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 item 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 or contact details. Staff must make sure all details are correct and current.

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 is held, solicitor details must be entered. A start date for authority is required, Service Officers are to enter the receipt date of the first valid third party authority document on 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 form (MO026), or
• Notice of judgment or settlement form (MO022), or
• Notice of reimbursement arrangement form (MO027)

The agency may be notified 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 item number (WIN) to be assigned, and
• documents to attach to the claim

To create a provisional WIN the agency requires:

• an injured person's name and address, or
• a notifiable person's business name and address

If no address is provided for either party:

• the document is invalid
• no letter is sent, and
• Service Officers must add case notes in 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 record

• 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 item 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

Registered claim

• An Active Standard claim may be registered if the submitted form or letter includes all the mandatory information for MCRS
• 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 for more details

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

Staff must update a compensation claim if:

• documents received contain updated contact details
• 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
• 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

See:

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

The Rapid Addressing tool is available in MCRS to help with updating addresses.

• It is not available for:
• postal addresses, for example, PO boxes, GPO boxes or locked bags
• overseas addresses
• 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)
• For overseas addresses, select the Address outside Australia button:
• Key # if no overseas postcode is provided. Do not enter 9999 for an overseas postcode
• If a state is not provided enter a full stop in the state field
• If the Rapid Addressing tool is unable to locate an address, enter the address details manually

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

• was enrolled in Medicare under a different name and/or date of birth. Make sure the name and date of birth details are re-confirmed 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.

An injured person may not be enrolled in Medicare, however if the agency is advised there are care related costs to be recovered, or we have received a Notice of judgement or settlement (NOJS) and a S23A statement is not provided and accepted:

• register a claim in MCRS, and
• issue a Notice to claimant (NTC) for care costs only

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 reciprocal health care agreement for Medicare may also exist for visitors to Australia. See Reciprocal Health Care Agreements (RHCA) eligibility for Medicare and Pharmaceutical Benefits Scheme (PBS)

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

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

Services 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-submitted 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 minors date of birth (DOB)

Sensitivity Indicators identify customers with various circumstances 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. The MCRS includes a sensitivity indicator feature. 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 sensitivity indicator, if appropriate, by selecting the most relevant category from one of the eight sensitivity indicators for use by Service Delivery. Three of the indicators (BPA, staff claims and high profile claims) will be automatically directed to Program Management once selected. The remaining indicators are for indication purposes only, prompting staff to recognise that further actions may be required.

Note: the sensitivity indicator is not appropriate for every claim that may apply to an indicator in the table, 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 sensitivity 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 sensitivity indicators
• comments in case notes do not automatically apply the sensitivity indicator

Sensitivity indicators will alert Service Officers:

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

Contact a Program Support Officer (PSO) for further assistance

See Resources for the Sensitivity indicator categories

A BPA is an agreement between the Chief Executive Medicare and the notifiable person. This being the compensation payer or insurer, where the notifiable party 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 relates to a class action where a BPA exists, Service Officers must register a provisional claim and turn on the sensitivity indicator for BPA. If a claim is registered, the indicator can be applied. This will direct the claim to Program Management.

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

• advise that the claim is to be registered in the normal manner in MCRS, and
• progress the claim to the status of 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 make themselves aware of the BPA list to learn the Notifiable Parties they apply to. Injury descriptions that may be referred to include:

• Psychological/psychiatric
• Failure of knee prosthesis (there is currently no hip or mesh implant BPA)
• 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 compensation payer 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

Medicare Compensation Recovery use case notes to document all activity that occurs for every claim processed in MCRS. Case notes inform the reader of the status of a claim and may be required as evidence in court to provide a true and accurate account of decisions made.

They are:

• a public record of information received about a claim, including:
• all actions, and
• decisions made
• used to make informed decisions for the next course of action
• important if the following are involved:
• Program advice & Privacy Branch (Legal Services Division)
• Administrative Appeals Tribunal (superseded by the Administrative Review Tribunal (ART) from 1st July 2024)
• Ombudsman, or
• Ministerial enquiries

The below Services Australia staff use the case notes:

• Medicare Compensation Recovery
• Service Delivery
• Program Management
• Compensation Finance
• Payment Assurance Operations, and
• Accounting

Case notes are used throughout the agency to record information, and are a free form text field in the:

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

When a case note is required

Staff must enter case notes every time they view, access or process a claim. This includes when:

• viewing a claim, and no action is taken
  Note: the MCRS audit trail captures and records data each time a claim is viewed/accessed
• following any communication with a person involving a claim
• advice is provided to another staff member about a claim
• making a decision in relation to a claim
• a payment or refund is processed, or recovery action starts

Examples of when a case note must be recorded include:

• Service officers that have talked to any party involved in a claim. For example:
• an injured person
• a claimant, or their solicitor
• a compensation payer, or their solicitor
• Team Leaders after accessing 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
• Service Officers and an APS5 (if involved) when a case is to be escalated to Program Management, both staff record a case note
• Program Management staff recording a case note to notify of a decision made with an explanation of the decision
• Accounting Operations 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 Process page for steps on how to access this function.

Structure of case notes

Case notes must include:

• a full and accurate record of work-related decisions and activities
• details allowing others to easily understand when, how, where and why actions occurred, and the decisions made
• why the claim was viewed, accessed or processed
• actions and decisions made
• reason/s why the action/decision was made, for example:
• why a change of address was recorded, or
• who authorised an action
• requests for actions to be performed
• instructions for future actions or decisions that are required
• when, what and why information was requested or provided, and by who and to whom
• 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
• compensation payer

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, use logon IDs only

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 must 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 (such as a 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 (or above). See Process page for steps on how to complete this function.