Statement by claimant (SBC) and care costs - Medicare Compensation Recovery 011-15030060

When a Notice to claimant (NTC) is completed and returned to Services Australia it becomes an SBC.

The claim’s status determines the issue of either a:

• Notice of past benefits (NOPB)
• Notice of charge (NOC), or
• Notice of past benefits - advance payment (NOBP-AP)

If a completed SBC is not returned by the due date (inclusive of a granted extension), all items on the NTC will be taken as relating to the injury/illness. This is referred to as an all services included notice.

If the SBC is incomplete it will be assessed as not substantially correct.

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

Go to Notice of past benefits (NOPB) and Notice of charge (NOC) for more details.

Each request for an extension to return an SBC must be:

• received on or before the due date on the statement
• assessed independently as the claim status determines whether an extension can be granted

Go to Extensions, not substantially correct, decisions and reviews for more details.

To be considered complete, the SBC must include:

• Yes or No indicated in the tick box for the care services statement
• Full name of the person making the declaration
• Tick in the relevant box to indicate who is making the declaration
• Business name (if applicable)
• Address of the person making the declaration
• Signature of the person making the declaration
• Date the declaration is made

Note: the declaration can be accepted as complete when the:

• tick in the relevant box to indicate who is making the declaration is not completed, but
• name provided is the injured person

If the injured person/claimant has identified services by selecting at least one Yes or No box, the agency will assume the only services that relate are the ones which are selected Yes. Any blank box is to be considered as No.

The agency will:

• assume that only previously identified services (if applicable) are relating if the:
• injured person/claimant has not ticked any boxes on the statement, and
• declaration has been completed in full
• treat the statement as incomplete if:
• one of the care services statement boxes (yes or no) has not been selected, and
• the declaration has not been completed

Advanced Payment (AP) claims and pre-settlement

If the SBC is incomplete:

• a Statement not substantially correct (Z2805) letter will be sent asking the injured person/claimant to submit a new or amended statement, and
• the claimant will be granted an additional 28 days from the date on the letter to return the completed statement

For valid AP claims the extension to the due date applied by the issuing of the Z2805 letter results in an extension applying to the S33D date.

All services will be considered as relating and an all services included notice will be issued if:

• no response to the Z2805 letter is received, or
• the returned amended SBC is still assessed as incomplete

No further Z2805 letters will be issued unless an administrative error has occurred, for example, the initial Z2805 letter was issued to an incorrect address.

Failed AP and Notice to claimant (NOC) claims

There are no extensions granted or not substantially correct decisions issued on claims that do not meet the advance payment criteria, the due dates under section 24(4) are never extended. If the SBC is incomplete an all services included notice must be issued along with the Z2805 letter.

Removing services

If a subsequent SBC indicates that previously verified services do not relate to the injury/illness, Service Officers can process as requested unless:

• there is a Notice of past benefits (NOPB) that is current and valid
• the claim has reached judgment/settlement, or
• the claimant is seeking to remove care costs (this will need evidence and/or approval from a Program Management APS5 or above)

Go to:

• Extensions, decisions and reviews for amending a valid NOPB or if the claim has reached judgment or settlement
• the Process page for how to process an SBC

The injured person may have multiple claims for the same or similar injury/illness, but Services Australia can only recover the cost of a provided service once. The process of checking whether services have previously been recovered is called cross-referencing.

Service Officers must cross reference the SBC for a claim against closed claims for the same injured person. When services indicated on an SBC have been previously recovered the service cannot be included in the new:

• Notice of past benefits (NOPB),
• Notice of past benefits - advance payment (NOPB-AP), or
• Notice of charge (NOC)

Cross referencing will make sure that indicated services have not already been recovered by the agency in relation to another compensation claim. If identified that services indicated were not to be included, Service Officers must add a case note to detail which services were not included and why.

Cross referencing must be done when there is a previously closed claim for the same injured person which has:

• an overlapping period of liability, and
• a verified NOPB-AP or NOC and payment has been made, or
• an all services NOPB-AP or NOC and more than 2 years has passed from the date of judgement or settlement

Cross referencing is not needed when:

• the current SBC has no services indicated
• an all services included notice is being issued due to an incomplete or not returned SBC
• the other claim(s) has not settled
• the other claim(s) does not have overlapping periods of liability
• previous NOPB-AP or NOC is for a nil recovery
• the other claim has an outstanding debt
• the other claim has an all services included NOPB-AP or NOC and it has not reached the 2 year time frame since the date of judgement or settlement

Note: when determining previously recovered services, Service Officers must not solely rely on the most recent system issued NOC or NOPB-AP. A manual amendment may have previously been completed. Case notes and documents on the claim need to be assessed to determine the latest NOC.

Go to Escalations and case notes for details about case notes.

A NOPB provides the total Medicare and care cost recoverable amount for a compensation claim. The notice is then sent to the notifiable person and a copy to the claimant.

Go to Notice of past benefits (NOPB) and Notice of charge (NOC) for more details.

If an injured person received residential care facility or home care services because of their compensable injury or illness, there may be recoverable care costs.

Care costs refers to the:

• nursing home benefits
• residential care subsidies, and
• home care subsidies

These are paid to service providers by the Australian Government on behalf of an injured person for those services.

When an SBC is:

• returned and showing care services were provided, a care costs check will be completed. When a care costs check is selected in MCRS, the work will be allocated to an APS 5 Service Officer for action
• not returned, all services will be taken to be related to the compensable injury/illness. In this situation:
• care costs cannot be deemed as related
• a new care costs check is not completed, and
• if care costs were previously identified, these will be brought forward to the new Notice of past benefits (NOPB), Notice of past benefits - advance payment (NOPB-AP), or Notice of charge (NOC)

Go to the Process page for how to request a care costs check.

A trained Service Officer APS5 (or above) will calculate care costs from the date of injury/illness until:

• the date of judgment or settlement, or
• the date a reimbursement arrangement was made

Where a judgment, settlement or reimbursement has not yet been made, the amount is calculated:

• up to the date the care costs check is performed, or
• the date of discharge from the care facility or service, or
• the date of death

Only the increase in the level of care after the date of injury is recoverable:

• where a person was already in care before the date of injury/illness, and
• continues to be in care because of the compensable injury/illness

The home care subsidy is recoverable from 1 July 2015. If home care subsidy was paid before this date, those amounts are not recoverable.

A Notice of past benefits (NOPB) or Notice of charge (NOC) only includes a total figure for care costs, it does not include an itemised breakdown of costs. A request for a breakdown of care costs can be received as a verbal request, or in writing, from:

• the injured person
• the claimant
• an authorised third party
• the compensation payer, or
• the compensation payer’s solicitor

The breakdown of care costs:

• is calculated by a Service Officer APS5 (or above)
• is sent to the person who made the request, along with a copy of the NOPB or NOC
• is an itemised summary of Australian Government payments made for care services provided to the injured person. Note: it must not contain screen shots or reports from Services Australia systems
• lists the time period and levels of care that were subsidised

Go to the Process page for:

• how to complete a request for a breakdown of care costs, and
• the breakdown of care costs is provided

Amendments to care cost amount can be approved by a Program Management APS5 (or above) and need evidence from a treating medical practitioner.

Go to Extensions, decisions and reviews.