Claim management - Medicare Compensation Recovery 011-15040010

Service Officers before registering a new claim must:

• assess all correspondence
• confirm that a claim is notifiable, and
• check that a work identification number (WIN) does not already exist

If a legacy CCMS claim exists, it must be migrated to MCRS when accessed to allow for any action to be taken, including adding a case note. All available legacy claim information will transfer to MCRS. This does not include address details, contact details or claimant details. Staff must make sure all details are updated.

Note: existing third party authorities received in CCMS remain valid unless revoked, replaced, or the injured person/claimant dies. If a valid Third party authority form is held, these details must be entered onto the claim.

See the Process page for more details.

Service Officers can register a compensation claim in MCRS when Services Australia receives a:

• Notice of past benefits request (MO026) form, or
• Notice of judgment or settlement (MO022) form, or
• Notice of reimbursement arrangement (MO027) form

The agency may be notified of a claim prior to a settlement, judgment or reimbursement arrangement being made, but does not have to be notified of a compensation claim until:

• an amount has been fixed by judgment or settlement, or
• a reimbursement arrangement has been made

If all mandatory information is not received to register an Active Standard claim, a provisional claim is created. This allows for:

• the 'We need more information to register a compensation claim' (Z2798) letter to be issued
• a work identification number (WIN) to be assigned, and
• documents to be attached to the claim

To create a provisional WIN the agency requires, at minimum, an injured person's name and address, or an injured person’s name and notifiable person's business name and address.

Note: a provisional WIN can be created without a notifiable person’s details, however, the address of the document sender is needed to issue a ‘We need more information to register a compensation claim’ (Z2798) letter.

If no address is provided for either party:

• the document is invalid
• no letter is sent, and
• Service Officers must add a note on the Medicare National Compensation Recovery Information (NCRI) screen

Note: notification using one of the agency’s forms is preferred. The agency may only accept a letter in limited circumstances. An escalation to Program Management must be completed to seek approval for acceptance, after 2 unsuccessful attempts have been made requesting the information to be provided on the appropriate form. The contact attempts:

• may include outbound calls to the sender, and
• must include the issuing of either a:
• 'We need more information' (Z2798) letter at provisional registration stage, or
• 'We are unable to process the notice of past benefits request/third party authority/notice of judgment or settlement/reimbursement arrangement' (Z2802) letter in each instance after

See Escalations - Medicare Compensation Recovery

The Resources page has links to the forms

Provisional claim

• Create a provisional claim if the submitted form or letter does not include all the mandatory information to fully register a claim in MCRS
• Allocate a work identification number (WIN) and issue a 'We need more information to register' (Z2798) letter. No further processing occurs unless a new form with all mandatory information is:
• received
• accepted, and
• updated on MCRS

Service Officers can register a provisional claim upon receipt of a Third party authority (MO021) form, Section 23A Statement (MO023) form or Bank account details collection (MO024) form only. This is to reduce the risk of documents not being actioned if received prior to a registration document (MO022, MO026, MO027), see Table 3 on the Process page.

Registered claim

• An Active Standard claim may be registered if the submitted form or letter includes all the mandatory information
• A WIN is allocated and an 'Information about a compensation claim' (Z2799) letter is issued
• A notice to claimant is also issued, if required, and the claim is ready for other processing activities to occur. See Notice of past benefits request and Notice to claimant (NTC) - Medicare Compensation Recovery for more details

The Process page has instructions on how to register a provisional or new claim.

Staff must investigate and, if necessary, update a compensation claim if:

• documents received contain updated contact details, such as an address or a change to parties involved in the claim
• a customer advises the agency that contact details need updating or changes to authority are to be made, for example, during a phone call
• the nature or the date of injury has been changed
• a claim has been reopened and updated details have been provided
• the claim is a legacy claim (unmigrated)
• additional information has been provided to convert a provisional claim to a standard claim
• Medicare details have recently been updated, only if the date of effect is more recent than the signature date on the most recent document

See:

• Process page for details about updating a claim
• Resources page for links to forms and contact details

It is important to record current information on claims. However, it is not mandatory to update a claim with:

• email addresses
• ABN information
• telephone numbers

If non-mandatory information fields are:

• Current - no updates are required
• Not current - remove the outdated information and leave the field blank if current information is not available

See:

• Process page for details about updating a claim
• Resources page for links to forms and contact details

Rapid Addressing is available in MCRS to help with updating addresses. It is designed to increase the speed of address additions or updates and make sure accurate recording of customer addresses. Rapid Addressing must be used unless the address it generates does not match the address specified on the form. In such instances, the address provided on the form must be used.

• Rapid Addressing is not available for overseas addresses, for overseas addresses select the Address outside Australia button.
• Update overseas address already recorded manually
• for PO and GPO boxes or locked bags, enter the suburb first, then the PO box, GPO box or locked bag details (DX addresses are not to be entered)
• if Rapid Addressing is unable to locate an address, enter the address details manually

If a Medicare record cannot be found, this could mean that the injured person:

• was enrolled in Medicare under a different name and/or date of birth. Confirm the name and date of birth details with the customer that submitted the information, and check MCRS again
• is not enrolled in Medicare, for example:
• their birth in Australia may not have been registered and they have never attempted to access Medicare entitlements, or
• they may be a non-resident from overseas who is not eligible for Medicare enrolment

Note: Reciprocal Health Care Agreements (RHCA) exist between Australia and other countries to provide immediate necessary medical treatment during a temporary visit. See Reciprocal Health Care Agreements (RHCA) eligibility for Medicare and Pharmaceutical Benefits Scheme (PBS)

Medicare record not found for injured person

A claim is notifiable if compensation exceeds $5,000 from a judgment (excluding costs) or a settlement (including costs). This rule applies regardless of the injured person's eligibility for Medicare benefits as they may have received other residential, nursing home or home care services. Staff must establish if residential or home care services were provided to treat the injury/illness where there were no Medicare services.

If an injured person is not enrolled in Medicare, it must be established if residential, nursing home or home care services were provided to treat the injury/illness where there were not Medicare services.

If the agency receives a MO022 or an MO026 and a Medicare record is not found for an injured person, see Table 5.

An injured person may have enrolled in Medicare with a different name or date of birth. If there is a mismatch with the injured person’s details, see Process Correspondence - Medicare Compensation Recovery.

Note: even if a person has not lived in Australia for many years and has renounced their Australian citizenship, a record of their enrolment for the period of their citizenship or residency will exist in the Medicare system.

A provisional work identification number (WIN) cannot be registered, and letter issued where:

• a minor is listed as the injured person, and
• no claimant has been listed

Service Officers can:

• call the sender to ask them to supply supporting evidence confirming who the claimant is
• tell the sender:
• that the documents previously sent will not be actioned, and
• to re-submit with the supporting evidence
• enter notes on the minor's record in Medicare National Compensation Recovery Information (NCRI) screen and invalidate the work item

Note: Service Officers must not action any other workarounds such as:

• selecting a parent as claimant to register, or
• removing the minor’s date of birth

To register a claim or update a claim with a date of death in MCRS for a deceased injured person, the claimant section must first be recorded with the deceased's legal representative for the estate. Once claimant section is updated, correspondence related to the claim can be issued.

If no information or insufficient evidence has been received about who the legal representative of the estate is, see Authority to access a claim - Medicare Compensation Recovery.

Sensitive Indicators identify customers who may need additional support and understanding.

The indicators:

• improve staff awareness of an injured person’s situation, and
• support the delivery of safe and respectful services

Knowledge of sensitive information could be gained either through direct communication from the person making the claim, or through details provided on supporting documents. Recognising relevant situations for a claim can help staff to make informed decisions, such as expediting a claim for an injured person with a terminal illness/injury. MCRS includes a sensitive indicator feature, which can be activated when registering or updating a claim or through Restricted Claim Actions. Service Officers can select this feature to mark a claim as sensitive and choose the appropriate indicator that applies to the customer’s current circumstances.

Evidence of the severity of the illness or situation is not required. If a request is received for priority processing due to a terminal illness or another relevant situation, it is essential that Service Officers exercise discretion and sensitivity, accompanied by sound judgement, while making decisions. This will make sure that all aspects of a situation are considered and responded to in an appropriate and respectful manner.

Service Officers must add a sensitive indicator, if appropriate, by selecting the most relevant category from one of the nine sensitive indicators. Four of the indicators (Deceased, BPA, Staff and High profile) will direct any future cases for the claim to Program Management. Service Officers that add one of these four indicators, are still required to escalate the claim. The remaining indicators are for alert purposes only to prompt staff to recognise that further actions may be required.

Note: the sensitive indicator is not appropriate for every claim that may apply, see Resources page. For example, if a claim is submitted with an injury description of Mesothelioma, but the injured person is deceased, do not use the terminal illness/injury sensitive indicator.

Service Officers must continue checking case notes for any indication of sensitive information as:

• a customer may present with circumstances not relevant to one of the sensitive indicators
• comments in case notes do not automatically apply the sensitivity indicator

Sensitive indicators alert Service Officers:

• about the customer’s circumstances, and
• to support them in protecting the customer’s safety, privacy and dignity

Service Officers can contact a Program Support Officer (PSO) for further assistance. See Resources for the Sensitive indicator categories.

A BPA is an agreement between the Chief Executive Medicare and the notifiable person. Where the notifiable person, being the compensation payer or insurer, is required to pay compensation for claims involved in a class action or multiple claims for the same or similar injury as the result of a known cause.

Where it has been identified that a compensation claim is linked to a notifiable person where a BPA exists, Service Officers must register a provisional claim and add the sensitive indicator for BPA. The claim then needs to be escalated to Program Management for assessment, see Table 3.

If the claim does not settle under the BPA, Program Management will:

• remove the BPA sensitive indicator
• advise that the claim is to be processed in the normal manner in MCRS, and
• return the case to Service Delivery to progress as an Active Standard Claim

See the BPA list located on Resources page to check if a BPA exists.

Injury descriptions relevant under the BPA list can be extensive. Service Officers must familiarise themselves with the BPA list to learn the Notifiable Persons they apply to. Injury descriptions that may be referred to include:

• Psychological/psychiatric
• Failure of various medical implants (there have previously been agreements for hip, knee and mesh implants)
• Historical/childhood abuse
• Respiratory diseases. These may be listed as Mesothelioma, Asbestosis, Silicosis, Pleural lung disease, Alveolitis, Pneumoconiosis, Pulmonary Fibrosis

See Table 10 on Resources page in Medicare Compensation Recovery to assist with determining the notifiable date of illness or injury.

Service Officers must:

• confirm that the Agreement relevant to the claim being assessed is active, or
• register the claim as per normal procedures if a BPA has expired

For some class action claims without a BPA in place, the solicitor may be acting for the notifiable person and the injured person.

A solicitor representing both parties:

• must complete a Medicare Compensation Recovery Third Party Authority form (MO021) to act on behalf of the injured person
• has no conflict of interest in these situations, and
• is not in breach of privacy

Service Officers must register these class action claims as per normal practices using the details on:

• Notice of judgment or settlement (MO022) form, or
• Notice of past benefits request (MO026) and Third party authority (MO021) form

Contact a Program Support Officer (PSO) if needed.

Purpose of case notes

MCRS core business functions include capturing essential claim information and presenting it on tabs provided on the View Compensation details screen. The tabs include:

• Claim Details - Data entered in the relevant processing fields is presented. This tab provides a summary of information related to the:
• injured person
• claim
• claimant, including authorised third party
• notifiable person
• pre-settlement
• judgment/settlement
• payments and debts
• NORA (if relevant), and
• reviewable decisions
• Documents - holds all documents received and attached to the claim. Includes copies of legacy system letters if claim was migrated
• Case notes - provides a list of notes added by system users
• Correspondences - holds copies of all outbound correspondence sent by MCRS
• History - reflects any changes made to the record and standard processing actions

Each case also contains a History selection on the Actions menu. This provides an audit trail of the individual case to show what actions have occurred.

Although not necessary to record every action on a claim, there are instances where documenting actions or information is vital.

Case notes can be a crucial resource for relevant information, such as:

• inbound or outbound contact with stakeholders that won’t be recorded in system process logs
• claim access for review and quality checking purposes
• requests and responses for guidance on procedural or technical matters
• program advice & privacy branch (Legal Services Division)
• engagement with external entities. For example, the Administrative Review Tribunal, Ombudsman or Ministerial enquiries

Case notes used to record information are a free form text field in the:

• Medicare Compensation Recovery System (MCRS)
• Medicare mainframe screens and systems

When a case note is required

Case notes must be added every time an interaction occurs with a stakeholder, or a significant decision or action is taken on a claim that falls outside of core system processes. This includes:

• conversations or verbal confirmation of information
• significant decisions, for example rejection of forms, cross referencing, refusal reasoning, claim being held awaiting advice/further information
• updating information from an external system access. For example, SAP, Aged Care staff portal, CDMS, Mainframe
• procedural or technical advice provided for a claim
• quality checking and disputes
• manual actions required

Examples of when a case note must be recorded include:

• A Service Officer has talked to any party involved in a claim. For example:
• an injured person/claimant, or their solicitor
• a legal representative
• a notifiable person, or their solicitor
• Issuing of manual letters. For example, ‘More information is needed to process a payment’ z2277 letter
• Payment information located in SAP
  Note: only required to be recorded once in case notes. Service Officers can check to confirm details are correct, if recorded accurately it is not necessary to duplicate information
• Sending of Finance templates
  Note: do not copy contents of templates into a case note - only that the action has been taken
• Team Leader accesses a claim to view information for the purpose of providing feedback to a staff member
• Program Support Officers (PSO) after reviewing a claim to help a staff member
• An escalation to Program Management
• Program Management staff responding to an escalation to notify of a decision made, with an explanation of the decision
• Finance staff recording a case note about:
• payments received and allocated, or
• when debt recovery action starts

Case notes should not be added to a closed or terminated claim through an enquiry case. To add a case note to a closed or terminated claim, use the Restricted Claim Actions function. See Table 6 on the Process page.

Structure of case notes

Case notes must include:

• plain English
• approved acronyms
• decisions made that result in action taken outside of normal system processes
• requests for actions to be performed including reason/s why the action/decision was made, for example:
• why a change of address was recorded, or
• who authorised an action
• instructions for future actions or decisions that are required
• details of telephone conversations. When, what and why information was requested or provided, and by who and to whom
• the full name and details of the person spoken to during a telephone conversation, for example, solicitor’s name and solicitor’s business name, family member’s name and relationship, notifiable person

Note: Service Officers are only authorised to access personal information on customer records when they have a business need to do so.

Do not include in case notes:

• personal comments or opinions, as case notes may be requested for viewing by members of the public under certain provisions in the Freedom of Information Act 1982
• acronyms and abbreviations unless they are approved
• information that is not relevant to the claim
• actual names of any staff member

Amending case notes

If a case note has been entered on a claim in error or an inappropriate case note has been identified, Service Officers can submit a request for it to be amended or removed. Examples of errors where case notes should be edited or deleted from a claim include:

• case notes entered on incorrect claim
• case note entered against the wrong customer
• incorrect information entered into case note
• inappropriate information entered into case note, for example personal opinions or Service Officer’s name

Service Officers must send an email describing what has occurred and what actions are required to fix the problem to an APS5. See Table 8 on the Process page.