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Medical Assessment (MAt) 008-20102224

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This document provides an overview of an Initial Medical Assessment for a DSP New Claim, and steps taken by an Assessor to make a recommendation.

On this page:

Assessor receives MAt referral

Assessor completes MAt recommendation

Connected Assessor Pathway (CAP)

Assessor receives MAt referral

Table 1: this table describes the process for Assessors when they receive a MAt referral.

Expand table

Step

Action

1
Assessor receives MAt referral for DSP New Claim in Process Direct (ZCRF_DSP_MATDOC)

Before commencing the MAt, the Assessor must check there is a DSP claim present:

  • Online or Assisted Customer Claim (ACC) select Open left slider; Close right slider and Enter full screen icon to view claim
  • Paper claim - check for an SA466, SA494 or SA439 in Documents

Where an Assessor identifies any of the following:

  • No DSP claim present (for example, MEDSA466 only has been lodged, document incorrectly uploaded as an SA466)
    • Cancel the MAt referral
    • Annotate the DSP Progress DOC with ‘MAt referral cancelled as not required. DSP NCL created incorrectly’
  • Customer is DSP/CUR or DSP/RTW
    • Cancel the MAt referral
    • Annotate the DSP Progress DOC with ‘MAt referral cancelled as customer is DSP/CUR or DSP/RTW’
  • Customer is age precluded
    • Cancel the MAt referral
    • Annotate the DSP Progress DOC with ‘MAt referral cancelled as customer is age precluded’
  • Claim on the incorrect customer record (for example, uploaded to parent/nominee’s record)

Where a DSP claim is present

  • Assessor should consider the customer’s:
    • medical information
    • medical condition/s
    • personal circumstances, and
    • any previous Employment Services Assessment (ESAt) or Job Capacity Assessment (JCA) assessments within the last 2 years

Customer currently working or studying

Assessors must consider the customer’s current employment and educational circumstances in the MAt outcome if:

  • the customer is manifestly medically eligible, or
  • there is a current and valid assessment supporting DSP eligibility, or
  • the customer needs a JCA referral, and
  • the customer is working in unsupported open employment or undertaking mainstream studying/training of 15 hours or more per week

DSP (Blind) customers can work unlimited hours and do not require an assessment of Continuing Inability to Work (CITW).

Note: the assessment of where a customer's CITW occurred for residence purposes may still be required. See Assessing Continuing Inability to Work (CITW)

Additional checks

Assessors must check:

  • Referral Summary (RRSUM) screen before proceeding with SA479 assessment
  • The medical evidence has been correctly scanned in the Medical Information File Envelope (eMIFE). Where an error has occurred, documents must be corrected. See Requesting a document rescan, retrieval or location

Is there a current and valid assessment present?

2
Review customer’s record for manifest medical eligibility indicators

Manifest medical eligibility is met if the evidence supports that the customer meets one of the following,

Intellectual Disability, valid IQ less than 70 (INT)

  • Requires nursing home level care (NHM)
  • Terminally ill (TRM)
  • Permanently blind (BLI)
  • Category 4 HIV/AIDS (HV4)
  • DVA Disability Compensation Payment at Special Rate (TPI)

See Disability Support Pension (DSP) manifest eligibility and the Resources page, for more information.

Where the customer:

  • clearly meets Manifest Medical eligibility
  • has lodged a Claim for DSP For a Terminal Illness (SA494), or
  • has lodged a Verification of Terminal Illness (SA495)
  • See Table 2 > Step 1

If there are any indicators that a customer may have a condition that meets manifest eligibility criteria, the Assessor needs to fully explore this by any of the following methods:

  • Contact with the Treating health professional (THP)
  • Contributing Assessor (CA) Consultation
    • Consultation with a CA Psychologist is required for any possible intellectual disability (verified or unverified)
  • Health Professional Advisory Unit (HPAU) consultation
  • Psych SARG consultation
  • Third party organisations as appropriate for example, schools
  • Contact nominee/review Carer record for relevant medical information relating to the customer

Whilst the Assessor explores potential manifest eligibility, they must:

  • Apply Hold to User (HTU) to the MAt work item in Work Optimiser per Work Optimiser for staff
  • Place the SA479 template (within Process Direct) on hold for 7 days and update with any relevant THP or customer contact
  • Annotate the DSP progress DOC with ‘MAt assessment pending THP contact’

If manifest eligibility is met after further checks:

If manifest medical eligibility has been excluded:

3
Review customer circumstances

Review customer’s record for the following:

4
Current and Valid (CVA) JCA/Upgraded ESAt

Where there is an upgraded ESAt/JCA on the record, consider whether the report is current and valid for the purposes of medical eligibility for DSP and the current date of claim being assessed. Note: where an upgraded ESAT/JCA has been completed 13 weeks after the DSP date of claim, return to Step 3 for further consideration of medical eligibility.

  • A Current assessment means that an upgraded Employment Services Assessment (ESAt) and/or Job Capacity Assessment (JCA) has been completed within the last 2 years, was completed under the correct impairment tables and has a status of Submitted or Finalised on the system
  • A Valid assessment means the job seeker’s medical condition/s or work capacity has not changed since the previous ESAt/JCA and the report does not contain any fundamental errors
    • Fundamental Errors may include incorrect outcome based on evidence for example, missed manifest, fundamental terminology errors
    • If fundamental errors are present, consult with a Team Leader

Where there is a current and valid upgraded ESAT/JCA complete the SA479 with the appropriate recommendation.

Reject based on current and valid assessment

Is appropriate where a customer has had a previous upgraded ESAT/JCA submitted that has not met medical eligibility, and:

    • there is no new medical evidence lodged, or
    • the new medical evidence is unlikely to result in changes to the previous JCA for example, medical condition, impairment rating, work capacity etc
  • Complete and submit SA479 as per the following with:
    • Medical Conditions: Relevant medical conditions
    • Relevant medical evidence: Enter details of assessment used and/or relevant medical evidence
    • Recommendation: Reject based on current and valid assessment

Medical eligibility indicated in current and valid JCA

  • Is appropriate where a customer has had a previous upgraded ESAT/JCA submitted that has met medical eligibility and is considered current and valid as noted above
  • Complete and submit SA479 as per the following with:
    • Medical Conditions: No entry required
    • Relevant medical evidence: ‘Enter details of assessment used’
    • Recommendation: Medical Eligibility indicated in current and valid JCA
    • Has the customer resided in Australia for 10 years or do they have a Qualifying Residence Exemption (QRE): Yes/No

Note: where the JCA/ Upgraded ESAt indicates manifest medical eligibility, the SA479 must be completed with the recommendation of manifest medical eligibility and not as current and valid assessment.

5
Remote or very remote located customer
  • Where a customer is in a remote or very remote area, additional checks are required. If medical evidence indicates condition likely to persist for more than 2 years with uncertain diagnosed, reasonably treated and stabilised (DTS) condition progress to JCA, see Table 2
  • If there is no medical evidence on the record or the Assessor is unable to obtain any evidence, contact remote leadership group
  • If medical evidence indicates condition/s are clearly unlikely to persist or not diagnosed, reasonably treated or stabilised (for example, surgery pending that will improve functioning), see Table 2 > Step 3

Note: if there is a current and valid assessment on the customer’s record with recent THP contact and no change in condition, complete as a CVA. Go to Step 4

6
Trans Vaginal Mesh (TVM)

If the medical evidence indicates a possible TVM condition:

  • Submit a Development, Assurance and Support (DAS) query
  • Apply Hold to User (HTU) to the MAt work item in Work Optimiser per Work Optimiser for staff
  • Place the SA479 template (within Process Direct) on hold for 7 days and update with any relevant THP or customer contact
  • Annotate the DSP progress DOC with ‘Mat Assessment pending specialist advice’

7
Forensic Psychology

Assessors can refer to Forensic Psychology Team at MAt where:

  • The evidence supplied to the Assessor indicates the person may be vulnerable due to forensic history and/or significant behavioural concerns/sensitivities
  • The available evidence is unclear or insufficient and the Assessor needs support to complete the MAt
  • The person is disengaged or unable to obtain or supply additional medical evidence
  • The assessor has been unable to obtain the necessary additional information or clarification from the person’s THP, HPAU or CA
  • All of the above are true and a Job Capacity Assessment is best completed by a Forensic Psychology Assessor

Assessors can also refer to forensic psychology where customers have forensic history and significant behavioural concerns/sensitivities and diagnostic information is unclear. In these instances, a vulnerable customer assessment (VCA) may be required to determine a provisional diagnosis.

If the medical evidence warrants a forensic psychology referral:

  • Complete the Forensic Psychology Referral template on the Assessment Services SharePoint page
    • If the referral is not accepted by the Forensic Psychology Team, refer back to Step 1
    • If referral is accepted by Forensic Psychology, follow instructions from Forensic Psychology team
  • Apply Hold to User (HTU) to the MAt work item in Work Optimiser per Work Optimiser for staff
  • Place the SA479 template (within Process Direct) on hold for 7 days and update with any relevant THP or customer contact
  • Annotate the DSP progress DOC with ‘MAt assessment pending specialist advice’

8
Psychology Specialist Assessment Reference Group (Psych SARG)

A referral to Psych SARG may be required where there is an undiagnosed/diagnosed Intellectual Disability, Brain Injury, and/or Learning Disability and either there is no evidence, or evidence provided is inadequate.

If the Assessor determines (after consultation with a Psychologist Contributing Assessor if the primary Assessor is not a Psychologist) that a customer requires an assessment of intellectual and/or adaptive behaviour or a Vulnerable Customer assessment, they should complete a Psych SARG Referral Template.

  • Assessors can refer for an assessment of cognitive, intellectual and or adaptive behaviour functioning where:
    • The evidence supplied to the Assessor indicates the person may be eligible for DSP
    • The available evidence is unclear or insufficient for the Assessor to complete the report
    • The person is unable to obtain or supply additional medical evidence, and
    • The assessor is unable to obtain the necessary additional information or clarification from the person’s THP, HPAU or CA
  • Assessors can refer for a vulnerable customer assessment (VCA) for customers with suspected mental health conditions who:
    • are likely to be medically eligible for DSP or eligible for a significant reduction in their participation requirements, but
    • are unable to be effectively assessed through normal processes because they are disengaged from the health system, or they do not acknowledge the impacts of their condition on their capacity to participate in an activity or comply with requirements

If required, complete a Psych SARG Referral Template via Assessment Services SharePoint page.

  • Apply Hold to User (HTU) to the MAt work item in Work Optimiser per Work Optimiser for staff
  • Place the SA479 template (within Process Direct) on hold for 7 days and update with any relevant THP or customer contact
  • Annotate the DSP progress DOC with ‘MAt assessment pending specialist advice’

Note: once advice is received, update SA479 with Psych SARG outcome (and logon of Psych SARG member) in rationale section of the SA479 and indicate the requirement for specialist assessment, if needed.


Assessor completes MAt recommendation

Table 2: this table describes the process for Assessors completing the SA479, depending on the medical outcome.

Expand table

Step

Action

1
Manifest Medical Eligibility

Medical evidence on the record, including customer report confirm manifest medical eligibility. Complete and submit SA479 with:

  • Medical Conditions: ‘Enter Primary condition only’
  • Relevant medical evidence: ‘Enter Primary medical evidence only’
  • Recommendation: ‘Manifestly medically eligible’
  • Manifest eligibility reason: ‘Enter appropriate reason’
  • Has the customer resided in Australia for 10 years or do they have a Qualifying residence Exemption (QRE): Yes/No
    • If there is no residency information available on the customer record, submit a query via DAS Professional and Technical request - All Items
    • Apply Hold to User (HTU) to the MAt work item in Work Optimiser per Work Optimiser for staff
    • Place the SA479 template (within Process Direct) on hold for 7 days
    • Annotate the DSP progress DOC with ‘MAt assessment pending residency information’
  • If no, did the CITW arise in Australia?: Yes/No
    • Include a brief statement in the rationale explaining the decision
  • Recommendation rationale: clear and succinct rationale regarding how manifest criteria is met

2
Insufficient Medical Evidence (IME)

An outcome of Insufficient Medical Evidence (IME) may be indicated:

  • Where there is no medical evidence provided with the claim and the customer is not considered vulnerable or potentially manifest, or
  • Where there is very limited medical evidence provided with the claim

Service Offer Interview (SOI)

Where a MAt Assessor makes a recommendation of IME, the Assessor must attempt the Service Offer Interview (SOI). See Disability Support Pension (DSP) Service Offer Interview (SOI).

The purpose of the SOI is to assist the customer to understand the DSP claim outcome, and to offer any supports required

  • Assessors must attempt an SOI in every instance where an IME outcome is indicated, unless valid reasons apply

When an IME SOI is not required

  • the customer is deceased
  • the customer is in prison
  • the customer is in psychiatric confinement
  • there is no contact number on record
  • the SOI is not appropriate, for example customer is overseas
  • the customer has service channel restrictions under a current Managed Service Plan preventing telephone contact

Note: if potential manifest medical eligibility or vulnerability is indicated during discussion with the customer (for example, customer is in crisis, homeless, significant mental health impacts and/or affected by family and domestic violence) additional contact attempts must be made to confirm or exclude manifest medical eligibility before completion of the SA479.

Where the outcome is IME

  • Complete the SA479 as follows:
    • Medical Conditions: Enter any relevant verified medical conditions
    • Relevant medical evidence: Enter any relevant medical evidence that is contained on record. If no medical evidence note: No medical evidence was provided with this claim
    • Claimant contact: Enter details of attempts at customer contact or discussions with the customer
    • Recommendation: Insufficient evidence to assess medical eligibility
    • Recommendation rationale: Enter clear and succinct rationale

3
Manifestly Medically Ineligible

Where the evidence clearly indicates the customer is manifestly medically ineligible for DSP for one of the following:

  • Condition(s) not diagnosed, reasonably treated and stabilised (NDT)
    • the medical evidence provided does not support assessment against the Impairment Tables, or
  • Diagnosis criteria not met (MDI)
    • where there is a single medical condition of either Psychological, Hearing or Visual conditions and diagnostic criteria have not been met, or
  • Clearly no Continuing Inability to Work because of current unsupported employment (MCW)
    • There is clear evidence the customer is currently working at least 15 hours a week in open employment that is sustained and not in jeopardy, or
  • Conditions clearly temporary (MTM)
    • The customer’s medical condition/s are clearly likely to persist for less than 2 years, and the functional impacts are expected to resolve within the next 2 years
  • Complete the SA479 as follows:
    • Medical Conditions: Include any verified medical conditions noted within the medical evidence
    • Relevant medical evidence: Include any relevant medical evidence that is contained on record.
    • Recommendation: Manifestly medically ineligible
    • Manifest ineligibility reason: Select one of the following: Clearly no CITW/Diagnosis criteria not met/Conditions clearly temporary/Conditions not diagnosed, reasonably treated and stabilised
    • Recommendation rationale: Enter clear and succinct rationale with detailed rationale for each medical condition for why medical eligibility is not met

4
Job Capacity Assessment (JCA) required

For a recommendation of JCA to be made, the following criteria need to be met:

  • Medical evidence supports that at least one condition is diagnosed
  • An impairment rating (including impairment rating of 0) is applicable, and
  • There is sufficient medical evidence available regarding treatment and stability of the condition to warrant further investigation at JCA

The following medical conditions require specialist diagnosis. If this is not available, the Assessor must attempt to obtain confirmation of diagnosis. This is not applicable if evidence clearly indicates customer is not reasonably treated.

  • Neurodevelopmental
  • Intellectual Disability
  • Psychological
  • Hearing
  • Vision

Note: detailed evidence of functional impairment is not required before progression to JCA.

Medical evidence obtained from THP contact at MAt must contain sufficient information for Assessor (JCA) to:

  • confirm details of the main medical conditions affecting the person’s capacity to work
  • assess how these conditions affect the person’s capacity to work or take part in other activities, and
  • identify suitable interventions and assistance to help the person into work or stay in a job

For more information on reasonable contact attempts to THP, see Table 3 > Step 2 in Job Capacity Assessments (JCA).

Complete the SA479. Within the SA479 template, select the following:

  • Medical Conditions: ‘Enter Primary condition only’
  • Relevant medical evidence: ‘Enter Primary medical evidence only’
  • Recommendation: Job Capacity Assessment required
  • Recommendation rationale: Medical evidence requires further assessment at JCA. This report may not include all medical conditions or information as a Job Capacity Assessment (JCA) is recommended
    • If manifest medical eligibility was indicated in the evidence, or customer reported information, but manifest eligibility has been excluded, Assessor must include a manifest exclusion statement within the rationale
  • Recommended Mode of assessment: Phone/File/Face. (See Job Capacity Assessments (JCA) to determine appropriate mode of assessment)
    • If the customer meets file assessment guidelines or the Assessor has had contact with the customer within the MAt and has all available information to complete the JCA, see Table 3 for Connected Assessor Pathway (CAP)

Note: if a referral for specialist assessment is requested, note this within the ‘Other information required for the assessment’ section of the template.


Connected Assessor Pathway (CAP)

Table 3: this table describes the process for Assessors requesting return of the JCA following a MAt via the CAP process.

Expand table

Step

Action

1
Connected Assessment Pathways (CAP) Overview

The Connected Assessment Pathway allows an Assessor to request the return of the JCA referral following completion of the MAt. This can be requested as a File assessment or a Phone assessment.

For a CAP File, Assessor must determine the following:

  • the customer meets the file format guidelines in line with Job Capacity Assessments (JCA), or
  • the Assessor has had contact with the customer within the MAt assessment and has all available information to complete the JCA
  • Go to Step 2

For a CAP Phone, there are 2 JCA pathways:

  • If the Assessor has successfully contacted the customer by phone during the MAt, go to Step 2
  • If the Assessor has completed MAt and wants to complete the JCA by phone, go to Step 3

Note: rapid streaming of the DSP new claim, including the JCA referral, will be completed by Disability Processing in line with current workload priorities. No guarantee can be given regarding timeliness of return.

2
Complete SA479 requesting CAP for a File Assessment

The customer must meet the file format guidelines or had contact at the MAt.

Within the SA479 template, select the following:

  • Other information required for assessment: Refer JCA to [Services Australia Logon/ESSWeb Logon] in [ESSWeb site code]
  • Recommended mode of assessment: File

Go to Step 4.

3
Complete SA479 requesting CAP for a Phone Assessment

Within the SA479 template, select the following:

  • Other information required for assessment: Refer Phone JCA to [Services Australia Logon/ESSWeb Logon] in [ESSWeb site code] (day/s of week) (time of day), Time zone
  • Recommended mode of assessment: File

Go to Step 4.

4
Add keyword

Use the keyword icon to add the keyword FILEJCA to the DSP claim in Process Direct.

Note: make sure the customer record is entered via the DSP claim in the inbox or select the submitted DSP claim from the Transactions icon. See Process Direct navigation, common screens and functions.

5
ASCST book JCA under CAP

For Assessment Services Customer Support Team (ASCST) Support Team only.

  • JCA booking referral (ZCRF_ASB_BOOK_FILE) work item is allocated to ASCST in line with workload priorities
  • ASCST will check the SA479 in documents to confirm if the assessment indicates for the JCA to be referred back to the Assessor who completed the MAt
    • For a CAP File, ASCST will create a JCA session at 4pm in the diary nominated in the SA479 and contact the assessor via either Microsoft Teams or email to advise the JCA has been booked
    • For CAP Phone, ASCST will create a JCA session at the time in the diary listed in the SA479 and contact the assessor via either Microsoft Teams or email to advise the JCA has been booked

Note: if the Assessor has not advised a specific time, ASCST will book the Assessor's next available Phone JCA within 17 calendar days.

If no Phone JCA sessions are available within 17 days, ASCST will contact the Assessor to open an additional session.

If the assessor is unavailable to complete the file JCA due to leave (scheduled or unscheduled) the assessor’s Assistant Director is responsible for arranging allocation of the assessment dependent on the period of absence.