Escalations - Medicare Compensation Recovery 011-15040000

If an MCRS Enquiry case needs a decision by another staff member with the appropriate MCRS skill tag, it will be transferred to them:

• automatically by MCRS if there are:
• identified care costs assessment required
• Notice of judgment or settlement (NOJS) refunds or debts over $50,000
• Notice of reimbursement arrangement (NORA) refunds or debts over $50,000
• decisions that are required to be made at a certain delegation
• manually by a Service Officer redirecting the work item using SSO5 or Program Management escalation buttons provided when:
• they are unsure if a compensation claim is notifiable or not notifiable
• help or advice from Program Management is required
• help or advice from an APS5 (or above) is required
• a review of decision is required
• a not substantially correct decision is required
• a care cost, amendment or breakdown is needed
• manually by a Service Officer redirecting the work item when they are untrained in the received work type

The system will escalate work automatically or as directed by operational procedures.

Staff must add a detailed case note explaining why the Enquiry case has been escalated.

Escalated Enquiry cases (automatic or manual) are picked up by staff members with the appropriate MCRS skill tag through Work Optimiser - Health.

Note: staff must not use the transfer assignment function in MCRS.

Ask for help from a APS5 or higher with decisions such as:

• removing services for uncompensated injuries where medical evidence has been submitted for the decision
• exceptional or out of scope requests and enquiries. Including giving an accurate interpretation of policies to make sure the correct course of action is taken

Service Officers need to escalate work items to an APS5 or to Program Management if they are unable to resolve it themselves. See the Escalation scenarios on the Resources page for further information.

When a claim is triaged by an APS5 it may be deemed as requiring a higher level of delegation for a decision. The APS5 will escalate the claim to Program Management, providing relevant information and requesting a decision.

The APS5 and Program Management consider all of the relevant legislation and policy requirements and apply it to the enquiry and the customer’s individual circumstances. A final decision will be made that aligns with the policy intent.

In most cases the APS5 and Program Management do not contact the customer unless required but will give instructions to Service Delivery with actions needed in the case notes on the claim.

See the Resources page for escalation scenarios and where to escalate the work item.

For details about priority processing requests, see Enquiries and authenticating a customer - Medicare Compensation Recovery.

Priority processing requests may be considered in certain situations. For example:

• Financial hardship
• An injured person has a limited life expectancy
• An injured person is a minor before the court
• There is a court mandated requirement
• Ministerial complaints
• Other sensitive claims

Sensitivity indicators are added to a claim, to allow for easy identification of scenarios that need priority processing.

See Claim Management - Medicare Compensation Recovery for a list of sensitivity indicators.

When a caller requests priority processing, Service Officers are to:

• advise that all claims are progressed in date order to make sure of procedural fairness for all customers, unless the claim falls within certain priority parameters
• request information from the caller as to why the processing is to be prioritised
• review the correspondence on file, and
• advise the caller if all necessary information has been provided

Note: only trained staff can action priority process claims. If necessary the case is escalated, for more details see Table 1, Step 2.

See:

• the Process page of Enquiries and authenticating a customer - Medicare Compensation Recovery for steps on priority processing
• Table 4, Step 8 in Mail process and work optimiser for further information on escalating an enquiry case to a trained Service Officer
• Claim Management - Medicare Compensation Recovery

Work items may be allocated to a Service Officer that is not trained in that work type. Staff trained only in Introduction to MCRS should use manual escalations to re-categorise the work item through Workload Manager (WLM).

Scenarios include:

• unclassified documents
• settlement documents, for example a deed of release
• MO022 attached to enquiry, but not identified by KOFAX

See Table 2 on the Process page for more information on re-categorising work items.