Quality checking dispute process for Medicare 111-23051519

Is the quality checking dispute for a staff member in training/consolidation?

• Yes:
• Direct the dispute to the facilitator/technical support Service Officer
• If reversal is required, attach all relevant details including the original feedback email from the quality checker and send to Quality and Skill Tags
• Procedure ends here
• No:
• Service Officer/Processing Operator, see Item 2
• Team Leader, see Item 3
• Service Support Officer (SSO), see Item 4
• Quality Checker, see Item 5

• Discuss Quality Check (QC) feedback with a Team Leader
• After the discussion, complete the QC error dispute email template:
• Include evidence to support the dispute, such as the relevant Operational Blueprints (including the Table and Step number where applicable)
• Attach all relevant information including the original feedback email from the Quality Checker
• Email the completed email template to the Team Leader

The Team Leader:

• receives the QC dispute email from Service Officers/Processing Operators, and
• must consider the dispute appropriate before they send it to the relevant program area

Does the Team Leader consider the QC dispute email is appropriate?

• Yes:
• Forward the email to the relevant Health Service Delivery Division - Program area. Note: program areas only accept emails from a Team Leader
• Do not email the Quality Checker directly
• No:
• Send a reply email to the Service Officer/Processing Operator
• Include the reasons why the dispute email is not appropriate

SSOs in the relevant program area:

• Must document the dispute. See Resources for the QC dispute tracker template
• Investigate the QC dispute
• Liaise with the appropriate team/Subject Matter Expert (SME) for the investigation (as needed)
• Escalate any issues to the relevant team for business process improvements:
• Operational Planning Health, Integrity and Child Support Branch - Training
• Operational Blueprint (OB) - Policy and OB feedback
• Program, Policy and Quality team - QC Error codes
• Determine the final outcome. Note: if the dispute outcome identifies additional errors, follow the successful process

Successful dispute outcome:

• To get the error reversed:
• Complete the Service Support Officer (SSO) QST/QBBI QC reversal request email template
• Send the email to Quality and Skill Tags
• When the reversal is actioned, email the reason for the decision to the:
• Service Officer/Processing Operator and cc their Team Leader
• Quality Checker and cc their Team Leader

Unsuccessful dispute outcome. If the error was given to the Service Officer correctly:

• Complete the SSO QST/QBBI dispute unsuccessful email template
• Email the dispute outcome to the:
• Service Officer/Processing Operator Team Leader
• Service Officer/Processing Operator

The SSO decision is considered final.

If the Quality Checker receives an email from a Service Support Officer (SSO) about a successful QC dispute:

• review the feedback and explanation provided
• if necessary, discuss with Team Leader and provide a reply

If the Quality Checker incorrectly receives a QC dispute, refer the staff member to either:

• Service Officer/Processing Operator, see Item 2
• Team Leader, see Item 3

• Discuss Quality Check (QC) feedback with a Team Leader
• After the discussion, complete the QC error dispute email template:
• Include evidence to support the dispute, such as the relevant Operational Blueprints (including the Table and Step number where applicable)
• Attach all relevant information including the original feedback email from the Quality Checker
• Email the completed email template to the Team Leader

The Team Leader receives the QC dispute email from Service Officers/Processing Operators.

Does the Team Leader consider the QC dispute email is appropriate?

• Yes:
• Forward the email to Medicare National Portfolio - Face to Face. Note: only email from a Team Leader is acceptable
• Do not email the Quality Checker directly
• No:
• Send a reply email to the Service Officer/Processing Operator
• Include reasons why the dispute email is not appropriate

The Face to Face strategic support team:

• must document the dispute. See Resources for the QC dispute tracker template
• Investigate the QC dispute
• Liaise with the appropriate team/Subject Matter Expert (SME) for the investigation (as needed)
• Escalate any issues to the relevant team for business process improvements:
• Operational Planning Health, Integrity and Child Support Branch - Training
• Operational Blueprint (OB) - Policy and OB feedback
• Program, Policy and Quality team - QC Error codes
• Determine the outcome. Note: if the dispute outcome identifies additional errors, follow the successful process

Successful dispute outcome:

• QBBI - Complete the reversal in Mainframe. Send an email to Service Delivery Quality and Evaluation team for any changes required in the Error Explanation Sheet (ESS)
• QST - Complete the Service Support Officer (SSO) QST/QBBI QC reversal request email template. Send an email to Quality and Skill Tags
• When the reversal is actioned, email the reason for the decision to the:
• Service Officer/Processing Operator and cc their Team Leader
• Quality Checker and cc their Team Leader

Unsuccessful dispute outcome

If the error was given to the Service Officer correctly:

• Complete the SSO QST/QBBI dispute unsuccessful email template
• Email the dispute outcome to the:
• Service Officer/Processing Operator Team Leader
• Service Officer/Processing Operator

The Face to Face strategic support team decision is considered final.

If the Quality Checker receives an email from Face to Face strategic support team about a successful QC dispute:

• review the feedback and explanation provided
• if necessary, discuss with Team Leader and provide a reply

If the Quality Checker incorrectly receives a QC dispute, refer the staff member to either:

• Service Officer/Processing Operator, see Item 1
• Team Leader, see Item 2

The dispute must be lodged within the required timeframe. If the staff member was on leave and could not lodge the dispute within 30 days of the quality check being completed, their Team Leader must provide evidence.

Make sure overall QOL/QMA accuracy is affected. Both of the following must apply:

• The error is proficiency impacting:
• QOL - activity is returned, or
• QMA - proficiency impacting (shown on the QMA feedback tile in Process Direct)
• The QOL/QMA decision is incorrect. Do not lodge a dispute if the overall outcome of the quality check (that is, error or returned) is correct due to other errors identified within the activity

Research Operational Blueprint:

• Make sure the dispute is supported by a business process or policy
• Submit this evidence when lodging the dispute

Check other nationally endorsed references current when the check was completed. For example, Network News Updates (NNU) or Roxy.

Staff can get support from technical support:

• to understand a QOL or QMA result and feedback
• for advice about completing the activity

Staff member lodging the dispute:

• Complete all actions on the customer's record as a priority
• Do not 'HOLD' or leave a 'NOT' or 'STA' activity on the customer's record pending the outcome of a dispute
• Talk to a team leader if unsure about the correct action to take pending outcome of the dispute

• Open and complete the QOL and QMA Dispute Form. See Resources for a link
• Do not include any customer identifying details in the form, such as names or Customer Reference Number (CRN)
• Select Submit a dispute
• Read and acknowledge the privacy statement
• Complete all fields (mandatory fields are marked with an asterisk (*)):
• Key the Work Item ID for QMA, AMR for QOL and the Date the QMA or QOL check was sampled or submitted exactly as they appear in the QOLCheck tool or QMA Feedback tile in Process Direct
• For QOL - open the QOLCheck tool, select Replay Work and complete search criteria to locate activity details
• For QMA - select the QMA Feedback tile in Process Direct to view results and comments from Quality Management Officers (QMO)
• Ensure that all feedback from the check is copied into this section, even if it does not directly relate to the disputed error
• Document any supporting evidence, including:
• relevant Operational Blueprint references (including Table and Step numbers and historical versions if they apply)
• other nationally endorsed references current when the quality check was completed. For example, Network News Updates (NNU) or Roxy
• Select Submit

If the form is not completed correctly and there is insufficient information available to assess the dispute:

• the dispute will be closed, and
• Service Officer will be notified by email

To view the progress of the dispute, see the QOL and QMA Disputes page. See Resources for a link.

An Independent Reviewer will decide the outcome of the dispute and send a notification email to all parties when the dispute is finalised.

Generally, when the QOL/QMA dispute decision is finalised there are no further escalation steps available. However, the staff member should talk to their Team Leader if they have evidence the dispute outcome is potentially incorrect. For this process, see Table 4 > Step 13.

Does the staff member want to withdraw the dispute?

• Yes, go to Step 5
• No, procedure ends here

Go to My disputes on the QOL and QMA Disputes page.

Is the status of the dispute New?

• Yes:
• Select Edit. Open the QOL and QMA Dispute Form
• Read and acknowledge the privacy statement
• Scroll to the bottom of the form and select Withdraw
• No, go to Step 6

In My disputes on the QOL and QMA Disputes page:

• Select Edit. Open the QOL and QMA Dispute Form and find the Independent Reviewer
• Contact the Independent Reviewer:
• Ask them to change the status to Return to Pool as New
• If the Independent Reviewer is not available, email the Aged Care Customer team
• When the status is showing as New:
• Select Edit. Open the QOL and QMA Dispute Form
• Read and acknowledge the privacy statement
• Scroll to the bottom of the form and select Withdraw

To select a dispute:

• Go to the QOL and QMA Disputes page. See Resources for a link
• Go to Inbox from left hand menu
• Select the New tab
• In the Service Delivery column, select Health Service Delivery
• Action disputes in the following order:
• disputes with a priority flag
• from oldest to newest within skillset
• Select the dispute to review:
• Select Edit. Open the QOL and QMA Dispute Form
• Read and acknowledge the privacy statement
• Key logon ID in the Independent Reviewer field to allocate the dispute

If information is missing, contact the Service Officer.

Check the following free text sections for customer identifying information and/or inappropriate comments:

• QOL checker
• QMO feedback
• Reason for dispute

Is there any customer identifying information or inappropriate comments?

• Yes, go to Step 3
• No, go to Step 4

• Select Edit to the right of the Dispute details line in the dispute form
• Remove the customer identifying information
• Remove or edit inappropriate comments
• Select the reason from Edits made
• Select Save changes

Give feedback to the staff member using the Staff Feedback Tool.

Did the staff member lodge the dispute within 30 days of the quality check?

• Yes, go to Step 5
• No, if the staff member's manager confirms the staff member has:
• returned from leave in the past 14 days, go to Step 5
• not returned from leave in the past 14 days, finalise the dispute. Go to Dispute outcome > Next action and select Dispute not lodged within timeframe. Procedure ends here

Check if the error is proficiency impacting:

• QOL - activity is returned
• QMA - states proficiency impacting in the Error Report on the QMA Dashboard Helpdesk tile in Process Direct

Is the QOL or QMA check proficiency impacting?

• Yes, go to Step 6
• No:
• Finalise the dispute. Go to Dispute outcome > Next action and select non proficiency impacting error
• Procedure ends here

Check if the dispute is a duplicate:

• Go to the Inbox, select the All Disputes tab
• Filter the Service Officer column. Select the staff member who lodged the dispute
• Check for disputes with the same Activity (AMR) or QMA Work Item ID. Note: if the AMR displays in the QOLCheck tool more than once, a dispute can be lodged against each return and is not a duplicate

Is the dispute a duplicate that has already been lodged?

• Yes:
• Email the Aged Care Customer team
• In the email, include both dispute IDs and advise which dispute to delete
• Procedure ends here
• No, go to Step 7

If there is enough information to complete the dispute, go to Step 8.

If more information is required:

• Review the information and try to correct it (for example, AMR or Work Item ID) instead of returning the dispute to the staff member:
• Select Edit to the right of the Dispute details line in the dispute form
• Correct information in the relevant field
• Select QOL/QMA details from Edits made list
• Select Save changes
• Note: the AMR or Work Item ID must be correct to ensure that SmartTools is updated if a QOL/QMA decision is overturned. Correct the AMR/Work Item ID if required
• Go to Step 8
• If unable to correct the information, return the dispute to the staff member and ask for more details:
• In the Independent Reviewer determination field, select either Insufficient evidence or Activity not located
• The Next action field will auto populate with Finalise and notify Service Officer
• In the Independent Reviewer comments field, enter comments with the reason for the return
• Select Submit to finalise dispute outcome
• Review the dispute outcome email and select Confirm. To amend the email, go back to the dispute form and update as required
• Procedure ends here

• Identify the facts relevant to the dispute, these may include:
• Date of event (DOV) for a change of circumstances
• Date of receipt (DOR)
• Scanned documents
• The order of events
• Use resources (Operational Blueprint, Network News Updates (NNU), policy advice) to review the dispute and make a recommendation. Use only relevant information available at the time of the original check (including historical versions)
• Use either QOL Check Replay or QMA Dashboard to review the quality check
• Decide if the staff member and Quality Checker followed the correct procedure
• If an error is identified, update the customer's record as soon as possible. Do not wait for the outcome of the right of reply process (if implemented)
• Mark the dispute as overturned if:
• the QOL/QMA Replay function is not available, and
• the customer outcome is correct

Can the Independent Reviewer finalise the determination without consulting a technical expert or asking for technical or policy advice?

• Yes, go to Step 10
• No, go to Step 9

• If the Independent Reviewer does not have technical expertise to review the dispute, consult with a technical specialist. Seek technical expertise from the:
• Service Support Officer (SSO) network
• Service Delivery Support team, or
• SSO Program Support Manager co-ordinator. They will escalate to find an appropriate business or policy team
• If needed, ask for technical or policy advice to make a determination, for example from:
• Service Delivery Support Team
• Level 2 Helpdesk
• Business Process
• Business Owner
• If the Independent Reviewer is consulting with a third party:
• Independent Reviewer determination, select Decision pending technical advice/clarification
• Independent Reviewer comments, record the third party consultation details. Include who was contacted and what advice was requested

When advice is received, go to Step 10.

Does additional feedback need to be provided to the Quality Checker? For example, feedback about the quality of the QOL/QMA feedback:

• Yes:
• Provide feedback via the Staff Feedback Tool. See Feedback templates on the Resources page of QOL and QMA dispute processes for face to face, smart centre, Service Delivery Partner and CAO staff
• Under Service Details, select Programme & Business Assurance > Quality Management > QMA or QOL
• Complete the remaining fields in the Staff Feedback form, including feedback
• Select Send
• Go to Step 11
• No, go to Step 11

Independent Reviewer recommendation is:

• Upheld - agree with the original quality check result. Go to Step 12
• Upheld for a different reason - original quality check decision is correct but for a different reason. For example, when other errors or actions were not identified from the initial check. Go to Step 12
• Overturned - recommendation is to overturn the original decision. Go to Step 14

Update the following fields:

• Independent Reviewer determination: select either:
• Upheld
• Upheld for a different reason
• Independent Reviewer comments: enter comments supporting the determination
• Next action will auto populate to Finalise and notify Service Officer
• Have you provided staff feedback to the QOL checker/QMO: select Yes or No as appropriate:
• If Yes, select the reason for giving staff feedback (multiple options can be selected)
• Has further action been taken: select Yes or No as appropriate (that is, has the Independent Reviewer taken further action on the customer record):
• If Yes, document the action taken in the Further action taken field
• Select Submit to finalise dispute outcome
• Review the dispute outcome email and select Confirm. To amend the email, update the dispute form as required

The system automatically sends the email explaining the outcome to the:

• staff member and their Team Leader, and
• original Quality Checker and their Team Leader

If the staff member who lodged the dispute has evidence that the outcome is potentially incorrect, they talk to their Team Leader about this. For this process, go to Step 13.

Otherwise, procedure ends here.

If the staff member has evidence that the outcome is potentially incorrect, they must talk to their Team Leader.

Evidence includes Operational Blueprint and other nationally endorsed references current when the check was completed. For example, Network News Updates (NNU) or Roxy.

The Team Leader:

• must collate this evidence and present a case in support of the staff member
• emails this to the Aged Care Customer team. Include in the email:
• the original dispute outcome email
• all evidence supporting the case, that is, reference the Operational Blueprint or other endorsed references

The Aged Care Customer team will investigate and determine the next steps.

Procedure ends here.

When the Independent Reviewer recommends overturning the original Quality Checker's decision, the Quality Checker has a right of reply before the dispute determination is finalised.

Record recommendation to overturn the decision. Update the following fields:

• Independent Reviewer determination: select Overturned
• Independent Reviewer comments: add comments supporting the recommendation
• Next action: select Send to QOL checker/QMO for right of reply
• Select Submit
• Review the dispute outcome email and select Confirm. To amend the email, update the dispute form as required

The system automatically sends the email to the original Quality Checker and their Team Leader. The email includes:

• the Independent Reviewer's recommendation
• how to contact the Independent Reviewer if they wish to discuss the recommendation
• instructions for submitting a right of reply

The review will show as 'awaiting reply' until one of the following happens:

• the original checker 'accepts/agrees with' the Independent Reviewer recommendation - the dispute will auto finalise
• the original checker submits their response - the dispute status will change to Reply received and the dispute will show under the Open tab in the inbox

If the 5 business days right of reply period ends with no right of reply received - the dispute remains under the awaiting review tab in the inbox and will need to be manually finalised.

Monitor response in the My Inbox tab from the Dispute management inbox.

Does the original Quality Checker need access to the QOL and QMA Disputes page?

• Yes, go to Step 15
• No, procedure ends here

• Select Manage QOL checker/QMO access (from the left hand menu)
• Select the dropdown arrow next to New. Select Add Users
• Key the original Quality Checker logon ID or name and select the correct user
• Select show options and untick send an email invitation
• Select Share

If the Independent Reviewer's recommendation is to overturn the original QOL or QMA decision, the original Quality Checker has a right of reply:

• Original Quality Checker, go to Step 2
• Independent Reviewer, go to Step 5

Read the 'right of reply' email. It has the reasons the Independent Reviewer recommends overturning the original Quality Checker's decision.

The Quality Checker must respond within 5 business days unless they are unable to do so, for example, they are on leave.

Will the Quality Checker respond within 5 business days?

• Yes, go to Step 4
• No, and they:
• Agree with/accept the decision, no action needed. The dispute will finalise as Original decision overturned if a response is not received within 5 business days. Procedure ends here
• Disagree with/do not accept the decision, go to Step 3

Email the Aged Care Customer team. In the email, include the following:

• Email subject: Right of reply - disagree with dispute recommendation
• Email body:
• Original Quality Checker's name and logon ID
• Reason unable to respond within 5 business days
• Quality check type QOL or QMA
• Benefit Type
• Activity (AMR) or work item ID
• Outline right of reply response

The Aged Care Customer team will decide if the right of reply will be accepted.

Procedure ends here.

Select the link in the 'right of reply' email to open the dispute and submit a response.

Acknowledge the privacy statement.

Select either:

• Agree with/accept decision from the QOL checker/QMO right of reply:
• Add supporting comments in the Comments field
• Select Submit
• Procedure ends here
• Disagree with/do not accept decision from the QOL checker/QMO right of reply:
• Add supporting comments in the Comments field. Include evidence, such as Operational Blueprint (include Table and Step numbers), and/or other nationally endorsed references current when the check is completed, such as Network News Update (NNU) or Roxy. Include historical versions if they apply
• Select Submit. The response is returned to the Independent Reviewer. They will review and finalise the outcome
• Procedure ends here

Did the original Quality Checker send the right of reply response within 5 business days?

• Yes, go to Step 6
• No, go to Step 10

Read the response from the original Quality Checker. If the Independent Reviewer:

• agrees with the original Quality Checker's comments/evidence, go to Step 11
• disagrees with the original Quality Checker's comments/evidence, go to Step 7

• Contact another Service Support Officer (SSO) using Microsoft Teams
• Discuss the decision and response from the original Quality Checker with the independent SSO

Do the SSOs reach agreement?

• Yes, go to Step 12
• No, go to Step 8

Follow Business As Usual (BAU) procedures to refer to the relevant program or policy team to get advice. For example:

• Service Delivery Support Team
• Level 2 Helpdesk
• Business Process
• Business Owner

If unsure where to refer the dispute, email the Aged Care Customer team.

Update the QOL and QMA Dispute Form to reflect the referral. See Resources for a link:

• Select Edit. Open the dispute and scroll down to Dispute outcome section
• Independent Reviewer determination: select Overturned
• Independent Reviewer comments:
• do not delete the original comments
• add the date and outcome of the consultation with the independent SSO, and
• details of advice requested from the relevant program or policy team
• Next action: select the appropriate option
• Select Submit
• Review the dispute outcome email and select Confirm. To amend email, update the dispute form as required

When advice is received, go to Step 9.

• Review the response
• Finalise the determination considering the recommendation/response from the program, policy team or Level 2 Helpdesk
• Go to Step 13

• Select Edit. Open the dispute and scroll down to Dispute outcome
• Independent Reviewer determination: select Overturned (original decision overturned. That is, agree with the dispute)
• Independent Reviewer comments: add note: 'Dispute finalised - no right of reply received from original Quality Checker'
• Next action: select Finalise and notify Service Officer
• Have you provided staff feedback to the QOL checker/QMO: select Yes or No as appropriate:
• If Yes, select the reason for giving staff feedback (multiple options can be selected)
• Has further action been taken: select Yes or No as appropriate (that is, has the Independent Reviewer taken further action on the customer record):
• If Yes, document the action taken in the Further action taken field
• Select Submit to finalise dispute outcome
• Review the dispute outcome email and select Confirm. To amend the email, update the dispute form as required

The system automatically sends an email explaining the outcome to the:

• staff member and their Team Leader, and
• original Quality Checker and their Team Leader

Procedure ends here.

• Select Edit. Open the dispute. Scroll down to Dispute outcome
• Independent Reviewer determination: select as appropriate:
• Upheld - agree with the original check result
• Upheld for a different reason - original checking outcome is correct but for a different reason. For example, when other errors or actions were not identified in the initial check
• Independent Reviewer comments: update comments to support determination
• Next action: select Finalise and notify Service Officer
• Have you provided staff feedback to the QOL checker/QMO: select Yes or No as appropriate
• If Yes, select the reason for giving staff feedback (multiple options can be selected)
• Has further action been taken: select Yes or No as appropriate (that is, has the Independent Reviewer taken further action on the customer record):
• If Yes, document the action taken in the Further action taken field
• Select Submit to finalise the dispute outcome
• Review the Dispute outcome email and select Confirm. To amend email, go back to the dispute form and update as required

The system automatically sends an email explaining the outcome to the:

• staff member and their Team Leader, and
• original Quality Checker and their Team Leader

Procedure ends here.

• Select Edit. Open the dispute. Scroll down to Dispute outcome
• Independent Reviewer determination: select as appropriate:
• Upheld - agree with original check decision
• Upheld for different reason - original checking decision is correct but for a different reason. For example, when other errors or actions were not identified in the initial check
• Overturned - original decision overturned. That is, agree with dispute
• Independent Reviewer comments: enter comments supporting the determination, clearly noting:
• the dispute was referred to another SSO and the date of referral
• the detail of the mutual decision reached between the 2 SSOs
  Note: do not delete the original comments
• Next action: select Finalise and notify Service Officer
• Have you provided staff feedback to the QOL checker/QMO: select Yes or No as appropriate:
• If Yes, select the reason for giving staff feedback (multiple options can be selected)
• Has further action been taken: select Yes or No as appropriate (that is, has the Independent Reviewer taken further action on the customer record):
• If Yes, document the action taken in the Further action taken field
• Select Submit to finalise dispute outcome
• Review the dispute outcome email and select Confirm. To amend email, go back to the dispute form and update as required

The system automatically sends an email explaining the outcome to the:

• staff member and their Team Leader, and
• the original Quality Checker and their Team Leader

Procedure ends here.

• Select Edit. Open the dispute. Scroll down to Escalated to (program or policy team) details. Summarise or copy and paste the advice received from program, policy team or Level 2 Helpdesk into comments
• Scroll down to Dispute outcome
• Independent Reviewer determination: select:
• Upheld - agree with the original check result
• Upheld for a different reason - original checking outcome is correct but for a different reason. For example, when other errors or actions were not identified in the initial check
• Overturned - original decision overturned. That is, agree with dispute
• Independent Reviewer comments: enter comments supporting the determination
• Next action: select Finalise and notify Service Officer
• Have you provided staff feedback to the QOL checker/QM: select Yes or No as appropriate
• If Yes, select the reason for giving staff feedback (multiple options can be selected)
• Has further action been taken: select Yes or No as appropriate (that is, has the Independent Reviewer taken further action on the customer record)
• If Yes, document the action taken in the Further action taken field
• Select Submit to finalise dispute outcome
• Review the dispute outcome email and select Confirm. To amend the email, update the dispute form as required

The system automatically sends an email explaining the outcome to the:

• staff member and their Team Leader, and
• original Quality Checker and their Team Leader

Procedure ends here.