Extensions, decisions and reviews – Medicare Compensation Recovery 011-15030070

An extension of time to return the Statement by claimant (SBC) may be granted if received on or before the due date provided on the statement. Requests received after the due date must be rejected.

An extension request must be made in writing or via telephone by the:

• injured person or claimant
• authorised legal representative appointed to act on the injured person’s behalf (such as by a Court Order, as a Power of Attorney or Executor), or
• authorised third party (including a solicitor or an individual who is being authorised to act on behalf of the injured person, claimant or legal representative)

Services Australia will issue an 'Extension of period to give a statement request granted/refused' (Z2804) letter when a decision has been made or when a decision is internally reviewed.

Generally, no more than 2 extensions of time will be granted. This practice assures that no more than 3 months of services after the date of injury may be excluded when a NOPB is issued. Each case is assessed independently.

See:

• Process for information on granting an extension
• Escalations for information on escalating claims to Program Management

An extension may be granted when a case has:

• not settled
• the agency may grant an additional 28 days from the date the Statement by claimant (SBC) was due if the request is received before the current due date
• settled, as long as the compensation payer has made an Advance Payment (AP) and the claim qualifies as a valid AP claim:
• and the request is received on or before the due date of the SBC
• the agency may grant an extension for a period of up to 12 months. The requestor must advise of extension period, otherwise it will default to 28 days
• reimbursement arrangement reached
• the agency may grant an additional 28 days to return the completed SBC, if the request is received before the current due date

Requests for second or subsequent extensions must be escalated to Program Management.

See Escalations.

Do not grant an extension if:

• the due date provided on the Notice to Claimant (NTC) has passed
• a claim has settled but no AP has been received by the agency (this includes failed APs)
• supporting documents are missing, such as a Last Will and Testament or probate document, or
• the claim has reached settlement and the Section 33D date has passed

The Process page contains information about how to grant or refuse an extension request.

A granted extension of time to return the Statement by claimant (SBC) may change the date under s33D. This determines when the NOC is to be issued by.

If the extension due date is before the original s33D date there is no impact. However, if the extension due date falls outside of the original s33D time frame, the agency has an additional 28 days from that due date to produce the NOC.

See Notice of past benefits and notice of charge for calculation information.

Refusal to issue a new NOPB or NOC is referred to in sections 18 and 21 of the Health and Other Services (Compensation) Act 1995 (HOSC Act). The delegation to make the decision can be made by an APS3 (or above).

A 'Notice of refusal' (Z2806) letter is issued when:

• a request to issue a NOPB is received while there is already a valid NOPB on the claim
• a Statement by claimant (SBC) is returned late and a valid ‘all services included’ NOPB is on the claim
• the injured person/claimant has submitted an SBC to amend the NOC, NOPB or NOBP-AP without enough evidence. This may apply to previously verified Medicare services or care costs, or
• a request to amend a 'all services included' NOC was received outside of 2 years from the date of judgment or settlement

The Resources page contains information about reasons for issuing a notice of refusal.

In some circumstances the injured person, claimant or Authorised third party (ATP) may apply for an internal review of a decision. A valid review request must be made:

• within 28 days of notification of the decision, and
• in writing

The agency must review the decision and decide to affirm or vary the original decision within 28 days of receiving the application.

Review of decision - extensions

The injured person, claimant or ATP can request an internal review of decisions related to extensions. The application for an internal review may be because:

• the agency is denying an extension, or
• the claimant is not satisfied with the length of the extension period

An internal review of a decision must be completed by an APS4 (or above) and must not be made by the Service Officer who made the initial decision. The reviewer will consider if processes and policies were correctly applied in the original decision and decide to:

• affirm the original decision, or
• vary the original decision with a longer due date

When a decision has been made, the reviewer will process accordingly in MCRS and issue an 'Extension – Review of decision' (Z2804) letter.

The Process page contains steps on how to review an extension decision.

Review of decision - Notice of refusal

The only notice of refusal decision that includes the right to review is a refusal to amend a ‘Notice of charge - all services included.' This refusal could happen when the injured person, claimant or their Authorised third party (ATP) did not lodge a request to amend an ‘all services included’ NOC within 2 years.

The decision to refuse is reviewable under the Health and Other Services (Compensation) Act 1995 (HOSC Act).

An injured person or claimant asking for a review of the decision not to amend a Notice of charge - all services included must make an application in writing within 28 days of notification of the original refusal to issue the amended notice.

The due date for the review application will be given on the original refusal notice. It allows an extra 9 days for postage.

As 2 years is the maximum time frame under the HOSC Act, the decision to refuse to give notice will not be overturned on review unless the details of the claim led to an incorrect decision being made. Consider other circumstances if the injured person/claimant makes contact asking to amend an all services included notice more than 2 years from the date of judgment or settlement. Escalate the claim to Program Management and give reasons for why they should review the case.

An APS5 (or above) must complete the review of the original decision to refuse to issue a notice (known as a reconsideration). This:

• must be done within 28 days from receipt of the application, and
• must not be completed by the Service Officer who made the initial refusal decision

A 'Reconsideration of decision to refuse to issue a notice (Z2806) letter will be issued when all relevant evidence has been considered and an outcome reached. If the decision is made to accept the evidence and vary the original decision an APS5 (or above) delegate needs to re-process the Statement by claimant (SBC).

If the injured person/claimant is unsatisfied with the outcome of the reconsideration, they have the right to apply to the Administrative Appeals Tribunal (AAT) for a review. They will be told this via the reconsideration of decision (Z2806) letter.

The AAT will be superseded by the Administrative Review Tribunal (ART) on 14 October 2024.

Role of the AAT

The AAT (superseded by the ART on 14 October 2024) provides an independent review on a range of administrative decisions made by:

• government departments
• agencies, and
• some non-government bodies

The AAT will only review a decision after the agency has completed an internal review.

When an injured person or claimant disagrees with a decision

An injured person, claimant or their Authorised third party (ATP) may disagree with a decision about the reconsideration of refusal to issue a notice under section 18.

In these cases, they may apply to the AAT/ART to review the decision. In line with Section 27A of the Administrative Appeals Tribunal Act 1975, notice of a person’s right to have the decision reviewed is included in the relevant letters.

Note: AAT reviews may incur an application fee.

Receiving notification of an AAT appeal

If a request received is about an AAT appeal:

• escalate notification of an AAT appeal to Program Management
• all relevant documentation and previous decisions made about the disputed claim will be available on the claim for Program Management assessment

Program Management will send the required documents to the AAT. See Escalations.

Formal AAT decisions

When an AAT decision is in favour of the:

• agency, the compensation claim will proceed and money will be recovered in line with the decision details
• injured person or claimant, the agency is bound by the terms of the decision and will proceed accordingly

Charges for lodging an application

The AAT will inform the injured person or claimant:

• of any fees associated with lodging an application, or
• if they are exempt from paying any such fees

Contacting the AAT

The AAT website has the contact details for each State and Territory.

The Resources page contains a link to the AAT website.

An amendment to a NOPB, NOPB-AP or NOC can be considered in certain circumstances. Criteria for review will depend if the:

• claim is pre or post settlement
• notice is verified or all services included
• notice was valid or expired at the date of:
• review request, or
• date of judgment or settlement (DOJS)

General circumstances for review of a notice include:

• there is an identified processing error and services or costs have been incorrectly included
• there has been a request from an injured person/claimant or the Authorised third party (ATP) to remove previously verified services from a NOC or NOPB-AP (post-settlement). Evidence is needed and must be either a:
• letter from a treating medical practitioner confirming the services do not relate to the compensable injury, or
• statutory declaration completed by the injured person/claimant providing thorough rationale supporting the removal
• there has been a request from an injured person/claimant or ATP to remove previously verified services from an expired NOPB (pre-settlement). No more evidence (for example, medical statement or statutory declaration) is needed. The injured person or claimant will need to supply a completed Statement by claimant (SBC) with the verified services crossed out or ticked no on a subsequent SBC
• a request has been received for review of a care cost amount (in full or in part), stating that the cost does not relate to the compensable injury or illness. Medical evidence is needed to remove previously identified care costs and must be escalated to Program Management

Note: an amendment of care services must be approved and completed by a Program Management APS5 (or above) when the appropriate evidence is submitted.

See Escalations for more information on escalating these cases to Program Management.

If an administrative error is identified, a call must be made to both the compensation payer and injured person/ claimant/ Authorised third party (ATP). Tell them a new notice will be sent.

This makes sure:

• correct information is used when negotiating the settlement or judgment amount
• there is less future rework and enquiries

The Health and Other Services (Compensation) Act 1995 recognises Centrelink’s authority to recover amounts before Medicare. This means if the total compensation amount paid is not enough to cover both the Centrelink and the Medicare recovery amounts, any Medicare Compensation Recovery notice of charge will be reduced.

Once the Centrelink amount is entered in MCRS, the correct amount of the recovery will be calculated.

See Notice of past benefits (NOPB) and Notice of Charge (NOC). Notification of the Centrelink recovery may not be readily available when the Medicare Compensation Recovery processing is being finalised. If notification is received and the claim has been closed, go to Close, terminate, or reopen a claim to reopen the claim, enabling for the Centrelink recovery amount to be added and the NOC or NOPB-AP to be amended and re-issued.

Where a request is received to amend a NOPB, NOPB-AP or NOC by processing a new Statement by claimant (SBC) to remove previously verified services, the statement must be clear. Either:

• the services to be removed are ticked no, crossed out or have a line through them, or
• it has a comment beside the service indicating it does not relate

Note: initials are not needed when services are to be removed.

The Resources page contains more information about circumstances, evidence and delegation to approve amendments.