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

Reason

Use this option when…

Current Notice of Past Benefits (NOPB) exists – verified

a verified NOPB is currently valid and the injured person/claimant is seeking another Notice to Claimant (NTC), or the notifiable person is seeking another NOPB.

Current NOPB exists – deemed

a deemed NOPB is currently valid and the injured person/claimant is seeking another NTC, or the notifiable person is seeking another NOPB.

Insufficient reason or medical evidence for failing to submit the statement by the due date – Notice of charge (NOC) deemed

an injured person/claimant is seeking to amend either the Care Costs or Medical Services without evidence (as per current process).

Failed to submit the statement within 2 years from date of judgement or settlement (DOJS) – NOC deemed

the claimant is seeking to amend a deemed NOC more than 2 years from the date of judgment or settlement. (Other circumstances must be considered. The claim must be escalated to Program management with justification provided) See Escalations.

Reason for amendment

Delegation and evidence required

There is an identified processing error and services or costs have been incorrectly included

Service Delivery APS3 and all levels above can approve to correct the error.

No evidence is required.

Service has already been paid by the compensation payer

Service Delivery APS5 or above can approve to remove the service with:

• a copy of invoice and receipt that was paid by the compensation payer

See Escalations for more information on escalating a work item to the Service Support Officer (APS5).

A care cost amount (in full or part) does not relate to the compensable injury or illness

Program Management APS5 or above can approve to review the costs with a letter from treating doctor that the services specifying:

• some or all of the care costs do not relate to the compensable injury or illness, or
• the increase in the level of care was not related to the compensable injury or illness

See Escalations for more information on escalating a work item to Program Management (APS5).

Reason for amendment

Delegation and evidence required

Valid NOPB all services included

Generally, a notice of refusal will be issued in these circumstances. However, a Service Delivery APS5 or above can approve to process on a case by case basis with:

• a recompleted Statement by claimant (SBC) and
• written evidence from the compensation payer or claimant’s solicitor that the claim cannot be finalised without an accurate notice and must be endorsed by:
• a judge confirming the date has been set, or
• the Public Trustee or nominated Private Trustee

See Escalations for more information on escalating a work item to the Service Support Officer (APS5).

Valid verified NOPB

Consider a review if:

• there are processing errors, Service Delivery APS3 can approve
• there is an invoice/receipt from compensation payer showing that they have paid the account, Service Delivery APS 5 can approve
• care costs do not relate. Escalate to Program Management with the letter from the treating doctor

See Escalations.

Otherwise amend at expiry of notice or post settlement by processing new SBC.

Expired NOPB

Service Delivery APS 3 can approve to process a statement to remove previously verified services with a clear statement by the claimant.

If unsure, consult a Program Support Officer.

Note: this is not an amended NOPB. It is completed in statement capture by claimant processing.

See Statement by claimant and care costs.

Reason for amendment

Delegation and evidence required

Within 2 years of a judgment or settlement being fixed, a request to reduce NOPB-AP or NOC due to apportionment of liability to the injured person

Service Delivery APS3 can approve to reduce the NOPB-AP/NOC by the percentage of apportionment applied where written evidence has been supplied by the compensation payer.

A change only in the date of injury or illness (DOI) at date of judgment or settlement (DOJS)

• Consider if a new NTC is required, see Medicare Compensation Recovery for more information
• If a change to the DOI advised on the NOJS and is later than the previously registered date, Service Delivery APS3 can amend the DOI and re-process to remove any services before the new date of injury

NOC all services taken

• The Health and Other Services (Compensation) Act 1995 (the HOSC Act) provides for a review within 2 years of judgement or settlement (DOJS)
• Service Delivery APS3 and above can process a valid Statement by claimant (SBC)
• A completed SBC (inclusive of service list, care statement and declaration) must be provided

Verified NOC – valid at DOJS

• No provision in the HOSC Act to review a notice resulting from a verified statement, however consideration for review will be given within 2 years of DOJS
• Injured person/claimant must apply in writing and evidence will be required. Evidence must be in the form of a letter from a treating medical practitioner confirming the services do not relate to the compensable injury, or provision of a statutory declaration completed by the injured person that provides thorough rationale supporting the removal

Possible scenarios

Previously verified services are clearly unrelated to the injury or illness, Service Delivery APS5 can approve to process a recompleted statement by claimant.

Previously verified services that might relate to the injury or illness:

• Service Delivery APS5 can approve to process:
• a recompleted statement by claimant
• a statutory declaration by the claimant that the services do not relate

There has been a change in the nature of the injury or illness at DOS:

• Service Delivery APS5 can approve to process:
• a recompleted statement by claimant
• a statutory declaration by the claimant to explain the change in injury/illness and that the services do not relate
• supporting valid NOJS

If unsure, escalate to Program Management.

See Escalations for more information on escalating a work item to the Service Support Officer (APS5).

Verified NOPB – expired at DOJS

• No provision in the HOSC Act to review a notice resulting from a verified statement, however consideration for review will be given within 2 years of DOJS
• Injured person/claimant must apply in writing. This can be provided in the form of a returned SBC (updated NTC issued after valid NOJS received) with previously verified services struck out

Possible scenarios and further evidence needed related to the scenario (if necessary)

Previously verified services that are clearly unrelated to the injury or illness:

• Service Delivery APS3 can:
• process an SBC requesting to remove previously verified services
• consult a Program Support Officer if unsure

Previously verified services that might relate to the injury or illness:

• Service Delivery APS5 can approve to process a recompleted SBC with a letter from a treating medical practitioner or a statutory declaration by the injured person/claimant that the services do not relate

See Escalations for more information on escalating a work item to the Service Support Officer (APS5). If unsure, escalate to Program Management.

There has been a change in the nature of the injury or illness at DOJS:

• Service Delivery APS5 can approve to process if there is a recompleted SBC with supporting valid NOJS.

See Escalations for more information on escalating a work item to the Service Support Officer (APS5). If unsure, escalate to Program Management.