Communicate Decisions about Client Supports Policy v6.0
Summary
Objective
Use this guidance when identifying how to notify a client about a decision about support(s) relating to their claim.
1) When a written communication must be sent to a client
2) What a written communication is to specify
3) Types of written communication
4) Acceptance of late review when written communication not sent
5) Where to record decisions
Owner
9(2)(a)
Expert
9(2)(a)
Policy
1.0 When a written communication about a support must be sent to a client
a The following business rule defines the circumstances in which we must communicate a decision relating to support(s) for a client in writing.
Written communication of a decision about support for a client
NOTE When is a written communication not needed?
When do I not need to send a written notification? When ALL of the following are true:
1. The client has NOT requested written communication
2. The decision is in the client's favour
3. The client has been notified by some other channel (call, text, MyACC)
4. The client does not need to know the specific details (e.g. entitlement amount) of the decision
2.0 What a written communication is to specify
a The following business rule defines the information that we must include when we communicate a decision to a client in writing.
What a written communication to a client is to specify
3.0 Types of written communication
a This business rules defines the accepted forms of communication we can use when notifying a client about a decision in writing.
Written communication of decisions
4.0 Acceptance of late review when written communication not sent
a The following business rule defines what we must do if a client submits a late review application relating to a decision that was not communicated to them in writing.
ACC > Claims Management > Manage Claims > Operational Policies > Managing Claims at ACC > Claim management > Communicate Decisions about Client Supports Policy
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Acceptance of late review application when written communication not sent
5.0 Where to record decisions
a The following business rule defines where to record a d
ecision and other relevant information relating to a client's claim.
Recording decisions relating to clients
ACC > Claims Management > Manage Claims > Operational Policies > Managing Claims at ACC > Claim management > Communicate Decisions about Client Supports Policy
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Overseas Claim Policy v14.0
Summary
Objective
An overseas claim is where a client already has cover for a personal injury and qualifies for support and now lives outside of New Zealand. Overseas claims do not apply to clients ordinarily resi-
dent in New Zealand who incur an injury while overseas and seek cover for their injury on their return to New Zealand.
1. Rules
2. Types of support
3. Short-term absences
4. Taxation and Double Tax Agreement (Australia)
5. Medical Certificate, Privacy and Information
6. Abatements
Owner
9(2)(a)
Expert
9(2)(a)
Policy
1.0 Rules
a Overseas clients include overseas visitors who have worked in New Zealand and who may need further rehabilitation after they’ve left New Zealand.
Overseas clients are required to continue to participate in their rehabilitation and may also be required to return to New Zealand at their own expense for assessments in order to maintain
any weekly compensation payable.
2.0 Types of support
a Under current legislation we can continue to pay overseas clients weekly compensation or independence allowances/lump sums. The client must provide a medical certificate from their
overseas medical practitioner confirming their inability to work as a result of their injury, unless Serious Injury certification exemption applies.
See Medical Certification for Serious Injury Claims
Medical Certification for Serious Injury Claims
Make an International Client Payment
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b ACC can pay for or contribute towards client rehabilitation goods overseas where:
• the product is delivered in New Zealand and
— payment for the rehabilitation is made from a New Zealand bank account and
— ACC quality control requirements, for specific goods, are met.
This means that ACC may be able to pay the costs related to:
• overseas clients when they return to New Zealand for that rehabilitation (clients would be required to meet travel costs themselves) and then return overseas with the rehabilitation product,
eg a client returns to New Zealand to be fitted with a new wheelchair
• overseas clients who have a New Zealand delivery address, when the products don't need to be fitted, eg stump socks and medical consumables
c ACC will usually not pay for or contribute towards client rehabilitation services where either the provider or the client in not in New Zealand at the time the service is provided. See section
128 of the Accident Compensation Act 2001.
This means that ACC will usually not pay for or contribute the costs related to:
• clients in New Zealand receiving rehabilitation from overseas providers, eg overseas surgeons who provide treatment for ACC clients in New Zealand
• services from a New Zealand-based provider to an overseas client, eg counselling and teacher aides via email, telephone and Skype. This excludes attendant care. See providing atten-
dant care overseas for guidance.
Depending on the circumstances of the client, ACC may provide limited support to the clients. See the Overseas Claims Guidance document
Overseas Claims Guidance document
Assessing Overseas Clients For Non-contracted Care Service Page
3.0 Short term absences
a If a client is in receipt of weekly compensation and is on holiday or living overseas for less than three months:
• you must manage them as if they were on holiday within New Zealand.
• we’ll only pay them weekly compensation or IALS. You must pay any amounts into a New Zealand bank account. See Payments to clients outside NZ
• we do not pay for any GP visits, treatment, rehabilitation or social rehabilitation. See Accident Compensation Act, Section 128.
• they’re still required to participate in any vocational rehabilitation outlined in their Rehabilitation Plan, but at their own expense.
Payments to client outside NZ policy
Accident Compensation Act, section 128 - Payment for rehabilitation to claimant outside New Zealand
http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM101809.html
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4.0 Taxation and double taxation agreement (Australia)
a Clients living in countries outside of New Zealand may also be subject to taxes in that country. They may also apply for a refund on taxes paid here in NZ and TS accounting can advise fur-
ther on this.
Clients were asked to provide tax return information annually in 2018 and you will note it has been included in some action plans. This request cannot be enforced under non compliance
(Section 72) if not provided without good and sufficient reason such as suspicion of other income but can however be requested.
The DTA is an agreement between New Zealand IRD and Australia ATO so that our clients residing there do not pay taxes in both countries. After six months living in Australia they are
deemed as resident for taxation purposes. They should therefore file a tax return and declare ACC payments as ‘Foreign Income’. This also assists ACC to determine if there are unknown
earnings in Australia.
Those with tax exemptions should be monitored by IRD but this does not appear to be the case. Those who also work in Australia, should provide a copy of their tax return each year which
should show both ACC and PAYE income. The Australian tax year runs from 1st July to 31st June and CM can supply a payment summary from Infact for this period.
If you have any questions about this, please contact the Technical Accounting Specialist (TAS) team.
5.0 Medical certification, privacy and information
a Correct certification is essential for management of these claims. Please ensure the correct letter has been sent and send again if the medical certificate does not meet the certification
requirements.
If the medical certificate does not meet ACC requirements, the client may need to return to their doctor to have the certificate amended. Technical Specialist (TS) advice in this situation is to
add an extension of 4 weeks only to allow this to happen.
If the doctor supplies a letter in place of certificate, it must still include –
• Client’s name, address, date of birth
• Date of injury
• Pre-injury role (unfit to perform)
• Diagnoses/symptoms
• Timeframe up to 13 weeks
• Treatment plan
• Details and signature of treatment provider
• Signature of client
This information is to ensure that the certifying treatment provider has a treatment plan, is aware of work type they are signing off as unable to perform and what the covered injuries are.
This should not be provided just at client’s request.
Request Clinical Records
b PRIVACY – The ACC6300 does not extend beyond New Zealand. Therefore, ACC cannot request information directly from treatment providers. Obtaining medical reports and information
for ACC are the client’s responsibility. This can be more difficult if they are being treated via a public health system. Requesting consultation notes from the doctor may also need a sup-
porting letter from ACC as patients don’t have the same access to these as we do in New Zealand. It is important that if you include that any cost for these are the client’s responsibility on
the letter.
Psychologist reporting is not objective based from overseas providers. One solution is to provide clients with ACC forms (ACC266/267/268) amended to remove CM approval and funding
comments so their provider has an understanding of the information we require or may elect to use these.
Be sure to check the qualifications of the provider, as some are not psychologists but counsellors or social workers.
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6.0 Abatements
a Overseas earnings are abated using payslips.
Exchange rate information should be taken from the Crown Revenue website – https://www.rbnz.govt.nz/statistics/b1
The last day of the abatement period rate should be used as these vary over a week. As these are weekdays only, use most previous if working week ends on weekend.
Task is entered in comment box as – 15/3/19 – 21/3/19 20 hours $400aud = $429.12 .9521 (applicable exchange rate for 21/03/19)
Some have rolling abatements which is easier if their hours do not change significantly but a wash up is recommended if not amended when payslips available. Self employed abatement is
as above but elect self employed as per standard practice.
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Clients with rapidly deteriorating conditions Policy v6.0
Summary
Objective
Since 2004, ACC has provided application packs and processed Independence Allowance (IA)/Lump sum entitlements with more urgency where a client’s covered injury is recognised as immi-
nently fatal.
Some conditions are more obvious than others. If you're unsure about a condition’s likely impact, please refer to your Medical Advisor (MA), Clinical Services Directorate, or a Technical Specialist,
for advice.
Owner
9(2)(a)
Expert
9(2)(a)
Policy
1.0 ‘Rapid Assessment’ IA/Lump sum application process
a The IA/Lump sum team can prepare the claim(s) file records for the assessment process while the claim for cover is still being considered. This will reduce any delay between cover accep-
tance and the assessment outcome. While the cover decision is being finalised, the IA/Lump sum team can request a provider to complete (where possible) an assessment based on the
medical documents, without the need to see the client in person. Sometimes this assessment can be carried out by an appropriately qualified MA.
See Assessments on medical records.
Assessment
https://go.promapp.com/accnz/Process/22af356b-1252-4f1c-9570-ff2e688c9701
Assessing lump sum or independence allowance for rapidly deteriorating terminal conditions
2.0 Eligible conditions
a This rapid assessment process is relevant particularly in cases of work-related gradual process disease or infection (WRGPDI), asbestos-related diseases, eg mesothelioma, lung cancer,
and where diagnosis is often very late in the disease’s progression. However, it's not restricted to those conditions. Allowing an assessment prior to cover determination will protect the
client’s interests, without raising expectation that the cover decision outcome will be positive. Any injury condition, which has an obvious potential to be fatal, should be considered under the
rapid assessment process. These Guidelines must be carefully followed.
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3.0 What to consider
a If you're managing a claim for cover or managing a client for any other purpose, you need to ensure you consider the impact of the client’s conditions (and any extended cover time frames),
on the client’s ability to apply and be assessed for entitlements.
When sending an acknowledgement, either by letter and/or phone, for cases that appear imminently fatal, you should include proactive reference to the other entitlements which may be
available. Section 50 (1) (b) (ii) of the Accident Compensation Act 2001 requires the Corporation to “…facilitate the claimant’s access to those entitlements”.
NOTE: Great care must be taken to keep the client aware that the streamlined process does not presuppose the outcome of the application or the assessment. Letters of acknowledgement
may need to be amended appropriately.
Client privacy is not breached if information is disclosed to a third party for the purposes of determining entitlements, even before cover is established.
4.0 How to arrange an application for IA or Lump sum
a See how to generate an application.
Throughout the process the IA/Lump sum team will keep the current case owner updated on the progression of the application, assessment and decision.
Generating an Independence Allowance or Lump Sum application
5.0 Deceased clients
a Under ACC’s legislation, a client must be alive when assessed for Lump Sum compensation. This has been confirmed by the District Court. See rules for Deceased clients. The rules for as-
sessing the impairment for an Independence Allowance differ from those for Lump Sums.
6.0 Lump sum compensation
a To be eligible for a lump sum, the deceased client must have been assessed prior to their death and all of the following must apply:
• the client suffered a personal injury for which they have cover
• the client survived the injury for no fewer than 28 days
• the assessment established that the client's injury resulted in a whole person impairment (WPI) of 10% or above.
Use of the streamlined ‘rapid assessment’ policy, doesn't impact on the way ACC makes its cover decisions on other claims, or on the way other entitlements are assessed.
Lump sum eligibility requirements
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Lump Sum Eligibility Criteria Policy v5.0
Summary
Objective
When a client submits an application for a lump sum assessment or reassessment we must check their eligibility.
Owner
9(2)(a)
Expert
9(2)(a)
Policy
1.0 Eligibility to a lump sum entitlement
a Clients may be eligible for a lump sum if their claim has all of the following:
• an accepted cover decision
• a whole person impairment rating of over 10%
• a date of injury (or date of last event where relevant) is on or after 1 April 2002
b See the full list of lump sum eligibility criteria in the business rule below.
Lump sum eligibility requirements
c See also the transitional provisions for impairment entitlements in the AC Act 2001, Schedule 1, part 3, clauses 54 and 55.
2.0 Impairment assessment and whole person impairment rating
a To determine the whole person impairment rating of a client, the client must have an impairment assessment.
b To be eligible for an initial impairment assessment, the client must meet the criteria listed in the following business rule, which includes having medical certification of a permanent and stable
impairment.
Eligibility to an initial impairment assessment
c An impairment assessment can only be completed by an impairment assessor who meets the criteria in the business rule below.
Requirements for an assessor to perform an impairment assessment
d In some situations the whole person impairment rating must take into account any previous whole person impairment ratings. See the following business rule.
Determining the whole person impairment rating by taking into account a previous rating
3.0 Medical certification of permanent and stable impairment
a A person must be considered to have medical certification of a permanent impairment for a lump sum entitlement if a medical practitioner supplies the relevant information to ACC. The rele-
vant information is listed in the business rule below.
Information needed to confirm medical certification of a permanent impairment for a lump sum entitlement
b The ACC554 Application medical certificate form is used to capture the relevant information needed.
ACC554 LSIA Medical certificate
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ACC554 required method for supplying medical information for an impairment assessment
c You must decline the client's application if the information provided on the ACC554 does not meet the criteria for assessment.
See AC Act 2001, Schedule 1, part 3, clause 57.
AC Act 2001, Schedule 1, part 3, clause 57.
https://www.westlaw.co.nz/maf/wlnz/app/document?docguid=Ibad19a8fe02e11e08eefa443f89988a0&isTocNav=true&tocDs=AUNZ_NZ_LEGCOMM_TOC&startChunk=1&endChunk=1
4.0 Client under 16 with a mental injury
a If a client is under 16 years of age and has cover for personal injury that is a mental injury, we must not assess their eligibility for lump sum compensation for the mental injury until the client
turns 16, unless we are satisfied that there are compelling reasons for assessing eligibility earlier.
5.0 Reassessment
a See Lump sum reassessment.
Lump sum reassessment Policy
https://go.promapp.com/accnz/Process/e38cf259-ba39-4af3-8182-cf5058c855b2?force=False#
6.0 Overseas clients
a Clients based overseas are eligible to have their impairment assessed or reassessed for a lump sum if:
• they meet the standard eligibility criteria
• the medical practitioner completing the ACC554 medical certificate meets both the following criteria:
- holds registration in the country in which they practise
- holds a medical degree from a medical school approved by the New Zealand Medical Council. This includes universities listed in the WHO World Directory of Medical Schools.
b Financial help for an impairment assessment overseas or for travel to New Zealand for an impairment assessment must be approved by the Technical Services team and must be cost
effective. See the following business rule.
Impairment assessment extended discretion request
7.0 Deceased clients
a Estates may be eligible to receive payments for deceased clients. Different rules apply depending on when a client has died, the type of support applied for, and the stage in the request
process. Information is available at: lump sum deceased clients
Deceased client Policy
https://go.promapp.com/accnz/Process/ceda722c-753b-424c-9bb3-432a7125d2aa
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Cover criteria for treatment injury Policy v6.0
Summary
Objective
Use this guidance to determine cover for Treatment Injury claims.
Background
The Accident Compensation Act 2001 was amended replacing the provision for medical misadventure with treatment injury. The treatment injury provisions apply to all claims lodged for the first
time on or after 1 July 2005. For claims lodged before this date see Cover criteria for medical misadventure.
A treatment injury occurs when a person suffers a personal injury when undergoing treatment by a registered health professional (RHP). See Scenarios for treatment injury.
Owner
9(2)(a)
Expert
9(2)(a)
Policy
1.0 Rules
a You must consider all of the following factors when making a treatment injury cover decision:
• the client must have suffered a personal injury
• the injury must have happened in the context of treatment
• there must be a clear causal link between the treatment and the injury
• the injury must not be a necessary part or ordinary consequence of the treatment
• the claim must not fall under any of the treatment injury exclusions from cover.
Cover criteria for personal injury Policy
https://go.promapp.com/accnz/Process/d11b619d-e931-4005-8b5a-b3dad275184b
context of treatment Policy
https://go.promapp.com/accnz/Process/b7136db9-6a87-4714-96aa-42e5f68f50aa
causal link Policy
https://go.promapp.com/accnz/Process/9cfde804-0615-4533-a2bb-c1065c7027be
Necessary part or ordinary consequence of treatment
https://go.promapp.com/accnz/Process/bf28fd8e-acf3-4b57-affe-08e416e08a57
Treatment injury exclusions from cover
https://go.promapp.com/accnz/Process/2fddb171-3490-477c-a417-f7f41b63fd90
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2.0 Date of injury
a The date on which a person suffers a treatment injury is the date on which the person first seeks or receives treatment for the symptoms of that personal injury. This date applies, even if it
was not known at the time the treatment was first sought or received for the symptoms, that previous treatment was the cause of the symptoms.
We determine the date that a client first sought or received treatment by taking the advice of the treatment provider and any other medical experts who lodged the claim. This date must be
supported by clinical records.
See the Accident Compensation Act 2001, Sections 38 and 53.
Accident Compensation Act 2001, Section 38, Date on which person is to be regarded as suffering treatment injury
http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM100956.html
Accident Compensation Act 2001, Section 53, Time for making claim
http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM100979.html
3.0 Clinical trials
a We can accept cover for a treatment injury sustained during a clinical trial under either of these conditions:
• the client did not agree in writing to participate in the trial
• an ethics committee, which was approved by the Heath Research Council of New Zealand or the Director General of Health, approved the trial and was satisfied that is was not to be con-
ducted principally for the benefit of the manufacturer or distributor of the medicine or item being trialled.
4.0 Third party infections
a When an original infection is covered as a treatment injury, we'll also accept cover when a person passes on their infection to anyone else.
See the Accident Compensation Act 2001, Sections 32(7) and 18A.
Accident Compensation Act 2001, Section 32, Treatment injury
http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM100934.html
Accident Compensation Act 2001, Section 18A, Partner (and partner in relation to deceased claimant)
http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM100670.html
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How to manage legislative timeframes Policy v10.0
Summary
Objective
Treatment injury claims being complicated claims, are subject to stringent timeframes for making cover decisions. If ACC does not keep to these timeframes the claim is accepted by default. See
Timeframes to determine cover.
Owner
9(2)(a)
Expert
9(2)(a)
Policy
1.0 Rules
a We must have an additional claim registered for any mental injuries as a consequence of physical injuries. These are considered as uncomplicated claims.
We must determine a treatment injury claim within two months of lodgement, unless an extension is sought. For relevant timeframes and actions required, see Treatment injury claims and
the information in the attached table.
Treatment injury claims (Lodgement & Reg)
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How to manage legislative timeframes table 1.png
TI30 Time extension advise
TI01- Acknowledge and Extension combined- claimant.doc
TI31 Time extension request
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2.0 Extension from 120 - 270 days
a For time extensions from 120-270 days you must obtain the client's permission for the extension.
You must also inform the client that if they don’t agree to an extension, the claim decision will be made on the information available and this may be a decision to decline the claim.
The client must can agree to the extension verbally or by returning the ACC109 form attached to the TI31 letter. If they don't return this form you must call them and ask for verbal confir-
mation of the extension agreement.
Document conversation agreement or non agreement regarding extension of time frame in Eos contacts.
b See attached table for direction on the records in Eos.
How to manage legislative timeframes table 2.png
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Assess Claim for Cover (Treatment Injury) v17.0
Triggers & Inputs
Linked Process
Issue Cover
Decision (Treatment
Injury)
1.0
2.0
3.0
4.0
5.0
6.0
Linked Process
Cover Assessor
Assess claim
Prepare for
Conduct
Request additional
Review additional
Validate cover
Issue Cover
onboarding
onboarding
information
information
decision
Decision (Treatment
Specialist Cover Assessor
conversation
conversation
Injury)
Y
Can you
complete the
N
assessment and
Linked Process
Seek External
Specialist Cover Assessor
Clinical Advice
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Assess Claim for Cover (Treatment Injury) v17.0
Summary
Objective
To assess information on a claim and decide whether it meets the criteria for cover for a treatment injury.
Background
This process was developed to allow a consistent framework for Cover Assessors and Specialist Cover Assessors to investigate all claims requesting cover under Treatment Injury legislation. This
process ensures consistency across the organisation in the steps required for this to take place.
Owner
9(2)(a)
Expert
9(2)(a)
Procedure
1.0 Assess claim
Cover Assessor, Specialist Cover Assessor
a Consider Risk of Harm questions.
Risk of Harm Guidance 1.0.pdf
NOTE What if I believe there is a risk of harm?
The risk of harm data will be entered when you update the Treatment injury tab in Eos and will be processed via the Create Report for Risk of Harm Review Group process linked
below.
However, if at any time during the cover assessment process you believe there is an imminent risk of harm to the public and you believe you cannot wait until the cover decision is
made, then send an email to [email address] outlining your reasons why you believe there is an imminent risk of harm to the public.
PROCESS Create Report for Risk of Harm Review Group
b Review the client's claim and party record, including the ACC45, ACC2152 (if on file), all clinical documents and all open tasks on the claim.
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NOTE What if there is a request for treatment on the claim, ACC18, ARTP, weekly compensation request or other requests i.e. dental treatment, hearing aids, prosthesis and
district nursing care?
1. Ensure that an ENT05 Cover decision pending letter is sent out to the client. This letter advises the client that as cover is yet to be determined, we are not able to consider an
application for entitlement, unless cover is awarded on their claim. Ensure that you forward date the task associated with the request to the legislative date on the claim.
2. Create 'Follow-up cover' task and add in the description [Complex clai
m, please assess].
3. Set priority on the task as 'high' if:
a) the client requires a critical decision,
b) the client needs more than a week off work,
c) there is an ARTP on file,
d) the claim is on the complex list,
e) we determine the client needs some sort of other urgent assistance
4. Change the target date of the task to the lodgment date
5. Transfer 'Follow-up cover' task to TIC-Case Ownership."
c Generate ACC2184 Cover decision tool if required.
NOTE When is ACC 2184 is required?
ACC 2184 is required if ANY or ALL of these criteria apply:
• It is a complex claim
• A detailed timeline of the events is required
• Any tier 3 internal or external opinion is required
If the claim does not meet the above criteria use the below template and place into a contact on Eos.
ACCEPT or DECLINE (delete one) - (state the injury being accepted)
DATE OF INJURY:
ACC 45
ACC 2152
BACKGROUND
ANALYSIS
ADVICE
RESEARCH
d Confirm this is a newly lodged claim.
NOTE What if the claim is a re-assessment and the information is not new?
• If there is no new information on file, and we did not re-open the claim, add a contact to note this. Call the client to advise. This process ends.
• If there is no new information on file, and we re-opened the claim, go to 'Issue Cover Decision' process.
PROCESS Issue Cover Decision (Treatment Injury)
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NOTE What if the claim is a re-assessment and the information is new?
1) If there is new information on file which would warrant re-assessment, and the claim was initially lodged under the Treatment Injury legislation (claim lodged with ACC after 1 July
2005), continue with this process - Assess Claim for Cover - Treatment Injury.
2) If there is new information on file which would warrant re-assessment, and the claim was initially lodged under the Medical Misadventure legislation (claim lodged with ACC prior
to 1 July 2005), check if a personal injury was found d
uring the initial investigation.
• If a personal injury WAS found during the initial investigation of the claim, re-assess the claim under the Medical Misadventure legislation. Refer to 'Cover criteria for medical
misadventure Policy'.
• If a personal injury was NOT found, re-assess claim under the Treatment Injury legislation. Continue with this process.
If you are uncertain discuss the claim with a Specialist Cover Assessor, Practice Mentor or Technical Specialist.
Note, even though there are no timeframes on re-assessment, we must complete re-assessment in a timely manner.
Cover criteria for medical misadventure Policy
NOTE What if the claim is a duplicate?
Go to Identify and link duplicate claims.
PROCESS Identify and Link Duplicate Claims :: Treatment Injury
NOTE What if you identify the claim is consequential to another claim?
Refer to Consequential Injury Claims Policy
PROCESS Consequential Injury Claims Policy
NOTE What to do if claim was previously incorrectly accepted as PICBA?
If claim was previously accepted as PICBA in error, however, it was determined that this is a treatment injury claim and not a PICBA claim; transfer the claim to TIC - Admin Queue
for triaging. In the confirm cover decision task - add the following description "claim accepted by system in error - please reassess this claim for Treatment Injury" and follow the
Triage and Allocate Claim (Treatment Injury).
PROCESS Triage and Allocate Claim (Treatment Injury)
e Following an initial review of the claim, document your findings in Eos in a contact
NOTE What should be written in the contact?
Claim checked for PICBA, AE (accredited employer), consequential claims, reassessment, duplicate claims - nil found. No evidence of a mental injury on ACC45, ACC2152 or other
lodging documents ie ACC18, ACC21.
If one of the above claim types is identified, document this clearly in the contact and if relevant the associated claim number.
f Determine whether the client has suffered a personal injury.
NOTE What if the client did not suffer a personal injury?
Decline claim. Go to 'Issue Treatment Injury Cover Decision' process.
PROCESS Issue Cover Decision (Treatment Injury)
NOTE What if the claim is for a mental injury?
Asses whether there may be a physical injury that we can assess for cover (discuss this during the onboarding conversation):
• If there is a physical injury we can assess for cover, you will need to lodge a separate claim for the mental injury because of physical injury after completing the onboarding conver-
sation (see activity 3(d)).
• The mental injury claim will be initially declined because of the specific legislative timeframes associated with the lodgement of a separate claim. Once you have approved or de-
clined cover for physical injury, the mental injury claim will be re-opened to assess for cover either as MICPI (if physical injury is approved) or TIMI (if physical injury is declined).
Refer to the policy pages below for more information on mental injury policy and how to manage timeframes.
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Mental Injury Because of a Physical Injury Policy
Statutory timeframes for mental injuries Policy
Treatment injury mental injury Policy
g Assess whether the personal injury occurred within the context of treatment. Refer to the 'Context of Treatment Policy'.
Context of Treatment Policy
NOTE What if the injury did not occur within the context of treatment?
If the injury occurred within the context of accident, update the Treatment Injury tab to reflect PICBA status and ensure the fund code is not treatment injury. Then go to 'Assess
Claim for Cover :: PICBA'. This process ends.
If the injury occurred within the context of work, eg work-related personal injury and work-related gradual personal injury, return the claim to the Hamilton Reg - Cover Assessment.
This process ends.
PROCESS Assess Claim for Cover :: PICBA
h Determine if there is a direct causal link between the treatment sought or received and the personal injury. Refer to 'Causal Link Policy'.
Causal Link Policy
NOTE What if there is no direct causal link?
Decline claim. Go to 'Issue Treatment Injury Cover Decision' process.
PROCESS Issue Cover Decision (Treatment Injury)
i Consider whether the injury was a necessary part or ordinary consequence of treatment. Refer to 'Necessary Part or Ordinary Consequence of Treatment Policy'.
Necessary Part or Ordinary Consequence of Treatment Policy
NOTE What is the injury was a necessary part or an ordinary consequence of the treatment?
Decline claim. Go to 'Issue Treatment Injury Cover Decision' process.
PROCESS Issue Cover Decision (Treatment Injury)
j Check if any exclusions to cover apply. Refer to 'Treatment Injury Exclusions from Cover Policy'.
Treatment Injury Exclusions from Cover Policy
NOTE What if any exclusions to cover apply to the treatment injury claim?
Decline claim. Go to 'Issue Treatment Injury Cover Decision' process.
PROCESS Issue Cover Decision (Treatment Injury)
k Ensure that you are closing the relevant tasks for the information or work that you have completed on the claim. An example would be if you have assessed and competed the work asso-
ciated with an 'Alert you have mail' task, 'NGCM - Medical Notes Received', or other task type that is NOT a master claim task (Confirm Cover Decision) or other legislative task
l Review the knowledge articles for the particular treatment by going to the page below (search under 'Knowledge for Cover Assessors'), if applicable.
Next Generation Case Management landing page
m Updating Eos with relevant information
NOTE What do you document in the 'contacts' following/during assessment of the claim?
Ensure that with any work that you have completed on the claim that you are recording this in the contacts section of the clients claim with the heading stating: CLAIM UPDATE.
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?
Can you complete the assessment and issue cover decision?
Cover Assessor, Specialist Cover Assessor
YES....
PROCESS Issue Cover Decision (Treatment Injury)
NO....
Continue
2.0 Prepare for onboarding conversation
Cover Assessor, Specialist Cover Assessor
NOTE What if you're a Cover Assessor and you think you cannot complete the assessment because it's a complex claim?
Go to Activity 4.0 in 'Triage and Allocate Claim (Treatment Injury )' process.
PROCESS Triage and Allocate Claim (Treatment Injury)
a Determine what consent is necessary to collect medical and other records: ACC45, verbal consent, ACC6300 Authority to collect medical and other records, or ACC163 Authority to collect
information about a deceased person.
NG GUIDELINES Obtain Verbal or Written Authority
NOTE When is a ACC6300 required?
An ACC6300 is required to request notes after 12 months of a claim being lodged, or when a provider has indicated that they will not provide notes based on the ACC45 consent
and/or verbal consent.
• Verbal consent can be obtained during the onboarding conversation
• If you think you cannot rely on the verbal consent and the ACC45, as we need a significant amount of information from several providers, or we require external clinical advice -
send the ACC6300 form to the client after conducting the onboarding conversation
NOTE What if the client is deceased?
• If the client is deceased contact the lodging provider to obtain contact details for the NOK (next of kin)
• Contact the NOK to determine if there is an executor of the estate, if there is an executor of the estate, obtain the relevant consent documents regarding this (copy of the will
showing the named executor and send an ACC163, confirm with the executor of the estate that they wish to continue with the claim investigation
• If there is no executor of the estate, discuss with the Privacy team on Ext. 46464 that there is no executor of the estate and confirm that it is appropriate to then utilize the NOK as
the authority on the claim
• Despite the multiple attempt (maximum 2 attempts) to contact the NOK or executor of the estate (EOE) (without success) - please issue the appropriate decision after discussing
this with your Team Leader. However, do not send the decision (unless address is verified in last 2 months - though check with your Team Leader or Privacy Team) and in contacts
add "unable to contact the NOK or executor of estate - decision not sent".
• If you receive the call after decision is issued, please confirm the authority with NOK or EOE, re-open the claim if it required or asked by the NOK/EOE and reassess the claim
accordingly.
• If a client dies during the investigation of their claim, ensure that this is reflected in the party record by altering the 'Profile' tab and the 'Deceased Status' data field
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NOTE What if verbal consent is appropriate?
In Skype, during the call with the client, play the pre-recorded consent message:
1.Select "Invite More People" in the top right hand corner of the active call window
2. Enter the extension for the Verbal Consent Recording: 50013 and press OK
3. You will appear in a Conference with the Verbal Consent Recording and the Client
4. Once the consent recording has finished playing, it
will automatically leave the phone conference
Then verbally confirm that the client agrees, and note this down in a contact.
Refer to the process below for more information.
PROCESS Obtain Client Authority to Collect Information
NOTE What if you need to request consent to lodge a mental injury claim?
• obtain client's consent.
• inform the client they will receive a declined decision regarding the mental injury claim.
• advise we will reopen the claim to investigate once we have made a decision on their physical injury.
b Determine if the client requires an Authority to Act (ATA)
NOTE What if the client requires an Authority to Act?
Refer to the process below prior to conducting the onboarding conversation.
PROCESS Obtain Authority to Act (ATA)
c Determine what clinical information is required to make cover decision. Communicate the requirements to the client during the onboarding conversation.
NOTE When should you request ACC2152?
The ACC2152 can be beneficial when filled out by the provider who gave the treatment or a provider who has given subsequent treatment on the injury with a similar qualification
and/or scope of practice. Consider if ACC2152 would be helpful. If not, request clinical records.
NOTE What if you require an audiology assessment?
• Check with the client whether they have already undergone audiometry assessment during the onboarding conversation, ACC will not require a client to undergo a further test if
the audiometry has been undertaken in the last three months.
• If the client hasn't completed this assessment, let them know during the onboarding conversation that we will send the letter and purchase order for them to complete the assess-
ment. Advise the client that they will need to organise an appointment with the most convenient audiometry provider, who will send the report directly to ACC. Advise them that ACC
will fund this.
d Determine if the client can provide the additional information. Collect this information during the onboarding conversation.
e Check if the client has any existing language or cultural needs.
NOTE What if the client does have language or cultural needs?
To find resources to support a client with language and cultural needs, refer to the following documents.
NG GUIDELINES Supporting the Diverse Needs of our Clients
When to use an interpreter Policy
Working with an interpreter process
ezispeak - phone interpreting service for ACC
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3.0 Conduct onboarding conversation
Cover Assessor, Specialist Cover Assessor
a Contact the client or person acting on the client's behalf by their preferred method of communication. There must be an Authority to Act (ATA) on file if contacting someone other than the
client.
NOTE How many contact attempts should be made?
Claim lodged with ONLY ACC45 which does not fulfill complex claim criteria for direct allocation to Specialist Cover Assessor.
• Two attempts to contact client by phone, on different days/times, if unsuccessful send TI73.
• Request clinical notes from lodging provider
• If we receive no response from the provider after 14 days, remind the provider (letter/email) and after a further 14 days, if there is still no response from the provider or client - de-
cline the claim.
Claim lodged with ACC45 and ACC2152 or additional clinical notes
• Two attempts to contact client by phone, on different days/times, if unsuccessful send TI73.
• If we have been provided with sufficient information as to who provided the treatment on the lodging documents, it would be reasonable at this stage to request the clinical notes
from those providers.
• If we receive no response from the provider after 14 days, remind the provider (letter/email) and after a further 14 days, if there is still no response from the provider or client - de-
cline the claim.
NOTE What if you are unable to contact the client after making the above contact attempts?
Go to Activity 3.0 Update necessary records within the Issue Treatment injury cover decision process and decline the claim.
PROCESS Issue Cover Decision (Treatment Injury)
b Follow the 'TI Onboarding conversation' guide.
TI Onboarding conversation
c In Eos, upload the completed onboarding conversation to the 'Documents' tab.
NOTE What if you identify the client's condition is rapidly deteriorating?
• In Eos, in 'General' tab, tick Triage indicator.
• In Eos, in 'Confirm cover decision' task, update the description to note [Critical decision is required - client's condition is rapidly deteriorating].
NOTE What if the client has not given consent to continue to investigate the claim during the Onboarding conversation?
If the client does not give consent to continue the investigation, document this in Eos and proceed to Issue Cover Decision (Treatment Injury) procedure.
PROCESS Issue Cover Decision (Treatment Injury)
NOTE What if a client mentions self-harm or suicide?
Refer to NG GUIDELINES Managing Threat of Self-harm Calls for guidance.
NG GUIDELINES Managing Threat of Self-harm Calls
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NOTE What if the employer is a registered AEP participant and the client's injury is related to work?
If the client mentions their employer and you identify the employer is a registered AEP participant, advise the client their claim will be managed by their employer's Third Party
Administrator and someone will be in touch with them soon.
If you need to verify this, contact the TPA admin team using the hunt line: ext 45394. Or alternatively use the relevant emails below:
Work claims: [email address]
Non work claims: [email address]
Follow the process link to 'Transition Claim to an Accredited Employer'.
NB: Clients are not able to opt out of AEP managed for work related claims, only for non-work related claims.
This process ends here.
PROCESS Transfer Claim to Accredited Employer (AE) or Third-Party Administrator (TPA) Service
Accredited Employer List
Participating Accredited Employers (Non-work claims only)
d Complete outstanding actions.
NOTE What if you need to lodge an additional claim for mental injury?
After the client onboarding conversation where you have obtained consent from the client to lodge this claim
• generate and fill out the Referral for New Claim Lodgement
• email the complete form to [email address] (ensure you specify the date of lodgement is the date ACC received the claim, not the day you first spoke with the
client).
Referral for New Claim Lodgement
4.0 Request additional information
Cover Assessor, Specialist Cover Assessor
a Follow the appropriate process below for requesting additional information.
NOTE What if you require additional information because cover decision is being reviewed?
If the cover decision is being reviewed and the claim is in actioned cases department, go to 'Re-open claim' process. Recovery Administrators can only support additional infor-
mation requests if the claim is 'active'.
PROCESS Re-open claim
NOTE What if you require clinical records/report or ACC2152?
If you require an ACC 2152 from the relevant provider go to Request Clinical Records process step
PROCESS Request Clinical Records for Treatment Injury
NOTE What do I need to consider when writing questions to a provider?
Refer to the 'Clinical questions guide'.
Clinical questions guide
NOTE What if you require internal clinical, medical or technical guidance including hotline or written?
Please go to 'Seek Internal Guidance' process.
PROCESS Seek Internal Guidance
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NOTE What if you require external clinical advice?
Go to 'Request External Clinical Advice (ECA) Report' process.
PROCESS Seek External Clinical Advice
NOTE What if you require an archived physical claim file?
Go to 'Retrieve Archived Physical Claim Files' process.
PROCESS Retrieve Archived Physical Claim Files
NOTE What if an Audiology (audiometry - percentage of hearing loss) assessment is required?
Upload onto clients claim an ACC 612 Audiometric Report for Hearing Loss (this is the document that the client is required to take to their assessment with the Audiologist of their
choice).
Create a 'Send Letter' task (this will be auto routed to Recovery Administration Team to send)
• Select ‘create and send letter’
• Enter code and name of letter ‘HLS14 Audiologist Test letter’
• Select your method of delivery
• Copy the information below and place into the additional comments section of the task (the Recovery Administrator will follow these instructions to create the purchase order and
letter:
- Choose 'HL01' for entitlement code and rehabilitation action - hearing loss, click search
- Under 'entitlement in purchase order' add '1.00' for Quantity approved and frequency as 'quarter'
and create purchase order and save
- For the purchase method choose 'Claimant Reimbursement'
- Generate 'HLS14 Audiologist Test' letter and send to client
- Please send attached document ACC612 with the HLS14 Audiologist Test letter
- Please send task 'PRC HL: Review Claim & Check for Duplicate Claims' back to task creator
advising 'Hearing assessment letter sent to client' edit target date for 20 working days.
Attach the ACC612 document to the task
• Select ‘document’ tab
• Select ‘link’
• Select ‘clear’ in the associated documents date range
• Select ACC612 Audiometric Report for Hearing Loss
• Select 'OK'
NOTE What if a face to face Otolaryngologist/ENT assessment for a hearing loss claim is required?
1. Check that you have all of the client’s audiometry records on file, including one performed in the last three months. If you do not have this on file, please request using the note
above named ‘What if an audiology assessment is required?’ Ensure that the client is made aware that they will be receiving this letter and that they will need to organise an
appointment (ACC will fund this appointment).
2. If you have all of the relevant clinical notes related to the condition that the client is requesting cover for and clinical notes regarding the treatment event or events that have re-
sulted in the injury. (ie Radiation is the treatment cause, you will need all radiation fields and radiation dose summaries. If medication ie gentamycin is the cause, you will need all
medication charts and biochemistry results of serum peak and trough levels).
3. Create a memorandum utilising Ear Nose and Throat Memorandum template below.’ Ensure that the memorandum is included in the document group.
4. Perform privacy checks on documents.
5. Create a referral-specific document group with today's date and name it 'ENT assessment'
6. Add the necessary documents and include the ENT memorandum in the document group
7. Complete privacy checks. Refer to 'NG Supporting Information Inbound and Outbound Document Checks'.
8. Generate an ‘Organise Internal referral’ task (under the Specialist Cover Assessor name or creator)
9. Edit the 'Complete internal referral' subtask to state ‘Face ENT assessment required, please send document group labelled ENT Assessment with the referral’.
10. Send the ‘Complete internal referral’ sub-task to ‘hearing loss claims’ department queue.
ENT memorandum.docx
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NG SUPPORTING INFORMATION Inbound and Outbound Document Checks
NOTE What if a mental injury assessment is required?
1) Ensure you have requested sufficient clinical notes of current state of alleged causes of injury to support assessment.
2) If this is a treatment injury mental injury (TIMI), upload to the claim a memorandum to request a psychiatric review (this document will provide a summary of the claim, relevant
legislation and have particular questions for the psych
iatrist to answer). If a sensitive claim is on file ensure you specify this in the memorandum.
3) If a sensitive claim is on file ensure you specify this in the memorandum.
4) Create a referral-specific document group with today's date and name it 'Mental injury assessment'
5) Add the necessary documents - if this is for mental injury ensure you review the clients party record for any other claims relating to mental injury or pain disorder and include this
information
6) Add any specific questions that need to be included in the body of the letter
7) Complete privacy checks. Refer to 'NG Supporting Information Inbound and Outbound Document Checks'.
8) Discuss with your team leader regarding the next steps
Refer to the Psychiatric assessment memorandum example below for guidance on how this should be completed, and use the template below.
NG SUPPORTING INFORMATION Inbound and Outbound Document Checks
Psychiatric assessment memorandum template
Psychiatric assessment memorandum example
NOTE What if a face to face (other) specialist medical assessment is required?
Go to 'Arrange Medical Case Review (MCR) Assessment' process.
PROCESS Arrange Medical Case Review (MCR) Assessment
b Determine if the timeframe to make cover decision needs to be extended. Refer to the policy below.
How to manage legislative timeframes Policy
NOTE What if you need to advise of extension or request extension agreement?
Go to 'Extend Cover Decision Timeframe' process.
PROCESS Extend Cover Decision Timeframe
c Updating Eos with relevant information
NOTE What do you document in the 'contacts' following/during assessment of the claim?
Ensure that with any work that you have completed on the claim that you are recording this in the contacts section of the clients claim with the heading stating: CLAIM UPDATE.
5.0 Review additional information
Cover Assessor, Specialist Cover Assessor
a Review new information to make a cover decision.
NOTE What if you need more information?
Go back to activity 4.0 Request additional information.
NOTE How do you review the ENT assessment?
Refer to the guide below.
Review ENT assessment
NOTE What should you do with the open task associated with the information that you have reviewed?
Ensure that you are closing the relevant tasks for the information or work that you have completed on the claim. An example would be if you have assessed and competed the work
associated with an 'Alert you have mail' task, 'NGCM - Medical Notes Received', or other task type that is NOT a master claim task (Confirm Cover Decision) or other legislative task
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NOTE What are the next steps following a mental injury assessment (once the client has undergone an independent psychiatric review?
Proceed to 4.0, a, Request Additional Information, note 5 - What if you require written internal clinical, medical or technical guidance (Tier 3). Complete a referral for Psychology -
TIMI.
b In Eos, update the 'Medical' tab and 'Treatment Injury' tab based on the new information received.
NOTE What if you need to extend the timeframe up to 9 months
(extension request)?
Go to 'Extend Cover Decision Timeframe' process.
PROCESS Extend Cover Decision Timeframe
NOTE What if the client has not responded to you or not returned the extension letter to ACC agreeing to extend timeframes?
Follow up with the client via a phone call with two attempts, two different days and times. If consent to continue to investigate is not received ACC is to issue a decision 5 business
days prior to legislative decision due date. Go to the process below.
PROCESS Issue Cover Decision (Treatment Injury)
NOTE What if you are notified that the client has died during the investigation of the claim?
• If the client is deceased contact the lodging provider to obtain contact details for the NOK (next of kin)
• Contact the NOK to determine if there is an executor of the estate, if there is an executor of the estate, obtain the relevant consent documents regarding this (copy of the will
showing the named executor and send an ACC163, confirm with the executor of the estate that they wish to continue with the claim investigation
• If there is no executor of the estate, discuss with the Privacy team on Ext. 46464 that there is no executor of the estate and confirm that it is appropriate to then utilise the NOK as
the authority on the claim
• If a client dies during the investigation of their claim, ensure that this is reflected in the party record by altering the 'Profile' tab and the 'Deceased Status' data field
NOTE What if you're a Cover Assessor and think the claim should be assessed by a Specialist Cover Assessor or the claim might require External Clinical Advice?
• discuss the claim with a Practice Mentor first to agree on which role is best suited to continue with assessment.
• if the claim needs to be transferred to a Specialist Cover Assessor, go to the note 'What if it is a complex claim?' at step 4.0e in 'Triage and Allocate Claim (Treatment Injury)'
process.
PROCESS Triage and Allocate Claim (Treatment Injury)
c Updating Eos with relevant information
PROCESS
Seek External Clinical Advice
Specialist Cover Assessor
6.0 Validate cover decision
Cover Assessor, Specialist Cover Assessor
a Review 'Claim validation framework guide'.
Claim validation framework guide
b Answer the questions in 'Claim validation framework guide.'
NOTE What if you're unsure of the decision?
• Contact a Specialist Cover Assessor, or Practice Mentor to help validate your decision.
• In Eos, in 'Contacts' tab, add a contact to note who is validating your claim and what your pre-validation decision is.
If you're still unsure of your decision, go to 'Seek Internal Guidance' process.
PROCESS Seek Internal Guidance
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PROCESS
Issue Cover Decision (Treatment Injury)
Cover Assessor, Specialist Cover Assessor
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Issue Cover Decision (Treatment Injury) v10.0
Triggers & Inputs
1.0
2.0
3.0
4.0
Linked Process
Cover Assessor
Generate cover
Update Eos
Inform client of the
Finalise Eos
Match Claim to
decision
records
decision
records
Recovery Team
Specialist Cover Assessor
documents
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Issue Cover Decision (Treatment Injury) v10.0
Summary
Objective
To notify the client about the cover decision.
Background
When cover assessment is completed, ACC must let the client know about the decision. This process covers two main scenarios - when ACC accepts the claim (injury) for cover and when ACC
declines the claim (injury) for cover.
For each scenario, staff need to make sure they have clearly documented the rationale and updated the records, so they can clearly communicate the decision to the client. Staff always commu-
nicate our decisions to the client in writing and, if applicable, verbally. This helps the client to understand why we made a certain decision and gives them an opportunity to ask questions.
Once the decision to accept or decline the claim (injury) has been made, staff can determine the next appropriate steps in the client's recovery.
Owner
9(2)(a)
Expert
9(2)(a)
Procedure
1.0 Generate cover decision documents
Cover Assessor, Specialist Cover Assessor
a Update the ACC2184 Treatment injury cover decision tool if required.
NOTE When is ACC2184 is required?
ACC 2184 is required if ANY or ALL of these criteria apply:
• It is a complex claim
• A detailed timeline of the events is required
• Any tier 3 internal or external opinion is required
NOTE What if ACC2184 is not required? (If the claim does not meet the above criteria use the below template)
In Eos, update the 'Contacts' tab by adding a contact to explain rationale for cover decision made. Include the following:
• self-validation - ACCEPT or DECLINE (delete one) - (state the injury being accepted)
• DATE OF INJURY (Accepted claim)
• ACC45
• ACC2152
• Background - name, age and gender.
• Analysis
• Advice - short summary
• Research (if applicable) - short summary of events or evidence
NOTE What if it is PICBA?
In Eos, update the 'Contacts' tab by adding a contact to note 'Clinical information assessed - not treatment injury but meets PICBA criteria.'
b Generate appropriate cover decision letter.
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NOTE What if it is PICBA?
Generate TI60 Decline claim - treatment injury.
If you approve claim for cover, CVR40 will auto-generate and be posted to the client by completing the note in 4.0a.
NOTE What if there is a claim for mental injury?
• If you accept cover for physical injury, Supported Recovery
Team will assess mental injury caused by physical injury.
• If you decline cover because there is no personal injury, you'll need to discuss with the client and seek the client's permission to re-open the declined mental injury claim. Once re-
opened, you will assess it as treatment injury mental injury claim (TIMI)
Ensure that all lodged injuries are declined and that the letter references that the mental injury has been previously declined on the separately lodged claim.
PROCESS Assess Claim for Cover (Treatment Injury)
NOTE Consolidated Treatment Injury Letters
• TI51 and TI69 have been retired in CMS and have been consolidated into TI50
• TI68, TI72, TI61, TI62, TI64 have been retired in CMS and have been consolidated into TI60
TI50 Approve claim Treatment Injury consolidated TI51 and TI69
TI67 Approve claim - treatment injury (for employer)
TI80 Approve claim - fatal treatment injury
TI82 Approve claim - fatal consequential injury caused by treatment
TI85 Approve claim - treatment injury mental injury
CVR49 Claim approve - review decision - claimant
TI60 Decline claim - Treatment Injury - consolidated TI68, TI72, TI61, TI62, TI64.
TI63 Decline claim - withdrawal
TI65 Decline claim - no new information (Med Misadventure legislation)
TI81 Decline claim - fatal treatment injury
TI83 Decline claim - fatal consequential injury caused by treatment
2.0 Update Eos records
Cover Assessor, Specialist Cover Assessor
a In Eos, in the 'Medical' tab, check the injury codes are correct.
b In Eos, in the 'Medical' tab, open the injury code, set the 'Outcome status' to 'Approved' or 'Declined', update the 'Outcome date' to the date you made a decision and add in the 'Comments'
the exact injury being covered.
Injury outcome status definitions
Assign an outcome status and an outcome date to an injury code
c In Eos, in the 'Treatment Injury' sub-tab under the 'Injury' tab, update Injury Details, Treatment Context and Cover Decision sections. You must complete all mandatory fields.
Treatment Injury tab in Eos - Data fields guide
Data tables for Eos fields.pdf
Risk of Harm Questions for Cover Specialists
NOTE What if it is re-assessment?
In Eos, in the 'Treatment Injury' sub-tab under the 'Injury' tab, update Injury Details, Treatment Context, Cover Decision and Reassessment sections.
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NOTE What if it is PICBA?
In Eos, in the 'Injury' tab, update 'Accident' sub-tab.
d In Eos, check all treatment injury and cover related tasks are closed.
e What if the claim is accepted for cover?
NOTE Determine if the client require any assistance/support.
If client, require any assistance/support - create NGCM - Client Welcome Conversation Task (if cancelled previously) then add a brief description for Recovery Team.
NOTE Determine appropriate recovery team.
PROCESS Match Claim to Recovery Team
NOTE What if the client does not require any assistance/support from ACC?
Transfer claim to TIC - Actioned Cases
3.0 Inform client of the decision
Cover Assessor, Specialist Cover Assessor
a Call the client if cover is declined or partially declined or if you think its is appropriate. Make sure you check client's identity.
NOTE How many call attempts do I have to make?
Two attempts to contact client by phone, on different days and times. Then send the decision letter by email or post.
NOTE What do you need to cover during your conversation with the client?
Clearly communicate
• why you're calling
• cover decision made
• rationale for decision
• review rights (if applicable)
• confirm the preferred method of communication for the decision letter
• discuss client's recovery needs (if applicable)
• what happens next (ie letter to be sent, transferring claim to another team, medical certificates required etc.)
Identity Check Policy
NOTE What if the client requests a copy of their information?
• If the request is for one document, send a copy to the client directly.
• If there are multiple documents requested, go to 'Complete Client Information Requests' process.
PROCESS Complete Client Information Requests
b Update the decision letter if applicable.
NOTE Update 'What happens next'.
Enter appropriate recovery team for transfer of claim.
c Enclose Treatment Injury or Consequential Injury Report if required.
Treatment Injury Cover Assessment Centre: Style writing guide
NOTE When do you need to enclose the Treatment Injury or Consequential Injury Report?
You need to enclose the Treatment Injury or Consequential Injury Report if
• it is a decline (regardless of claim's complexity)
• it is a complex claim.
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d Set the letter's status to 'Complete'.
e Upload appropriate information sheets on the claim.
NOTE What are the mandatory information sheets?
• Kōrero mai - Working together
ACC255 Kōrero mai - Working together
NOTE What are the non-mandatory information sheets/attachments?
Determine if attaching the following would help client understand our decision or decide on the next steps:
• Copy of external or internal clinical advice
• Report from treating provider
Privacy Check Before Disclosing Information Policy
NOTE What if you find information that needs to be redacted?
Send an email to Recovery Administration ([email address]) and include the document to be redacted plus your specific redaction instructions, before adding the re-
dacted document to the document group.
f In Eos, at the Party level in Contact Details, check the client's preferred method of contact.
g Privacy check and send the decision letter via the client's preferred method of contact.
NG GUIDELINES Sending Letters in NGCM
NG SUPPORTING INFORMATION Inbound and Outbound Document Checks
NOTE What if the client's preferred method of communication is by post with a verified and valid postal address?
1) In Eos, go to 'Add Sub Case' and Select 'Recovery Plan'
2) From Recovery Plan Select 'Add Activity'. Then select 'Choose Activity’ type 'NGCM - Send Letter'
3) In the task description enter: list the title of the letter, information sheets and other relevant attachments that need to be printed out and included with the letter
4) Review "When to use ‘high’ priority indicator on the tasks sent to Recovery Administration" rules to determine priority of the task. Change the priority indicator to 'high' if your sce-
nario meets the rules.
5) Close
6) Open 'NGCM - Client Welcome Conversation' task then select 'Cancel' button.
When to use ‘high’ priority indicator on the tasks sent to Recovery Administration
NOTE What if the client's preferred method of communication is by post but postal address is not verified but a valid address?
Send the decision letter (attempt to verify is best practice) - add into the Send Letter task instructions along the lines of can send to this valid unverified address. This is not say that
you would never obtain verification if there is a need to do so.
1) In Eos, go to 'Add Sub Case' and Select 'Recovery Plan'
2) From Recovery Plan Select 'Add Activity'. Then select 'Choose Activity’ type 'NGCM - Send Letter'
3) In the task description enter: Address valid but unverified - cover decision letter - please send
a) address valid but unverified - cover decision letter - please send
b) list the title of the letter, information sheets and other relevant attachments that need to be printed out and included with the letter
4) Review "When to use ‘high’ priority indicator on the tasks sent to Recovery Administration" rules to determine priority of the task. Change the priority indicator to 'high' if your sce-
nario meets the rules.
5) Close
6) Open 'NGCM - Client Welcome Conversation' task then select 'Cancel' button.
NOTE What if the client's postal address is not valid and not verified?
Contact the client or person acting on the client's behalf by their preferred method of communication. There must be an Authority to Act (ATA) on file if contacting someone other
than the client.
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NOTE How many contact attempts should be made?
• Two attempts to contact client/ATA by phone, on different days/times.
NOTE What if unable to verify an invalid client's postal address?
Do not send the decision letter. Document this on Contact tab – 'Decision letter not sent as postal address not valid and not verified'.
NOTE What if the client/ATA provided us with a returned/signed
ACC6300 or client/ATA contacted ACC following response to TI73?
It would be reasonable at this stage to change or Update Client Address to verified. Then send decision letter.
PROCESS Update Client Address
NOTE What if the client's preferred method of communication is by email?
Must be a verified email address.
Follow 'Send an email with an Eos document' system steps.
Send an email with an Eos document (Eos Online Help)
4.0 Finalise Eos records
Cover Assessor, Specialist Cover Assessor
a In Eos, in the 'General' tab update Cover Status, Cover Status Reason and Accident Date & Time.
NOTE What if it is PICBA?
• In Eos, in the 'General' tab, in Cover Details section, update Cover Status and Cover Status Reason. If claim is accepted, set the Send Auto Accept Letters to 'Yes'.
• In Eos, in the 'General' tab, in Claim Type section take the tick off 'Treatment Injury'. Then fund code will change to 'Non-Earners' or 'Earners' depending on how the 'Employment'
tab has been set.
NOTE What if the claim is withdrawn?
• In Eos, in the 'General' tab, in Cover Details section, update Cover Status and Cover Status Reason.
• In Eos, in the ‘Injury Details’ tab, sub tab ‘Injury Diagnosis’ and ‘What treatment gave rise to the injury’ tab - write Claim withdrawn.
• In Eos, in ‘Treatment Context’ tab, sub tab ‘Treatment Context’, ‘Event’ and ‘Primary Injury’ tabs – write Unknown/lack of information.
• In Eos, in the ‘Cover decision’ tab, sub tab ‘Cover status - Personal Injury’ – select ‘Unknown’. In ‘Cover Decision Details’ tab, sub tab ‘Describe how you arrived at your decision…’
– write ‘Claim withdrawn’. In ‘Cover Decision’ sub tab – select ‘Declined – Withdrawn’.
b In Eos, in the 'Contacts' tab, add a contact to note any key points from the conversation with the client if applicable.
c In Eos, check the documents have not been left ‘incomplete’. All documents must be completed prior to transfer.
d In Eos, check all cover related tasks are closed.
e Go to 'Match Claim to Recovery Team' process.
NOTE What if the claim is declined?
• transfer claim to TIC Actioned Cases department.
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NOTE What if there are open tasks for support and or entitlements?
• Request for Nursing Services - Forward the task to the 'Elective SC – TMT Assessment dept' queue.
• Request for dental treatment - Forward the task to the ‘Dental Claims’ department queue.
• Request for hearing loss treatment or aids - Forward the task to the ‘Hearing Loss Claims’ department queue.
• Request for elective surgery - Forward the task to the ‘Elective SC – Surgery Triage’ department queue.
• Request for Independence Allowance/Lump Sum - Forward the task to the ‘Hamilton SC – IA/Lump Sum’ department queue.
• Request for orthotics - Forward the task to the ‘Hamilton SC – Orthotics’ department queue.
• Request for reimbursement costs
- Travel costs - Forward the task to the ‘Hamilton SC Transport’ department queue
- Pharmaceuticals - Forward the task to the ‘Elective SC – Claimant Reimbursements' department queue.
Move claim to actioned cases (Eos Online Help)
NOTE What if the claim is a staff claim?
Transfer the claim to the Staff Claims Unit department queue
NOTE What if it is a fatal claim (as the client has died as a result of their injuries)?
• transfer claim to the Accidental Death Claims department queue
• give the department a call to notify.
Accidental death team - contact details
NOTE What if the client's condition is rapidly deteriorating and the client is eligible for Independence Allowance/Lump Sum?
1) In Eos, create 'General task'
2) Add in the task description [Rapidly deteriorating client]
3) Set the target date to the current date
4) Set priority as 'High'
5) Send the task to 'Hamilton SC- IA/Lump Sum' queue
NOTE What if there is a previously declined mental injury related to the physical injury you have assessed?
If there is a previously declined mental injury, and you have accepted the physical injury for cover:
1) In Eos, generate 'Follow-up cover' task on the declined mental injury claim
2) Add in the task description [re-assessment required for mental injury, physical injury caused by treatment has been accepted for cover]
3) Set priority as 'High'
4) Send the task to Supported Recovery Team
If there is a previously declined mental injury, and you have declined the physical injury for cover:
1) Re-open the declined mental injury claim (you'll need to discuss with the client and seek the client's permission to re-open the declined mental injury claim. Once re-opened, you
will assess it as treatment injury mental injury claim (TIMI)
2) Go to 'Assess Claim for Cover (Treatment Injury)' to assess Treatment Injury Mental Injury
PROCESS Assess Claim for Cover (Treatment Injury)
PROCESS
Match Claim to Recovery Team
Cover Assessor, Specialist Cover Assessor
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Treatment injury claims v7.0
Summary
Objective
A treatment injury is a personal injury arising from treatment that meets ACC’s Cover criteria for treatment injury.
Owner
9(2)(a)
Expert
9(2)(a)
Policy
1.0 Treatment injury claim identification
a A treatment injury claim may be identified by any of the following:
• text on the ACC45 ACC Injury claim form (ACC45) stating the client has an existing physical injury claim, and while receiving treatment for this injury, incurred a further injury
• the key words ‘treatment’, ‘medical’, ‘hospital’, ‘surgery’, ‘physiotherapy’, ‘chiropractor’ or ‘doctor’ appearing on the ACC45
• a tick in the ‘Is this claim for treatment injury?’ box on the ACC45 or the ‘Medical misadventure’ box on older ACC45s
• material accompanying the ACC45, eg the ACC2152 Treatment Injury Claim (123K) form and any medical notes.
ACC2152 Treatment Injury Claim
2.0 The difference between consequential injury and treatment injury
a The key point in the difference between a treatment injury and a consequential injury is understanding what the treatment is provided for, that gives rise to the claimed new injury:
• if the treatment is for an underlying condition and the person suffers new injury from the treatment provided by a registered health professional , it is considered under the treatment injury
provisions (s32 of the AC Act 2001)
• if the treatment is for a covered ACC injury and the person suffers new injury from the treatment, it is considered under the consequential injury criteria (s20(2)(d) & (h)) – TI delegation to
determine cover
• if the person has a covered ACC injury and that injury through gradual process, disease or infection develops into another injury, this is a consequential injury that the branch has dele-
gation to determine cover [as there is no intervening treatment that gives rise to the additional injury] (s20(2)(g).
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3.0 Lodgement date
a A claim for treatment injury must be lodged within 12 months of the later of:
• the date the registered health professional (RHP) first considered the personal injury to be a treatment injury
• the date the client suffered the injury as determined under the AC Act 2001, Section 38.
4.0 Late lodgement
a ACC must not decline a claim on the grounds that it was lodged late, unless the claim’s lateness prejudices the ability of ACC to determine cover. See Eligibility of late claims.
Eligibility of late claims Policy
5.0 Transitional claims
a If a client lodges a claim for the first time on or after 1 July 2005, apply the treatment injury rules. The rules for medical misadventure apply to claims lodged before 1 July 2005.
Cover criteria for medical misadventure Policy
6.0 Exception
a We can consider a claim under the treatment injury provisions if it was lodged on or after 1 July 2005 and previously declined under the medical misadventure rules if no personal injury was
established at the time, but a personal injury arises after the claim was declined from that past incident. The personal injury could arise before or after 1 July 2005.
NOTE Example
After a period of hospitalisation before 1 July 2005, a client is diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA) but they have no symptoms at the time. Some
time after 1 July 2005 they develop a serious infection. A personal injury becomes present so their claim can be considered under the treatment injury provisions.
7.0 Forwarding treatment injury claims
a When you receive a treatment injury claim, you must capture the details as a new claim and forward any hard copy materials to the Treatment Injury Centre. This includes any material
accompanying the ACC45, eg the ACC2152 Treatment Injury Claim (123K) form and any medical notes.
Specialist staff in the Treatment Injury Centre assess the claim and make the cover decision.
You must:
• refer any enquiries about treatment injury claims to the Treatment Injury Centre
• ensure any material that accompanied the ACC45, eg the ACC2152 and clinical notes, is clearly marked with the claim number or ACC45 number.
See Receiving and streaming treatment injury claim for further information.
Receiving and streaming treatment injury claim Policy
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8.0 The Accident Compensation (Definitions) Regulations 2019 and determining treatment injury cover
a The Accident Compensation (Definitions) Regulations 2019 moved the key definitions of ‘registered health professional’ and ‘treatment provider’ and associated definitions from the Accident
Compensation Act 2001 to standalone regulations.
b The Accident Compensation (Definitions) Regulations 2019 took effect on 01/10/2019.
c When assessing cover for Treatment Injury, we need to determine the date of injury based on when a person first seeks treatment for the signs or symptoms of their injury. So a claim may
be lodged after 1/10/2019, but have an earlier date of injury.
d The relevant date to consider whether someone was an RHP is the date of the treatment. If a client claims after 01/10/2019 for an event occurring earlier the amendment does not apply.
The changes are not retrospective.
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Accept Claim v16.0
Triggers & Inputs
Cover Assessor
1.0
2.0
3.0
Lodgement Administrator
Confirm injury
Communicate
Update cover
Recovery Assistant
outcome status
cover decision
status
Recovery Coordinator
Recovery Partner
4.0
Generate and
send CVR40 cover
letter and CVR48
Employer
Eos
Outputs
4.1
Send electronic
cover notification
4.2
Match Claim to
Recovery Team
Cover Assessor
Lodgement Administrator
Recovery Team Member
Linked Process
Match Claim to
Recovery Team
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Accept Claim v16.0
Summary
Objective
To advise a client that we've accepted their claim. This process addresses accepting PICBA claims only, it does not include accepting specialist claims.
Background
A staff member has investigated a claim and determined that it meets criteria for cover and can accept it.
Owner
9(2)(a)
Expert
9(2)(a)
Procedure
1.0 Confirm injury outcome status
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Review the outcome status of the injury or injuries in Eos and update if necessary. The default outcome status is Provisional however this should be updated to Approved or Declined in cer-
tain scenarios. See the Injury outcome status definitions guide below.
Injury outcome status definitions
NOTE What if ACC is accepting some of the injuries but declining others?
Leave the outcome status for the accepted injuries as Provisional and update the outcome status for the injuries you're declining to Declined.
NOTE: If you've received medical records that confirm the injury or injuries being covered, then you must change the outcome status for the accepted injuries to Approved after
you've created the CVR43 cover letter. This is because Eos will only populate the details of the accepted injuries in the letter when the outcome status is Provisional.
Assign an outcome status and an outcome date to an injury code
2.0 Communicate cover decision
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Determine which cover letter should be sent to the client using the guide below.
Cover Letter Quick Reference Guide
NOTE What if the guide says you should send the automatic CVR40 letter?
- Ensure the Send Auto Accept Letters radio button is set to Yes.
- Go to step 3.0 to update the cover status in Eos.
NOTE What if the guide says you should create and send a letter that is not the automatic CVR40 (ie CVR43, CVR45, CVR47, CVR70, WSI02 or CVR41)?
- Ensure the Send Auto Accept Letters radio button is set to No.
b Generate the relevant accept cover letter in Eos that you identified using the guide above.
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NOTE What if the claim is for a mental injury?
Go to the Issue Recovery Decision process
PROCESS Issue Recovery Decision
Upload an Incomplete Electronic Document
NOTE What if the client's address is not verified? - FOR CLAIMS ASSESSMENT
- If the address is verified but not valid, it is okay to send a letter to the client. However, if speaking with the client as part of the assessment process, please ensure the address de-
tails are verified.
- If the address is not verified and not valid, add a note in the contact for the document stating: 'Letter not sent to client as address is invalid.' Send a copy of the accept cover letter
to the provider who lodged the claim instead.
NOTE CLIENT ADMINISTRATION - when working on sending information for Claims Assessment. Continue to send to unverified addresses.
NOTE What if the client address is not verified - FOR RECOVERY TEAM MEMBERS
-If an address is verified the letter can be sent regardless of whether the address is valid or invalid
-If an address is not verified the letter cannot be sent regardless of whether the address is valid or invalid. Add a note in the contact for the document stating: 'Letter not sent to
client as address is invalid.' Send a copy of the accept cover letter to the provider who lodged the claim instead.
c Print and sign the letter.
d Add the Working Together information sheet.
ACC255 Kōrero mai - Working together
e Complete a privacy check to ensure you are only sending information to the client that is relevant to this claim.
NOTE Do I have to complete the privacy check myself?
In some business units a separate team will complete this privacy check. Ask your manager if this is the case for your team. If there is not a separate team responsible for privacy
checking you will need to complete the check yourself.
NOTE What if I'm only accepting some of the injuries but declining others?
Now that you've created the CVR43 cover letter, you can update the injury outcome status for the accepted injuries to Approved if you've received medical records that confirm the
injuries. If you haven't received medical records that confirm the injuries then leave the outcome status for the accepted injuries as Provisional.
3.0 Update cover status
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a In Eos, change the cover status to Accept and update the cover status reason to Criteria for Cover are met.
NOTE What if the claim is for a wilfully self-inflicted injury (WSI)?
Include the following statement in the cover status change reason:
Cover accepted for physical injuries - if entitlements sought must be investigated for wilfully self inflicted by managing department.
Update Cover Status
b Add a contact to the claim explaining your cover decision rationale.
Add a client contact
c Close the Confirm Cover Decision task.
Close a Task
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NOTE What if I've received a Notification Decision task?
You've received this task because the claim has a specialist claim type (WRGPDI, Hearing Loss, Mental Injury, Work Related Mental Injury, Treatment Injury, Dental). In general, it's
good practice to send the automatic electronic notification to the client informing them that their claim has been accepted. However in some instances it might not be necessary, for
example you may have just confirmed cover over the phone with them.
- If you want to send notification, close the Notification Decision task and select Send Notification when prompted.
- If you don't want to send notification, close the Notif
ication Decision task and select Discard Notification when prompted.
Note that Sensitive and Fatal claim types will never be sent automatic notification, and electronic notification is automatically sent for PICBA claims.
NOTE Why does a new Confirm Cover task get created?
Before you can successfully close the Confirm Cover task all Information Required tasks need to be actioned and closed. You also need to change the Cover Status on the General
Screen to "Accept". If you close the Confirm Cover task before these steps have been undertaken a new Confirm Cover task will be created.
4.0 Generate and send CVR40 cover letter and CVR48 Employer Notification letter (if applicable)
Eos
a If the Send Auto Accept Letters radio button is set to Yes and the cover status has been updated to Accept, then the CVR40 cover letter will be automatically generated. Eos transfers the
letter data to an external mail house who print and send the letter to the client.
b If the claim is accepted and is a work-related injury, then the CVR48 Employer Notification letter will be automatically generated. Eos transfers the letter data to an external mail house who
print and send the letter to the client's employer.
NOTE What if the employer is noted as being Proxy, and we receive updated details?
Review Identify Clients Employer - Step 2.0
PROCESS Identify Client's Employer
4.1 Send electronic cover notification
Eos
a An electronic notification is automatically sent to the client that confirms their claim has been accepted. Note that there are some situations where this notification is prevented, for example if
the claim type is Fatal or Sensitive, if the client is a minor or deceased, if the claim is managed by the Remote Claims Unit or Te Ara Tika (previously Wellington Central Branch), if the client
has a Safe Contact on their party record, if the Stop Notifications attribute on the client's party record is set to Yes etc.
4.2 Match Claim to Recovery Team
Cover Assessor, Lodgement Administrator, Recovery Team Member
a Use this process to determine the appropriate team to manage the client and their recovery.
PROCESS
Match Claim to Recovery Team
Cover Assessor, Lodgement Administrator, Recovery Team Member
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Receive and Input Manual Claim :: Email v27.0
Triggers & Inputs
1.0
2.0
Linked Process
3.0
Receive claim
Input claim data
Identify Client
Complete claim
Lodgement Administrator
lodgement
Outputs
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Receive and Input Manual Claim :: Email v27.0
Summary
Objective
To capture ACC45, ACC46 and ACC46N manual claim forms received via email into Eos on behalf of the provider and then prepare the forms for further document management. This can also in-
clude forms that a Provider faxes to ACC which are received as an email.
Background
A Provider has submitted a claim form to ACC manually by emailing it directly to ACC.
Emailed manual claims are completed in a priority order of:
1) Fatals/Accidental Death Unit (ACC21)
2) Early Cover (ACC7422) and Urgent
3) Pre-1982 claims
4) Treatment Injury (ACC2152) & Sensitive Claims
5) Assistance Required/Time off (ACC18s)
Owner
9(2)(a)
Expert
9(2)(a)
Procedure
1.0 Receive claim
Lodgement Administrator
a Filter the Registration Inbox to prioritise the processing order.
b Read the email content and attachments.
NOTE What if the email has no attachments?
Respond to the email and/or request the claim form from the sender.
NOTE What if it's a returned Accredited Employer claim?
Go to Action Returned Accredited Employer Claim. This process ends.
PROCESS Action Returned Accredited Employer Claim
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NOTE What if the email is from MFAT (Ministry of Foreign Affairs & Trade) or an Embassy?
If the email is from a staff member posted overseas, we still need to register their claim.
We will also register claims on behalf of their family members – usually the email will still come from the MFAT staff member
- Lodge the claim using a dummy number
- If there is insufficient information on the email from the client regarding their personal details
(eg. Date of birth, Middle name etc.), Please respond to the email and get clarifying details.
If the client has not attached enough information about the accident – please clarify this, this could be done by requesting a medical certificate or doctors notes to show they have
sought treatment.
If the client has supplied an address, then please update their details otherwise leave all information as it is.
- Let the claim stream to Cover Triage for assessment and suppress the letters
NOTE What if I'm unable to resolve the email without gathering further information?
Contact the relevant party to gather the necessary information, to update the next person in the team who may pick up the follow up action on the email edit the email adding the
reason it is flagged so it's clear about what action was taken and why. Steps to edit the email are: Open email (double click) > Actions > Edit email > Write and highlight reason
email is flagged > Close. Once the email has been processed and completed repeat previous steps but erase comment added. This process then continues.
NOTE What if we have received a ACC2152 (Treatment Injury) with no ACC45/42 form attached?
Please respond back to the email/task sender to request a copy of the ACC45/42 as we cannot lodge a treatment injury claim without this.
c Go to step 2.0 Input claim data if the email has an attached ACC45, ACC45+ACC18, ACC46 or ACC46N.
NOTE What if it's an ACC18 Medical Certificate only?
Go to Complete ACC18 Medical Certificate Request process.
PROCESS Complete ACC18 Medical Certificate Request
NOTE What if it's an ACC42 Dental claim form?
Go to Receive and Input Manual Claim: Dental process variation.
PROCESS Receive and Input Manual Claim :: Dental
NOTE What if it's an Early Cover request (ACC7422 Early cover application form)
Go to Receive and Input Manual Claim: Early Cover process variation.
PROCESS Receive and Input Manual Claim :: Early Cover
d Go to step 3.0 Complete claim lodgement if the email has an attached ACC2152.
2.0 Input claim data
Lodgement Administrator
a In Eos, attribute the client (if you can), using Identify Client process.
Identify Client
b Enter the remaining information on the claim form into the relevant fields.
Complete claim intake form
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NOTE What if you can see information or inconsistencies on the claim form that you can correct now so that they don’t trigger an IR?
Correct the information when you’re entering it in Eos.
Corrections can include:
• when the diagnosis side isn’t selected - but the injury description makes it clear what the selection should be.
• if the formatting of the address is wrong, (eg St use
d instead of Street) or address information has been entered in the wrong fields in the form.
NOTE What if there is no accident description listed on the claim form?
This will not drop out as an Information Required Task.
Please follow up with the provider or the client at the time of registration as we need to know how the accident occured.
If this has been picked up with another IR task then please confirm before completing the outstanding IR.
NOTE What if the claim form was lodged with ACC (ie received) prior to the date of claim intake?
Amend the date of lodgement in the claim intake form to the date that the claim form was received by ACC.
NOTE What if the answer to “Is this a work-related gradual process, disease or injury?” is Yes?
Add 'WRGP' to [Additional Injury Comments] to ensure that it matches to the Gradual Process team.
NOTE What if the Provider hasn't signed the claim form? (eg they've stamped the form instead)
Tick the ‘Claimant/representative has not signed the form’ box to No and leave the Provider ID field blank.
Even though this tick box is typically used for when clients do not sign the form, this will raise a Missing Signature IR as opposed to a Provider Invalid for Registration IR.
NOTE What if the Provider has signed the form, however there are no other provider details?
We must investigate who the provider is as we need to check for provider competencies.
Leave the Provider ID field blank and push through as this will raise a Provider Invalid for Registration IR and then try the following:
- Check inFact reporting to check the batch numbers to see if we can see a provider trend/match signature
- Check claim numbers before and after your claim to see if the provider details are the same
- Call the client to confirm where they were seen
NOTE When is it appropriate to use the Default Provider (J99966) ID?
- When it is a Sensitive Claim/Sensitive Engagement Form
- When it is a Treatment injury but there isn’t any additional information as to where they were seen
- When it is an Additional Claim for Lodgement.
- Helicopters - with the appropriate vendor ID in the vendor ID box.
- Prisons – make a registration note on the general screen with the prison and provider that the client was seen by (eg: Christchurch Men’s Prison, Dr John Smith).
NOTE What if more than one ethnicity has been selected on the claim form?
Please select all ethnicities listed on the ACC45/ACC42 form
c Click [NEXT] on the claim intake form to save the changes.
NOTE What if the ACC45 is for a Sensitive Claim?
The date of accident should be the date of consultation.
PROCESS
Identify Client
Lodgement Administrator
ACC > Claims Management > Manage Claim Registration and Cover Decision > Register Claim > Receive and Input Manual Claim :: Email
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3.0 Complete claim lodgement
Lodgement Administrator
a Check there is no Missing Information for Cover task once the claim has progressed through automation.
NOTE What if there is a Missing Information for Cover task?
Resolve the information requirements in the task using
the relevant Validate Claim processes.
b Close out of the Eos screen and out of the PDF attachments.
c Determine what to do with the email.
NOTE How do you determine what to do with the email?
• For ACC45/ACC42 attachments only, forward email to [email address].
• For ACC2152 attachments (email may also include ACC45), forward email to [email address].
• For ACC18 requests, go to Complete ACC18 Medical Certificate Request process.
PROCESS Complete ACC18 Medical Certificate Request
NOTE What if the claim number of client party details aren't clear in the body of the email or attachment that you're forwarding on to be processed?
To assist with ease of processing, please add these details to the body of the email which you forward on.
d Move email into Completed [current year] sub-folder in the Registration Email Inbox.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Register Claim > Receive and Input Manual Claim :: Email
Uncontrolled Copy Only : Version 27.0 : Last Edited Tuesday, July 27, 2021 1:20 PM : Printed Tuesday, September 28, 2021 2:34 PM
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Receive and Input Manual Claim - New claim lodgement with no claim form :: No claim
form v14.0
Triggers & Inputs
1.0
2.0
3.0
Receive claim
Input claim data
Complete claim
Lodgement Administrator
lodgement
Outputs
ACC > Claims Management > Manage Claim Registration and Cover Decision > Register Claim > Receive and Input Manual Claim - New claim lodgement with no claim form :: No claim form
Uncontrolled Copy Only : Version 14.0 : Last Edited Thursday, April 15, 2021 8:59 AM : Printed Tuesday, September 28, 2021 2:16 PM
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Receive and Input Manual Claim - New claim lodgement with no claim form :: No claim
form v14.0
Summary
Objective
To capture new claims requested by internal staff into Eos and file the relevant information
Background
In certain circumstances it’s necessary to create a new claim In these cases, there will be no standard ACC claim form so the information must be provided another way
Owner
9(2)(a)
Expert
9(2)(a)
Procedure
1.0 Receive claim
Lodgement Administrator
a Open the Registration Email Inbox and access the new claim request.
b Read the email content and any attachment(s).
NOTE What if the email doesn't have all the information I need?
Reply to the email and request the information from the sender.
c Confirm that the request meets the criteria for a new claim to be lodged
NOTE What’s the criteria for a new claim to be lodged?
A new claim may be lodged only if all of the following are true:
• The client has consented to the new claim being lodged via any of the following methods:
o verbally
o in writing
• and at least one of the following is true:
o the date of accident of the new claim is different from the date of accident of the claim that the client is currently being treated for
o the accident description of the new claim is different from the accident description of the claim that the client is currently being treated
o the claim contains at least one of the following types of claim:
complicated claim
non-complicated claim
Non-complicated claim definition
Complicated claim definition
NOTE What if the claim doesn’t meet the criteria for a new claim?
Return the request to the requestor for them to gather more information or cancel the request
d Confirm that you have all the information you need to register a new claim
ACC > Claims Management > Manage Claim Registration and Cover Decision > Register Claim > Receive and Input Manual Claim - New claim lodgement with no claim form :: No claim form
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NOTE What information do I need to register the claim?
A request for a new claim must contain all of the following information relating to the client:
• Person ID
• First name of client
• Surname of client
• Date of birth of client
• NHI number of client
• Fund code of new claim
• Accident description of new claim
• Date new injury identified
• Provider name
• ACC provider number
• Full name of the person submitting the request for a new claim
• Title of the person submitting the request for the new claim
• Date the request for a new claim was submitted
• The name of the ACC business unit submitting the request for a new claim
• The ACC45 number of the original claim, if there is one
• The name of the staff member if the new claim needs to be transferred to a specific person
• At least one of the following for the new claim:
o read code
o injury description
o injury diagnosis
• A copy of at least one of the following:
o Document where the injury is recorded
o Clinical notes with the relevant page number noted
o Instruction from the Technical Services team
o Medical Advisor comment
NOTE A request for a new claim may be on the Referral for new claim lodgement form
Referral for New Claim Lodgement
NOTE What if the email doesn't have all the information I need?
Reply to the email and request the information from the sender.
NOTE What if the email is from MFAT (Ministry of Foreign Affairs & Trade) or an Embassy?
If the email is from a staff member posted overseas, we still need to register their claim.
We will also register claims on behalf of their family members – usually the email will still come from the MFAT staff member
- Lodge the claim using a dummy number
- If there is insufficient information on the email from the client regarding their personal details
(eg. Date of birth, Middle name etc.), Please respond to the email and get clarifying details.
If the client has not attached enough information about the accident – please clarify this, this could be done by requesting a medical certificate or doctors notes to show they have
sought treatment.
If the client has supplied an address, then please update their details otherwise leave all information as it is.
- Let the claim stream to Cover Triage for assessment and suppress the letters
ACC > Claims Management > Manage Claim Registration and Cover Decision > Register Claim > Receive and Input Manual Claim - New claim lodgement with no claim form :: No claim form
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2.0 Input claim data
Lodgement Administrator
a In Eos, open the client's party record. See the Client Searches guide below.
Client searches
b Turn off notifications.
Stop notifications
c Request a Dummy ACC45 number using the Request Dummy 45 tool.
Request Dummy 45 spreadsheet
d In the reason for request box in the Request Dummy 45 tool, type: 'Referral for new claim lodgement'
e In Eos, enter the new claim information into the relevant fields.
NOTE What if it's been identified that it's a work related gradual process, disease or injury?
Add 'WRGP' to Additional Injury Comments to ensure that it streams to the Gradual Process team.
f In Part E, enter the default provider number (J99966) so that the claim receives a Held cover status.
g Click NEXT on the claim intake form to save the changes.
h Reopen the new claim and action any information requirements.
i Once the claim has a 'Registration Complete' status, remove the default provider and replace with the actual provider from the ACC45.
NOTE What if the claim has been streamed to a specialist department?
Transfer the claim to your queue (or contact the relevant department to ask for it to be transferred to your queue if you're not able to transfer it yourself).
j In Eos, upload any documents that came with the request to the claim.
File an inbound email
NOTE What document type should I use in Eos?
- Miscellaneous claims: VCF011 Internal document
- Sensitive claims: SC VCF011
NOTE What information should I include when I'm uploading and where?
- Contact details: Referral for new claim lodgement
- Status: Received
- Direction: Internal
- Reason: Contact with Internal Party
- Description: Referral for new claim lodgement
k Confirm cover status
- If meant to be Held, then transfer to relevant person or team.
- If meant to be Accept, then amend cover status to Accept and suppress auto accept letter.
l Open the client's party record and turn notifications on.
m Confirm to the requestor that you've created the new claim and advise of any changes or default info you had to use.
3.0 Complete claim lodgement
Lodgement Administrator
a Close out of the Eos screen and any related documents.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Register Claim > Receive and Input Manual Claim - New claim lodgement with no claim form :: No claim form
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b Move email into Completed [current year] sub-folder in the Registration Email Inbox.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Register Claim > Receive and Input Manual Claim - New claim lodgement with no claim form :: No claim form
Uncontrolled Copy Only : Version 14.0 : Last Edited Thursday, April 15, 2021 8:59 AM : Printed Tuesday, September 28, 2021 2:16 PM
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Your claim number is
[Claim number auto]
Date auto
Client Title Auto Client Full Name Auto
Additional Recipient Reference Auto
Address Line 1 Auto
Address Line 2 Auto
Suburb Auto
Town Or City Auto Post Code Auto
Dear Client Title Auto Client Surname Auto
We need more time to consider your claim
[Option 1] We’re still working on getting [information] from your [source of information]. It’s
important we have this information as it wil help us assess your claim.
We’l be in touch with you as soon as possible and advise that we are required to make a decision
by [date - 4 months from lodgement].
[Option 2] We’re stil working on getting the following information from your [source of information]:
• [information]
• [information]
It’s important we have this information as it wil help us assess your claim.
We’l be in touch with you as soon as possible and advise that we are required to make a decision
by [date - 4 months from lodgement].
[Option 3] We have received the following information from your [source of information]:
• [information]
• [information]
However, we’re stil working on getting the following information from [source of information]:
• [information]
• [information]
It’s important we have this information as it wil help us assess your claim.
We’l be in touch with you as soon as possible and advise that we are required to make a decision
by [date - 4 months from lodgement].
We’re happy to answer your questions
Please call me on [CONTACT_DETAILS] if you would like to talk about this letter. I’l be able to
help you faster if you have your claim number (LEGACY_CASE_ID auto) ready.
CVR30
Yours sincerely
[Staff_Name auto]
[Job Title auto]
Telephone: [CONTACT_DETAILS]
CVR30
Your claim number
LEGACY_CASE_ID
1 July 1974
CLM_TITLE
Claimant_First_Name Claimant_Surname
Claimant_Line1
Claimant_Line2
Claimant_Line3
Claimant_Line4
Dear CLM_TITLE Claimant_Surname
We need your agreement for more time to consider your claim
[Option 1] We’re still working on getting [information] from your [source of information]. It’s important
we have this information as it will help us assess your claim.
[Option 2] We’re still working on getting the following information from your [source of information]:
• [information]
• [information]
It’s important we have this information as it will help us assess your claim.
[Option 3] We have received the following information from your [source of information]:
• [information]
• [information]
However, we’re still working on getting the following information from [source of information]:
• [information]
• [information]
It’s important we have this information as it will help us assess your claim.
Why we need your agreement
The law gives ACC a limited period of time in which to assess claims. If we need longer than this, we
must ask for your agreement.
Although we will try to make a decision on your claim as soon as possible, we are asking for your
agreement to have until [9 months from lodgement date] to give us enough time to collect all the
information we need.
CVR31CLT
If we don’t have this information, we will have to use the information we currently have to make a
decision on your claim.
What happens now
If you agree to give us more time, please fill out the attached
Time extension to determine cover form
and return it in the enclosed reply-paid envelope by [date].
We’re happy to answer your questions
Please call me on
[CONTACT_DETAILS] if you would like to talk about this letter. I’ll be able to help
you faster if you have your claim number (
LEGACY_CASE_ID) ready.
Yours sincerely
Staff_Name
Job Title
Telephone: CONTACT_DETAILS
Encl.
Time extension to determine cover (ACC109), reply-paid envelope
CVR31CLT
“Use this form to agree or
ACC
disagree to a time
109
Request for time extension extension for ACC to
make a decision on your
claim”
Please read the statements below and tick one box.
I agree to an extension of time from [from date] to [to date]. This wil enable ACC to
gather required information to enable a decision to be made on my claim.
Or
I do not agree to an extension of time. I ask ACC to make a decision based on
available information.
Signed ........................................................................
Date ……./……./……..
CLAIMANT FULL NAME
Claim number: LEGACY_CASE_ID
CVR31CLT
Document Outline
