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

Reason

Use this option when:

Current Notice of Past Benefits (NOPB) exists – verified

a verified NOPB is valid and the injured person/claimant is seeking another Notice to Claimant (NTC), or the notifiable person is seeking another NOPB.

Current NOPB exists – deemed

an all services included NOPB is valid and the injured person/claimant is seeking another NTC.

Insufficient reason or medical evidence for failing to submit the statement by the due date – Notice of charge (NOC) deemed

an injured person/claimant is seeking to amend either the Care Costs or Medical Services with insufficient evidence (as per current process).

Failed to submit the statement within 2 years from date of judgment or settlement (DOJS) – Notice of charge (NOC) deemed

an injured person/claimant is seeking to amend a NOC more than 2 years from the date of judgment or settlement. (Consider other circumstances and escalate to Program Management if appropriate). See Escalations - Medicare Compensation Recovery.

Reason for amendment

Evidence required

Delegation

There is an identified processing error and services or costs have been incorrectly included

No evidence is required

Service Delivery APS3 and above

Service has already been paid by notifiable person

A copy of the invoice and receipt paid by the notifiable person.

See Escalations - Medicare Compensation Recovery for more information on escalating a work item to a Service Support Officer (APS5).

Service Delivery APS5 and above

A care cost amount (in full or part) does not relate to the compensable injury or illness

A letter from the treating doctor specifying:

• some or all of the care costs do not relate to the compensable injury or illness, or
• the increase in the level of care was not related to the compensable injury or illness

See Escalations - Medicare Compensation Recovery for more information on escalating a work item to Program Management (APS5).

Program Management APS5 and above

Reason for amendment

Delegation and evidence required

Valid NOPB - all services included

Service Delivery APS5 and above.

Generally, a notice of refusal will be issued in these circumstances. However, approval for amendment is assessed on a case-by-case basis upon receipt of:

• a re-completed Statement by claimant (SBC), and
• written evidence from the notifiable person or claimant’s solicitor that the claim cannot be finalised without an accurate notice that must be endorsed by:
• a judge confirming the date has been set, or
• the Public Trustee or nominated Private Trustee

See Escalations - Medicare Compensation Recovery for more information on escalating a work item to the Service Support Officer (APS5).

Valid NOPB - verified

Consider a review if:

• processing errors - Service Delivery APS3 and above
• an invoice/receipt has been received from the notifiable person showing that they have paid the account - Service Delivery APS5 and above
• a letter has been provided from treating medical practitioner advising care costs do not relate - Program Management

See Escalations - Medicare Compensation Recovery for more information on escalating a work item.

Otherwise amend following expiry of notice or post settlement by processing new SBC.

Expired NOPB

Service Delivery APS3 and above.

Processing a statement to remove previously verified services with a clear completed SBC.

If unsure, consult a Program Support Officer.

Note: this is not an amended NOPB. It is processed within a new NTC cycle.

See Statement by claimant (SBC) - Medicare Compensation Recovery.

Reason for amendment

Delegation and evidence required

Within 2 years of a judgment or settlement being fixed, a request is received to reduce NOPB-AP or NOC due to apportionment of liability to the injured person

Service Delivery APS3 and above

• Where written evidence is supplied by the notifiable person, approval is not required to reduce the NOPB-AP/NOC by the percentage of apportionment applied
• See Notice of judgment or settlement (NOJS) - Medicare Compensation Recovery

A change to the date of injury or illness (DOI) only at date of judgment or settlement (DOJS)

Service Delivery APS3 and above

• Consider if a new NTC is required, see Medicare Compensation Recovery for more information
• If a change to the DOI is advised on the NOJS and is later than the previously registered date, amend the DOI and re-process the SBC to remove any services prior to the new DOI.

NOC/NOPB-AP - all services included

Service Delivery APS3 and above

• The Health and Other Services (Compensation) Act 1995 allows for a review of the NOC/NOPB-AP within 2 years of the date of judgment or settlement (DOJS)
• A completed SBC (inclusive of service list, care statement and declaration) must be provided. See Statement by claimant (SBC) and care costs - Medicare Compensation Recovery

Verified NOC - valid at DOJS

Service Delivery APS5 and above

• There are no provision in the Health and Other Services (Compensation) Act 1995 to review a notice resulting from a verified statement, however consideration for review will be given within 2 years of DOJS
• Injured person/claimant must apply in writing and evidence will be required. Evidence must be in the form of a letter from a treating medical practitioner confirming the services do not relate to the compensable injury/illness, or a statutory declaration completed by the injured person/claimant that provides thorough rationale supporting the removal

Possible scenarios

Previously verified services are clearly unrelated to the injury or illness, Service Delivery APS5 can approve to process a re-completed statement by claimant.

Scenario 1

Previously verified services that might relate to the injury or illness requires:

• a re-completed Statement by claimant
• a statutory declaration by the injured person/claimant clearly stating that the services do not relate to the compensable injury/illness

Scenario 2

There has been a change in the nature of the injury or illness at DOJS. Evidence required includes:

• a re-completed Statement by claimant
• a statutory declaration by the injured person/claimant to explain the change in injury/illness clearly state that the services do not relate to the deemed compensable injury/illness
• supporting valid NOJS
• See Escalations - Medicare Compensation Recovery for more information on escalating a work item to the Service Support Officer (APS5).

Verified NOPB – expired at DOJS

• There are no provision in the Health and Other Services (Compensation) Act 1995 to review a notice resulting from a verified statement, however consideration for review will be given within 2 years of DOJS
• Injured person/claimant must apply in writing. This can be provided in the form of a returned SBC (updated NTC issued after valid NOJS received) with previously verified services crossed out or ticked no

Possible scenarios and further evidence needed related to the scenario (if necessary)

Scenario 1
Service Delivery APS3 and above.

Previously verified services that are clearly unrelated to the injury or illness:

• process an SBC requesting to remove previously verified services
• consult a Program Support Officer if unsure

Scenario 2
Service Delivery APS5 and above

Previously verified services that might relate to the injury or illness:

• Approval can be given to process a re-completed SBC with a letter from a treating medical practitioner or a statutory declaration by the injured person/claimant clearly stating that the services do not relate to the compensable injury/illness
• See Escalations - Medicare Compensation Recovery for more information on escalating a work item to Service Support Officer (APS5).

Scenario 3
Service Delivery APS5 and above

There has been a change in the nature of the injury or illness at DOJS:

• Approval can be given to process if there is a recompleted SBC with supporting valid NOJS.
• See Escalations - Medicare Compensation Recovery for more information on escalating a work item to Service Support Officer (APS5)

Scenario

Grant or Refuse

Service Officer received phone call to request second extension after due date of current SBC

Refuse - all requests received after the due date must be rejected

Service Officer received email prior to due date of current SBC requesting second extension as injured person is having trouble completing their 100-page statement. Claim has not settled or is valid AP

Grant - request received prior to due date and a reason has been provided

Claim has settled and a valid AP has been received. Request for a second extension was received prior to due date of current SBC

Grant - the 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

Claim is a failed AP; previous request was granted prior to receiving a NOJS

Refuse - full claim assessment will be required and NOJS processed where received valid and complete. See Notice of judgment or settlement

Request for second extension has been received; claim has not settled or is a valid AP and a statement not substantially correct (Z2805) letter has been previously issued. The extension request is received prior to due date on Z2805

Grant - the Z2805 has provided an extension, and the request has been received prior to the due date on Z2805