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

This process follows on from Table 1, Step 6 in Search for or update an existing claim or register a new claim.

If SBC is incomplete, go to Step 2 as cross referencing is not needed.

To identify claims which may need cross referencing:

• Select the work item number (WIN) hyperlink:
• View details of the claim, and
• Determine if dates of liability overlap with the current claim
• Repeat for each closed claim

Do the dates of liability overlap with the current claim?

• Yes,
• select the Documents tab
• select the Notice of claim (NOC) or Notice of past benefits - advance payment (NOPB-AP) document
• if the NOC is an ‘All services included’ notice select the Notice to claimant (NTC) to review services
• keep the document(s) open
• go to Step 2
• No, go to Step 2

Note: Service Officers must review case notes and check for previous amendments which may have occurred outside of the system. For legacy claims, the SBC/NOC will be visible in:

• the Documents tab, and
• Fuji Xerox Document Management Systems

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

Identify related compensation claim

• Select the button for the work identification number (WIN) that matches the current enquiry
• Select Continue

Select Statement by claimant from the dropdown menu.

Does the Medicare customer selected match the injured person named in the document?

• Yes,
• select the button Does the Medicare customer selected match the injured Person named in the document
• go to Step 5
• No,
• select the Return to Check Medicare hyperlink, or select the Back button twice
• locate the correct Medicare customer
• return to Step 1

Does the claim selected match the details in the documents?

• Yes, go to Step 6
• No,
• review claim details
• return to Check existing compensation through the hyperlink or select Back
• locate correct claim
• select Continue, return to Step 3

Do you want to refuse to issue a Notice of past benefits (NOPB)? (A valid one already exists)

• Yes, go to Extensions, not substantially correct, decisions and reviews for steps on how to issue a Notice of refusal (Z2806) letter
• No, go to Step 7

A pop up message displays:

• To continue to process the SBC, select Keep assigned to me > OK
• If the statement is incomplete and a Z2805 letter is needed:
• select Keep assigned to me > OK
• If the SBC is complete and is ready to be processed, only return to the queue if the Service Officer is not proficient:
• select Assign to the queue > OK

Does the injured persons address require updating?

• Yes,
• select Update address
• select Injured person from the Select the party dropdown list
• select Clear
• enter updated details into the relevant fields
• select Submit
• go to Step 9
• No, go to Step 9

Note: address cannot be updated from the Evaluate screen when processing an SBC.

Enter the SBC received date.

The following buttons are automatically selected:

Is the statement complete?

• Yes, go to Step 12
• No, go to Step 10

Review the claim details to decide if a Z2805 letter has been issued about the current SBC cycle.

Has a Z2805 previously been issued?

• Yes, do not issue a second Z2805:
• de-select Is the statement complete?
• de-select Issue Z2805
• select Submit, an all services included notice will be issued
  Note: if a Z2805 has previously been issued, the amended SBC substantially correct accepted date will automatically appear, defaulted to today’s date
• go to Step 16
• No, de-select Is the statement complete? A Pop-up message displays to confirm the Service Officer has the required APS4 delegation to complete the Not substantially correct decision:
• select Keep assigned to me to process a not substantially correct decision, or

Return to the queue to send the work item to an APS 4 delegate if not delegated

• select OK
• the button Do you want to issue Z2805 displays to issue the Z2805 letter
• select Submit.
• go to Step 18

Note: when de-selecting the Statement complete button, MCRS displays the date the latest Z2805 letter was issued. This letter may be about a previous NTC/SBC cycle.

Is the claim being closed as a failed advance payment (AP) on a deemed Notice of charge (NOC)?

• Yes, got to Step 11
• No, go to Step 12

If the claim is a failed AP, issue the Z2805 letter to complete the claim, but it does not extend the S24(4) dates.

An All Services Included (ASI) NOC is to be issued as per processing steps below.

• Complete NOJS capture as per Notice of judgment or settlement (NOJS)
• To deem SBC, proceed to Capture SBC screen:
• de-select Is the statement complete? > Issue Z2805
• select Deem > Submit, an all services included notice will be issued
• close the claim and take all required actions
• re-open claim and select Notice of judgment or settlement in document type dropdown
• do not update any details, proceed through capture screens to Review screen
• on the Review screen, select the Re-process SBC button
• deselect the Is the statement complete? button
• select Issue Z2805
• go to Step 18

Once a completed SBC is returned complete an amendment.

Is the notice to claimant (NTC) to be deemed?

• Yes,
• select Deem > Submit
• go to Step 16
• No, go to Step 13

Note: select Undeem if deeming needs to be reversed.

Cross reference previous claims to make sure services are not included in a charge twice.

To select verified services:

• Select the tick box next to the verified service
• Enter the relevant line numbers into the items field
• If all services are indicated as Yes, select the Select All button located under the heading Available services

Note: if all services are ticked, indicated as relating by the injured person, do not select Deem.

If previously verified services:

• are to be removed, select the tick box next to the verified service. A pop-up message displays to confirm- removing previously verified services
• do not require removal, do not select any lines for removal

If the claimant has identified care costs as related to the injury/illness, select Are care services involved or a care cost breakdown required?

A message displays:
‘Refer Care cost check to SO5 - Statement by Claimant with care cost will be assigned to an appropriate work queue. Would you like to continue?’

• Yes,
• select Save after services indicated on SBC are selected
• select Yes to route the work item to the APS5 queue for care costs calculation
• go to Step 16
• No,
• select No to return to the Capture SBC screen
• de-select the button Are care services involved or a care cost breakdown required?
• select Submit
• go to Step 15

The total amount of care costs display. Are the details correct?

• Yes, select Submit
• No,
• select cancel and return to the Capture SBC screen using the Actions dropdown menu
• re-process SBC, and
• select Submit

Note: if issuing a Notice of past benefits – advance payment (NOPB-AP) or Notice of charge (NOC), go to Notice of judgment or settlement (NOJS).

Go to Escalations and case notes, to enter case note information.

Procedure ends here.

To issue the Z2805 letter:

• progress through to Set correspondence screen and select correct letter option/s to notify why statement is incomplete
• select the preview link to view the letter
• select Submit to issue the letter, add a case note to document this process

If the claim has settled as a failed advance payment on a deemed Notice of charge (NOC):

• select Close Claim from the Actions dropdown menu, and
• close the claim

Procedure ends here.

The SBC was not returned:

• do not enter a SBC received date
• deselect Is the statement complete?
• a pop-up message displays advising the S23B decision requires an APS4 or above delegation

Is the Service Officer an APS4 or above?

• Yes:
• select Keep assigned to me > OK
• deselect Do you wish to issue Z2805?
• a message displays, By selecting Submit, an all services included notice will be issued
• select Submit
• No, select Assign to queue > OK. The procedure ends here

If there was a previous SBC processed and NOPB issued, there may have been an indication of care costs. Enter any previously calculated care costs.

Do not escalate for another care cost check.

Review the Summary screen to make sure all details are correct.

Are the details correct?

• Yes, select Submit
• No,
• select Cancel and return to the Capture SBC screen using the Actions dropdown menu
• re-process SBC and select Submit

Note: if issuing a NOPB, corresponding letters will be sent automatically. If issuing a NOPB-AP or NOC, go to Notice of judgment or settlement (NOJS) - Medicare Compensation Recovery.

Add case notes to the claim and include details of all actions taken.

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

Claim referred for care cost checks.

The APS5 (or above) picks up the SBC case to:

• calculate the applicable amount of care costs on the NOPB/NOPB-AP)/NOC
• file the calculation spreadsheet and associated breakdown in the shared drive folder CompRec Care Costs (nursing home residential care home care)
• add the calculated care costs to the Capture SBC screen in MCRS

Review the Summary screen to make sure all details are correct.

Are the details correct?

• Yes, select Submit
• No,
• select Cancel and return to the Capture SBC screen using the Actions dropdown menu,
• re-process SBC, and
• select Submit

Note: if issuing a NOPB, corresponding letters will be sent automatically. If issuing a NOPB-AP or NOC, go to Notice of judgment or settlement (NOJS).

Add case notes to the claim and include details of all actions taken.

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

If the claimant, injured person, or compensation payer is requesting a breakdown of care costs:

• add a case note to document this process
• explain what the customer is seeking
• save the work item (document assessment/enquiry case) in MCRS
• escalate via Work Optimiser, and
• enter:
• MCRS_SBC_CC_NOPB if SBC was the document received, or
• MCRS_SBC_CC_NOJS if Notice of judgment or settlement (NOJS) was the document received

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

APS5 (or above) will:

• generate the breakdown document
• forward the document to the requesting Service Officer for action
• save the breakdown table and attachments to the shared drive folder:
  CompRec Care Costs (nursing home residential care home care)
• add a case note to document this process

Print a copy of the below documents:

• Notice of past benefits or Notice of charge
• The returned care cost breakdown in colour
• The Notice of past benefits or Notice of charge letter and include the issue date

Then:

• post all of the above documents to the requestor
• add a case note to document this process
• finalise the enquiry case as Document Type Other

Note: the breakdown information is only sent to the person making the request. Copies are not sent to other parties. If the claimant’s solicitor requested the breakdown and the agency does not hold a Third party authority, send the information to the injured person.