go to Step 7
7	Review the Notice of charge (NOC) summary + Read more ... Are the details correct? Yes, select Submit to issue the NOC add a case note documenting the actions taken and reason behind the decision made No, select Back and correct details add a case note documenting the actions taken and reason behind the decision made Note: where the NOC/NOPB-AP has increased, an escalation to PM is required see Escalations - Medicare Compensation Recovery
8	Notify Compensation Finance + Read more ... Is the refund/debt over the $50,000.00 threshold? Yes, do not complete the Referring a case to Compensation Finance template. When quality checking is completed the quality checker will send the notification to Compensation Finance No, complete the Referring a case to compensation finance email template to advise Compensation Finance of any action required relating to the refund or SAP adjustment Procedure ends here.

Process an amendment post settlement - claim previously closed in CCMS

Table 7: this table follows on from Table 1 in Close, terminate or reopen a claim.

Step	Action
1	Evaluate - request to amend NOC + Read more ... Different messages will display depending on how the original claim was closed. Claims closed in CCMS will not show that they closed under S24(4), S25(4) or S33K. Has the claim been migrated? Yes, see Table 1 in Close, terminate or reopen a claim and then go to Step 2 No, see Table 2 in Claim management and then go to Step 2
2	Capture details screen + Read more ... If NOJS was selected from the dropdown menu, the NOJS Capture screen displays: See Table 1 in Notice of judgment or settlement (NOJS). Go to Step 3 If NORA was selected from the dropdown menu, the NORA Capture screen displays: See Table 1 in Notice of reimbursement arrangement (NORA). Go to Step 4 Make sure all fields are updated as required.
3	Assess NOJS details + Read more ... The most recent NOPB will display. The S23A button will be visible but cannot be selected or amended. Complete SAP searches for any additional money that may have been received after the claim was initially closed. If an amount was: received previously and added to the claim, continue with this Step not received previously and not added to the claim, the Has any amount been received for this claim in SAP button will be deselected Was an additional payment located? Yes, select the Has any amount been received for this claim in SAP button. Do not add payment amounts to these fields add additional payment by selecting the Any additional payment received button, enter payment details into the additional payment fields select Continue go to Step 5 No, select Continue go to Step 5
4	Assess NORA details + Read more ... Confirm that details in the Review screen are correct. Do services or care costs require amendment? Yes, select the Reprocess SBC detail and issue NOC button. Go to Step 5 No, select Submit. Go to Step 6
5	Capture SBC details + Read more ... Reprocess the SBC to match the amended SBC provided, or details as approved by an APS5 Service Officer or Program Management. See Statement by claimant and care costs to process the SBC. The claim does not need to be escalated for care cost checks if: care costs are shown on the care cost statement of the SBC being used to request an amendment, but the NOC being amended does not include a care cost charge Note: a valid NOC/NOPB-AP can only be increased following approval from Program Management and will be assessed on a case-by-case basis. If not sure, consult a Program Support Officer (PSO). Does the NOC need an amendment to decrease the care cost amount? Yes, select the Are care services involved or a care costs breakdown required? button for escalation to an APS 5 (or above) select Submit procedure ends here No, after finalising the SBC capture, select Submit. Go to Step 6
6	S23A and payment details + Read more ... Complete SAP searches for any additional money that may have been received after the claim was initially closed. If an amount was: received previously and added to the claim, continue with this Step not received previously and not added to the claim, the Has any amount been received for this claim in SAP button will be deselected Was an additional payment located? Yes, select the Has any amount been received for this claim in SAP button. Do not add payment amounts to these fields add additional payment by selecting the Any additional payment received button, enter payment details into the additional payment fields confirm the information is correct select and turn on the Is S23A and Advance Payment details verified? button select Submit No, confirm the information is correct select and turn on the Is S23A and Advance Payment details verified? button select Submit go to Step 7
7	Review the Notice of charge (NOC) summary + Read more ... Are the details correct? Yes, add a case note documenting the actions taken and reason behind the decision made select Submit to issue the NOC/NOPB-AP No, add a case note documenting the actions taken and reason behind the decision made select Back and correct details
8	Notify Compensation Finance + Read more ... Is the refund/debt over the $50,000.00 threshold? Yes, do not complete the Referring a case to Compensation Finance template. When quality checking is completed the quality checker will send the notification to Compensation Finance No, complete the Referring a case to compensation finance email template to advise Compensation Finance of any action required relating refund or SAP adjustment. See Medicare Compensation Recovery quality assurance Procedure ends here

Operational Information