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

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This document explains how Service Officers process an SBC and calculate care costs.

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Process a Statement by claimant (SBC)

SBC not returned - all services included

Re-processing of Statement by Claimant (SBC) and Notice of Judgment or Settlement (NOJS)

Process a Statement by claimant (SBC)

Table 1: this table follows on from:

  • Table 1 > Step 9 in Claim management - Medicare Compensation Recovery, or
  • Table 1 > Step 15 in Notice of judgment or settlement (NOJS) - Medicare Compensation Recovery
Expand table

Step

Action

1

Identify claim

Identify related compensation claim:

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

Does the claim require migrating from the legacy system?

2

SBC Capture

Does the SBC capture screen need re-instating to process or re-process?
For example, an M case has been invalidated, or a J case wants to issue an NTC when an SBC is available to process?

3

Document type

Select Statement by claimant from the dropdown menu.

Note: any updates to claim that are required (other than address updates for injured person or authorised third party) must be done in a separate enquiry prior to actioning SBC. As update details cannot be selected from the Evaluate screen when Statement by claimant is selected as the document type.

Go to Step 4.

4

Check Medicare details match

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

5

Check claim details match

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

6

Check for any ad hoc payments

Search for any ad hoc payments received using SAP GUI.

See Table 3 in SAP GUI processing - Medicare Compensation Recovery for instruction on locating payments.

Note: Doc Date is the correct date when confirming date of receipt of payment. Posting Date (Pstng Date) must not be used as this is the date Finance actioned the payment.

Was an ad hoc payment located?

7

Select any additional relevant options based on returned SBC

Do you want to refuse to issue a Notice of past benefits (NOPB)?

8

Assign or return to the queue

A pop up message will display:

Is the Service Officer proficient in the work type?

  • Yes, select Keep assigned to me > OK. Go to step 9
  • No, case note the reason for assigning back to the queue
    • select Assign to the queue > OK
    • procedure ends here

9

Update address

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 10
  • No, go to Step 10

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

10

Incomplete SBC

Is the statement complete?

11

Capture SBC details

Service Officers must enter the SBC received date into the SBC received date field.

Is the statement complete?

12

Incomplete Statement

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

Note: some buttons are automatically selected.

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 13
  • 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, Staff that:
    • have the APS4 delegation, select Keep assigned to me to process a not substantially correct decision. Go to Step 20
    • do not have the APS4 delegation, select Return to the queue > OK. Procedure ends here

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.

13

Failed advance payment (AP) with all services included

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

14

Incomplete statement when closing a failed AP claim

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 from the dropdown menu
  • 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 21

If a completed SBC is returned an amendment can be completed at that time.

15

Select services - deemed

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

Note: select Undeem if deeming needs to be reversed.

16

Select services - verified

Cross reference previous claims to make sure services they 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.

Go to Step 17.

17

Previously verified services

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

Go to Step 18

18

Care Costs

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,
    • leave a case note indicating claim is being sent to APS5 for care costs check
    • select Save
    • select Yes to route the work item to the APS5 queue for care costs calculation
    • procedure ends here
  • 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 19

19

Notice of past benefits summary

The total amount of service benefits displays. 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
    • select Submit

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

20

Add case notes

See Table 6 in Claim management - Medicare Compensation Recovery to enter case note information.

Procedure ends here.

21

Issue correspondence - Z2805

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.


SBC not returned - all services included

Table 2: MCRS will generate a work item for SBC when the statement has not been returned on time. If a statement is returned late, the agency may elect to process it as if it was received on time, provided processing of an all services included Notice of past benefits (NOPB) has not yet occurred.

Note: these work items will take a Service Officer from Work Optimiser directly to the Capture SBC screen.

Expand table

Step

Action

1

Capture SBC details

The SBC was not returned:

  • Do not enter an SBC received date
  • Do not deselect the buttons:
    • Is the statement complete?, or
    • Is the Statement substantially correct?
  • Select Deem button. The SBC received date, and the two buttons will be disabled
  • All services will be selected and total benefits paid amount will show
    Note: select Undeem if deeming needs to be reversed
  • If there was a previous SBC processed and NOPB issued, there may have been an indication of care costs. Manually enter any previously calculated care costs into the Care costs ($) field.
    Do not select the Are care services involved button
    Do not escalate for another care cost check.
  • Add case notes to the claim, include details of all relevant actions taken
  • Select Submit

2

Notice of past benefits (NOPB), Notice of past benefits - advance payment (NOPB-AP) or Notice to claimant (NOC) summary

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

Are the details correct?

  • Yes,
    • add case notes to the claim, include details of all relevant actions taken
    • select Submit
  • No,
    • select Back and return to the Capture SBC screen
    • re-process SBC and add case notes to the claim, include details of all relevant actions taken
    • select Submit

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


Re-processing of Statement by Claimant (SBC) and Notice of Judgment or Settlement (NOJS)

Table 3: this table includes the process to re-instate the SBC Capture screen if MCRS does not recognise that a Notice to claimant (NTC) has been issued or if a Notice of past benefits (NOPB) needs re-processing due to an administrative error.

This process continues from Table 2 > Step 9 in Claim management - Medicare Compensation Recovery if the claim requires migrating before processing the SBC.

Expand table

Step

Action

1

Document type

If migrating a claim before processing the SBC, complete Steps in Table 2 of Claim management - Medicare Compensation Recovery.

2

Create new enquiry

After all details are updated and the claim has successfully migrated:

  • Select Create > Enquiry from the left-hand panel on the MCRS homepage. A new enquiry case is created
  • Select Continue and enter the work identification number (WIN) on the Check existing compensation screen. Select Search
  • Select the button beside the WIN hyperlink. Select Continue
  • On the Evaluate screen, select the WIN hyperlink
  • Review the View Compensation Details screen
  • Review the Pre-settlement section
  • Confirm that a Notice to claimant (NTC) is recorded as issued, with no SBC recorded as being received after that date

3

MCRS to recognise the issued NTC
  • On the Evaluate screen select Notice of past benefits request as the document type
  • Select the button beside Does the claim selected match the details in the documents?
  • Select Continue
  • On the Capture NTC details screen select the button beside Process the SBC for last NTC and issue a new NOPB
  • Select Submit

A message will present - Are you sure you want to issue a new Notice to Claimant? > Select Yes

Has an SBC been received and there is a NOJS?

Note: the SBC can appear as SbyClaim, Z2801, Z2245 or Other on the document name list.

4

Capture NOJS detail
  • When the SBC screen loads, select Save. Exit work item from left hand panel to return to the MCRS home screen
  • Select Create > Enquiry from the left hand panel on the MCRS homepage. A new enquiry case is created
  • Select Continue and enter the WIN on the Check existing compensation screen > Select Search
  • Select the button beside the WIN hyperlink > select Continue
  • On the Evaluate screen, select Notice of Judgment or Settlement as the document type
  • Select the button beside Does the claim selected match the details in the documents?
  • Select Submit

A message will present - Are you sure you want to process a Notice of Judgment or Settlement? Existing NTC case is available for use in the NOJS case. Would you like to continue?

  • Select Yes
  • Complete SAP search for payment/s received. Go to Table 1 > Step 6
  • For NOJS capture steps, see Table 1 > Step 3 in Notice of judgment or settlement (NOJS) - Medicare Compensation Recovery
  • Once NOJS capture is completed go to Step 5

Note: MCRS will recognise that there is a pending SBC Capture and return to the SBC Capture screen once the NOJS capture is completed.

5

Process Statement by claimant (SBC)

Once the NOJS Capture is complete a message will present, NTC already issued and SBC pending Capture. Statement by claimant is waiting for processing.

Is the Service Officer proficient in the work type?

  • Yes, select Keep assigned to me, to process SBC go to Table 1
  • No, select Assign to the queue > Select OK

Procedure ends here