Notice of past benefits (NOPB) and Notice of charge (NOC) - Medicare Compensation Recovery 011-15030010

A NOPB or NOC provides the total recoverable amount for a compensation claim.

A NOPB is valid for 6 months from the date of issue. The NOPB is not payable unless:

• it is valid on the date the compensation amount is fixed, or
• the claim reaches a judgment or settlement and a valid S23a is submitted and accepted, extending the expired notice

A NOC never expires and is payable within 28 days of the date of the notice.

After Services Australia (the agency) receives a statement by claimant (SBC) (or if the time to return the statement has passed) the MCRS sends:

• the compensation payer:
• the Notice of past benefits or charge letter (Z2807) before judgment or settlement, or
• the Notice of charge letter (Z2811) after judgment or settlement, or
• no more correspondence if the agency has accepted a valid advance payment (AP), and
• the injured person or claimant:
• a copy of the Z2807 that was sent to the compensation payer on behalf of the injured person, or
• the Z2811 if the agency has accepted an AP - if there is a valid Third party authority form (MO021) attached to the claim, this is sent to the authorised third party (ATP) on behalf of the injured person

Note:

• if the agency accepts an AP, the compensation payer no longer has authority to access information about the claim
• if a valid Third party authority form (MO021) is attached to the claim, a copy of all correspondence is sent to the ATP on behalf of the injured person

See Payments, refunds and debts.

If a SBC was returned by the due date and is substantially correct, a list of the verified Medicare benefits is attached to the notice.

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

If a statement is returned late, the agency may elect to process it as if it were received on time. That is, if the processing of the SBC to issue a NOPB or the NOC has not yet occurred.

Note: any care costs identified in a previous notice of past benefits (NOPB) are carried forward.

See Extensions, not substantially correct, decisions and reviews.

If a complete SBC was not returned by the due date on the notice to claimant (NTC), either a Notice of charge all services included letter (Z2811) or a Notice of past benefits - all services taken letter (Z2807) is issued by the MCRS, unless:

• the claim has reached judgment or settlement and a valid Section 23A notice has been received and accepted, in conjunction with notification of a settlement, or
• an extension was granted and the due date has not yet passed, or
• a Statement not substantially correct letter (Z2805) is issued by the MCRS within the required time frames, and the due date has not yet passed

All services listed on the NTC will be taken as related to the claim. All nursing home benefits, residential care subsidies and home care subsidies identified in a previous notice of past benefits will be carried forward.

An additional care costs check is not required as these costs cannot be considered as relating to the claim.

When issuing an all services included notice, the list of Medicare benefits is not attached. The notice provides the total amount of all benefits listed on the NTC.

The Health and Other Services (Compensation) Act 1995 (HOSC Act) prescribes time frames for the agency to issue a NOC as 3 months from the date of notification of a:

• judgment or settlement or receipt of the advance payment (AP); whichever is later, or
• judgment or settlement if no payment (or an ad-hoc payment) is received, or
• reimbursement arrangement

The 3 month time frame may be extended in certain circumstances. For example, granting an extension, or if a Statement not substantially correct letter (Z2805) letter is issued.

See:

• the References page, it contains sections 24(4), 25(4) and 33D of the HOSC Act for more details
• the Resources page, it contains relevant issuing timeframes and how to calculate them
• Extensions, not substantially correct, decisions and reviews
• Medicare Compensation Recovery for payment criteria

Where no valid NOPB or completed section 23A statement has been received at the time of judgment or settlement, a notice to claimant (NTC) is sent to the injured person or claimant.

When accepting a section 23A statement, the amount from the most recently expired NOPB relating to the claim, becomes the amount payable on the NOC. If there is no previous NOPB the charge amount becomes $NIL.

If there is no section 23A statement and no current NOPB, dependent upon the stage that the claim is currently at, the MCRS will either:

• issue a NTC
• wait for a recently issued NTC to be returned for processing
• wait for the returned statement by claimant (SBC) to be processed, or
• wait for the due date to expire and raise the statement for deeming ‘all services included’

If the NTC was issued before receipt of the Notice of Judgment or Settlement (NOJS), MCRS will not issue another NTC, unless critical details are changed.

For example, a change to the date of injury. The system waits for the returned SBC for processing, or once the due date has lapsed will deem all services so the NOC can be issued.

If the SBC was returned before the NOJS but was incomplete, a Statement not substantially correct letter (Z2805) is issued with a new due date for the SBC. The system refers to this extension date for including all services on the notice, if required.

Calculation of s33D due date for Notice of past benefits – advance payment (NOPB-AP) with no extension

Under section 33D of HOSC Act, if an advance payment (AP) has been made that is compliant with section 33B (3), the date to issue a notice is 3 months from receiving the later of either:

• a complete and valid NOJS from the compensation payer, or
• the AP

Under section 33D of HOSC Act, there are no amounts recoverable by the agency where:

• more than 3 months has passed since a complete NOJS and valid AP was received
• no extension was granted, and
• a NOC has not been issued

See Payments, refunds and debts - Medicare Compensation Recovery.

Calculation of s33D due date for NOPB-AP after an extension

If an extension was granted to return an SBC, the new 33D date is 28 days after the new statement return date if the new statement return date is after the original section 33D(1) date. That is, 3 months after the date of receipt of NOJS or AP, whichever is later.

For example, if the section 33D (1) date was 2 April 2024, but the extension to return the statement was granted until 10 April 2024, a NOPB-AP must be issued by 8 May 2024. That is, 28 days after the new statement return date.

If an extension was granted to return an SBC, the s33D date remains the same if the new statement return date is on or before the existing s33D (1) date. That is, 3 months after the date of receipt of NOJS or AP, whichever is later.

For example, if the section 33D (1) date was 2 April 2024, but the extension to return the statement was granted until 30 March 2024, a NOPB-AP must still be issued by 2 April 2024. The original section 33D(1) date remains.

Calculation of s33D due date for NOPB-AP after incomplete statement received

If an SBC was incomplete and a Z2805 letter issued to the injured person or claimant, the s33D date will either:

• remain unchanged. That is, 3 calendar months from notification/payment date, or
• be extended to 28 days after the agency gets the resubmitted statement and it is accepted as being substantially correct. Whichever is later

Calculation of s24 (4) due date for NOC

Under section 24(4) of HOSC Act, where there has been no valid AP made the agency has a maximum of 3 months to issue a NOC to the compensation payer from the date a completed NOJS was received.

This date cannot be extended:

• by a not substantially correct decision, or
• by granting an extension

If the s24(4) date has passed and a Notice of charge (NOC) has not been issued, the agency will not recover any amounts. Any money received must be returned to the compensation payer, unless authorised to direct refunds to the injured person and any claimant.

See Payments, refunds and debts - Medicare Compensation Recovery.

After a section 23A statement is received

A section 23A statement may be submitted by the injured person if they have not received:

• any Medicare benefits relating to the injury or illness compensated for, or
• any Medicare benefits relating to the injury or illness since the date of their latest expired NOPB

The amount payable on the Notice of past benefits – advance payment (NOPB-AP) or NOC with a s23A statement will either be:

• the amount on the most recently expired notice of past benefits (NOPB), or
• $nil

After an advance payment (AP) is received

The AP is credited against the recoverable amount and an NOPB-AP is issued to the injured person or claimant. If there is:

• more owed to the agency, the amount is payable to the agency by the injured person within 28 days after receiving the notice, or
• a refund owed to the injured person or claimant, that amount is paid by the agency to the injured person. That is, unless the agency is directed to refund to another party by provision of supporting documents. For example, a court order directing a refund to the Public Trustee

See Payments, refunds and debts - Medicare Compensation Recovery.

After failed AP or an ad-hoc payment amount is received

All money received that does not meet the criteria for an AP is considered to be an ad-hoc payment in MCRS. The ad-hoc payment amount is credited against the recoverable amount and a NOC is issued to the compensation payer. If there is:

• money outstanding, the amount is payable by the compensation payer
• a refund owed, the amount is paid to the nominated party as per direction provided by the compensation payer on the:
• Notice of Judgment or Settlement (NOJS) form, or
• relevant supporting documents

Notice of reimbursement arrangement (NORA)

Where a compensation payer has notified the agency of a reimbursement arrangement, a new NTC is issued unless a recent one has been issued or an NOPB is current. If a statement by claimant (SBC) is:

• returned by the due date, or before processing:
• a NOC with an itemised list of services identified by the injured person or claimant will be issued to the compensation payer, with a copy to the claimant
• not returned, a Notice of charge - all services included letter (Z2811) is issued to the compensation payer. This does not have an itemised list attached

Percentage of apportionment

Where the injured person has been determined to have contributed to their injury or illness (contributory negligence), a percentage of liability is set at judgment or settlement. This is known as an apportionment and it reduces the total settlement amount received by the injured person.

The NOC or Notice of past benefits - advance payment (NOPB-AP) total amount owed to Medicare is reduced by the percentage of apportionment attributed to the injured person. For example, if the injured person were apportioned 20% liability, the recoverable amount is reduced by 20%.

Centrelink recovery amount can reduce available compensation for Medicare recovery

The HOSC Act recognises Centrelink’s authority to recover amounts before Medicare. In a situation where the total compensation amount paid is not enough to cover both the Centrelink and the Medicare recovery amounts, the agency must reduce the NOC.

If the Centrelink recovery amount is provided, entering this amount into the MCRS reduces the amount of money that the agency recovers.

MCRS calculates the maximum Medicare recovery amount by subtracting the Centrelink recovery amount from the total settlement amount.

Judgment fixes the amount of past expenses

Where the past Medicare expenses are fixed by the court at the time of judgment, this fixed amount becomes the maximum amount recoverable by the agency.

Where the past medical expenses are fixed by the court at the time of judgment the amount payable to the agency will be determined by the services identified by the injured person on the statement by claimant (SBC). If the NOC or NOPB-AP is greater than the fixed cost, the agency cannot recover more than the total fixed Medicare or medical expenses compensation amount.

See Notice of judgment or settlement (NOJS).

Submit for review

When the notice of charge (NOC) summary screen shows a refund or debt in excess of $50,000, the MCRS requires an approved quality checker to confirm there have been no processing errors before issuing the NOC.

Once the work item is reviewed by a quality checker, it is either:

• released as a notice by the quality checker, with the quality checker required to:
• notify Finance of the refund, or
• charge details
• returned to the Service Officer for correction

Returned for correction

When a work item is returned for correction the quality checker must leave a detailed note:

• explaining the error, and
• advising the Service Officer what actions are required to reprocess or fix the notice

After the Service Officer fixes any errors the claim must be re-submitted for review. That is, if the refund or debt is still $50,000 or more.

If a Service Officer receives a work item from quality checking and they are not the original processing Service Officer, it may have been released as not actioned within 48 hours. The receiving Service Officer must re-assign the work item to the processing Service Officer through Workload Management (WLM).

See Step 7 in the Use Work Optimiser - Medicare table.

Administrative errors

If an administrative error is found:

• immediately call both the compensation payer and injured person/claimant/authorised third party, and
• tell them a new notice will be sent as soon as possible

This will make sure correct information is used when negotiating the settlement or judgment amount and minimise future rework and extra enquiries.

Amended NOPB or NOC requested

A request may be submitted to remove Medicare services and/or care services included on a NOPB or NOC. A copy of the most recently returned statement by claimant (SBC) including the declaration must be returned with:

• a letter from a treating medical practitioner, or
• a statutory declaration indicating that services previously selected on the history statement do not relate to the compensated injury

See Extensions, decisions and reviews - Medicare Compensation Recovery.