GOV 027796 appendix 1.pdf

GOV-027796 Appendix 1
Seek External Clinical Advice v24.0
reatment
T
10.0
Determine next steps
Linked Process
Make cover or funding decision :: Make Injury cover decision
9.0
Review report
8.0
Follow up request for external clinical advice
6.0
Create purchase order
7.0
Create and send referral documents
5.0
Identify available ECA
3.0
Request external clinical advice referral
4.0
Review referral task
2.0
Contact client or representative and explain need for external clinical
riggers & Inputs
T
1.0
Determine external clinical advice required
Assessor
Assessor
Assessor
Administrator
Administrator
Assessor
Specialist Cover
Recovery
Recovery
Specialist Cover
Cover
Specialist Cover
ACC > Claims Management > Manage Claims > Gather Additional Information or Advice > Seek External Clinical Advice
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Page 1 of 8

GOV-027796 Appendix 1
Seek External Clinical Advice v24.0
NOTE How do you identify the specialty of ECA
Summary
needed?
• Identify the consultant that the care was pro-
Objective
vided under.
To request a report from an independent third-party provider
answering questions on the standard of care (if relevant), phys-
Be mindful that this is not always the most
ical injury, causation, background population risk (necessary
appropriate speciality to provide comment (eg.
part of treatment), ordinary consequence of treatment etc.
client had
cardiothoracic surgery and developed a bacte-
Background
raemia, which then resulted in a sternal wound
External Clinical Advice (ECA) is an opinion solely based on
infection). It may be more appropriate to seek
the paper file review from an independent provider. It helps to
advice from an infectious diseases physician in
answer the questions on the standard of care (if relevant), phys-
this
ical injury, causation, background population risk (necessary
case.
part of treatment), ordinary consequence of treatment etc.
• Look up their ECA speciality and sub speciality
The ECA’s role is to comment on clinical facts, accepted stan-
to ensure that you are seeking advice from a
dard practice, whether a failure has occurred and likelihood of
peer with
an injury occurring, taking into account the particular clients
similar training and registrations - (eg when
contributing factors.
considering cases where the treatment has been
provided at a rural hospital, be mindful that a
ECA's do not interpret the legislation. It is the role of the Spe-
rural hospital does not have emergency physi-
cialist Cover Assessor (SCA) and Cover Assessor (CA) to in-
cians in
terpret the legislation against the clinical facts, and obtain fur-
their emergency department which is usually run
ther internal advice if required.
by Rural Health General Practitioners).
• An ECA provider cannot provide comment on
Owner
[Out of Scope]
another practitioner's care if they do not have the
Expert
[Out of Scope]
same qualifications - (eg. an Obstetrician should
not be providing comment on the standard of
Midwifery care, we should be seeking comment
Procedure
from a Midwifery ECA if this is required).
1.0 Determine external clinical advice required
NOTE Where can you access a list of ECA discip-
Specialist Cover Assessor
lines and specialities?
a Confirm ECA is required.
Click on the link below and navigate to the Pro-
vider details.
NOTE When would you seek ECA?
• When you need specialised advice regarding
Treatment Injury ECA Referral tool
failure, standard of care, appropriateness of the
NOTE What if you are unsure of the correct ECA
chosen
discipline and/or speciality to use?
treatment pathway, identification of a physical
Go To 'Seek Internal Guidance' process. Use
injury, causation and determining what contri-
Tier 1 (self service) and Tier 2 (Hotline) guidance
bution patient
process.
specific factors had in contributing to developing
PROCESS Seek Internal Guidance
an injury and that advice would help you to
determine
NOTE Can you request an ECA provider by name?
cover.
• You can instruct Recovery Administration on
• When you've had a conversation with a Review
the medical discipline and speciality required.
Specialist or following internal guidance and you
The Recovery Administrator will then select the
determine external clinical advice is needed.
next available provider, with the discipline and
• You are not required to seek internal clinical
speciality required, that has capacity to receive a
advice before accessing external clinical advice.
referral.
b Identify the speciality of ECA needed.
• You can request an ECA provider by name, if
that provider has previously provided ECA
advice on the same claim.
2.0 Contact client or representative and explain
need for external clinical advice
Specialist Cover Assessor
a Contact the client and confirm you are speaking with the
right person by asking ACC's identity check questions.
Identity Check Policy
b Explain that you are referring for external clinical advice,
the reason seeking advice, what information will be in-
cluded in the referral, what the advice will be used for
and the possible outcomes.
ACC > Claims Management > Manage Claims > Gather Additional Information or Advice > Seek External Clinical Advice
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GOV-027796 Appendix 1
NOTE What else do you need to make the client
NOTE What if there are documents incorrectly on
aware of?
other claims that need to be moved to the
• timeframe of when you expect to receive the
correct claim that has the referral-specific
written advice.
document group?
• that sometimes the ECA may confer with other
To move documents from another claim to the
similar experienced vocationally registered
correct claim see the system steps below for
health professionals, eg. a blind review
Move a Document to Another Claim.
• next steps after receipt of the written advice.
Move a Document to Another Claim
NOTE What if the client does not agree to proceed
NOTE What if there are documents from other
to ECA?
claims that are relevant to the assessment?
Find out why the client does not want to proceed
When a request for a referral is required and
to ECA and consider their reasoning and alter-
there are additional supporting documents on
natives which may include making a cover deci-
another claim, it is important to upload a copy of
sion based on the clinical information that is held
the documents to the claim that has the docu-
on the claim. Agree with the client the next step.
ment group. This will ensure the right documents
c In Eos, add a contact note as a record of the conver-
support the cover decisions for each claim, whilst
sation.
retaining original documents on the correct
claims.
3.0 Request external clinical advice referral
To upload documents from one claim to another:
Specialist Cover Assessor
1) Create a bulk print of all documents on the
other relevant claim and complete mandatory
a Identify all the documents that need to be sent with the
fields and
referral.
description
NOTE What documents do you need to include?
2) Open PDF document from email link
• ACC45 Injury Claim Form
3) Upload the PDF document to the relevant
• ACC2152 Treatment Injury Claim
claim that has the document group for the refer-
• All clinical notes (including radiology reports,
ral
laboratory results and other miscellaneous med-
4) Repeat if there are relevant documents on
ical records
multiple claims.
on file)
• Treating specialist(s) report(s)
The PDF should be renamed to something short
• Internal medical advice
but relevant, identifying which claim number the
• Letters and notes provided by the client
information came from so that it is included/
• Death Certificate
printed in further referrals or copy files eg 'med-
• Coroners/Autopsy reports
ical records and reports from claim
• Hard copies of clinical evidence (dental moulds,
100xxxxxxxx'.
cytology slides, radiological images hard copy/
CD).
Do not create a bulk print on one claim and then
move it to another claim, renaming it and using it
b Perform privacy checks on documents.
in a referral for advice as it will not appear in any
NOTE What do you need to check?
file copy subsequently used.
Check documents:
Manage document groups
• are relevant to the referral
d Create a referral-specific document group with today's
• do not contain any third party information
date and name it 'External Clinical Advice'.
• do not contain any other information that needs
to be withheld.
e Perform final privacy check as per step 3.0, b on any
documents that have been added to document group
For details on what checks you need to complete
called 'External Clinical Advice'.
before sending documents out, refer to NG sup-
NOTE What if more than one ECA is requested for
porting information Inbound and Outbound Docu-
the same claim?
ment Checks and the Privacy Check Before Dis-
closing Information policy.
Perform privacy checks as per step 3.0, b on
documents to be sent to any other ECA.
NG SUPPORTING INFORMATION Inbound and
Outbound Document Checks
NOTE What do you need to document on Eos re-
garding privacy checks?
Privacy Check Before Disclosing Information Policy
Create a contact in Eos stating you have com-
NOTE What if you find information that needs to be
pleted privacy checks for the document group la-
redacted?
beled 'External Clinical Advice' and the date this
Send an email to Recovery Administration
was done.
([email address]) and include the
f From the Recovery Plan, add an activity for NGCM -
document to be redacted plus your specific
Manage Referral task and choose the External Clinical
redaction instructions, before adding the re-
Advice type.
dacted document to the document group. You
must not create and add to a document group
until all redactions have been completed. Wait
until you get the correct information back on the
claim and then you can create your document
group.
c Add the documents to the group.
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GOV-027796 Appendix 1
NOTE How do you generate and send a referral task
NOTE What if you don't have all the information you
for Recovery Administration?
need to proceed?
Go to System Steps NGCM Create a Referral
If required information is missing from the task,
Task.
contact the task creator.
What if this a Mesh claim?
If you need guidance on working within the
Administration Team, refer to the link below.
In the e-form sub-specialty list select Other, then
Principles of Working in the Administration Team
use the free type box to note Mesh and note pre-
ferred specialist
NOTE What if the referral task indicates the referral
is urgent?
Creating Manage Referral Tasks - System Steps
Contact the task creator to discuss the urgency
NOTE How do you complete the eform that is asso-
and work together to progress the urgent refer-
ciated with the External Clinical Advice type?
ral.
• Select specialty and sub-specialty
• Record the basis of the claim in the 'Questions
for referral' field, then leave a space
5.0 Identify available ECA
• Enter your specific ECA questions in the 'Ques-
Recovery Administrator
tions for referral' field, then leave a space
• Specify if you need to re-refer to a specific ECA
a Check the Treatment Injury ECA Referral tool for the
medical discipline and speciality requested and confirm
It is not necessary to link the document group to
the next ECA provider in line to receive a referral.
the task. The recovery administrator will be able
Treatment Injury ECA Referral tool
to locate the corresponding document group that
has been correctly labelled.
NOTE Where can you find guidance on how to use
and update the referral tool?
Clinical questions guide
The TI ECA Tool Guidance Info document is lo-
NOTE What if hard copy clinical evidence needs to
cated in the referral tool using the weblink pro-
be sent with the referral (ie specimens and
vided above or watch an instruction video below.
radiological imaging)?
TI ECA Referral Tool Training Videos
• send the whole ECA referral yourself via courier
so the hard copy clinical material is together with
NOTE What if the referral task indicated the referral
the full referral. See below note about additional
is urgent?
information you need to include in the task.
Work with the task creator to facilitate discus-
• complete activity 7.0 when you receive a Gen-
sions with the relevant ECA provider to accept
eral Task from Recovery Administration notifying
an urgent referral.
you this is ready.
NOTE How do you know which ECA provider to
• if you need to send hard material, also record in
use?
the task description "Hard material - Specialist
Cover Assessor will send referral".
• review the medical specialty and sub-specialty
requested in the task.
NOTE What if additional clinical information is re-
• search for providers which match the above
ceived after the referral has been sent to the
requirement in the Treatment Injury ECA Referral
provider?
tool:
• create a CM03 blank letter addressed to the
- Open Provider details and filter Specialty and
ECA provider advising that we are sending addi-
Sub-specialty (eg General Medicine, Infectious
tional information for them to consider as part of
Diseases)
their report and state clearly what the additional
- Note the geographical location of the client and
information is (eg Medical notes from General
select a provider from outside of the client’s
Practitioner Dr XXX).
geographical location.
• create another document group that will include
a CM03 blank letter and the additional clinical
If there are no providers outside of the client's
information for the ECA.
geographical location, advise the task creator
• create a NGCM Send Letter task and link the
and discuss alternatives and/or email your Client
documents for recovery administration to send
Service Leader who will escalate to Clinical Ser-
on your behalf.
vices for resolution.
• complete privacy checks as per step 3.0, b and
document in a contact on Eos.
g Set the priority indicator on the task to 'high'.
4.0 Review referral task
Recovery Administrator
a Following the task assignment in Salesforce, navigate to
Eos and select 'Do Task' from your task queue.
b Review the task to ensure it has all the information you
need to proceed .
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GOV-027796 Appendix 1
NOTE How do you confirm the provider is available
NOTE How do you correctly update the booking
and has capacity to receive a referral?
schedule?
In the Provider details tab of the Treatment Injury
Refer to 'Populating & Maintaining the Booking
ECA Referral tool check:
Schedule' within the TI ECA Referral tool Guide-
lines document located in TI ECA Tool Guidance
• their availability is "Yes".
Info for full instructions on how to and what
• the provider's Annual Practicing Certificate
should be recorded in the columns.
(APC) is current.
• the notes section, some providers like to be
When entering a new referral request:
called and asked whether the basis of the claim
1) From the Booking Schedule, click the ‘+ New’
is within their scope of practice prior to us send-
button on the top left of the screen
ing the request.
2) You will be presented with a form on the right
• compare the maximum referrals recorded
side of the screen. Populate the applicable fields
(signalling the number of referrals they can
(refer to guidelines for definitions if necessary).
manage at any given time), with the current
When complete, click ‘Save’.
volume already referred or wait-listed, and wait-
ing receipt of advice
When updating an existing referral request entry:
• If the maximum number of referrals has been
1) Select the referral request entry you wish to
reached and the referral is wait listed or waiting
update.
for an appropriate ECA provider to be recruited
2) Click edit.
with the specific specialty needed. If so the
3) You will be presented with a form on the right
Recovery Administrator to contact the task crea-
side of the screen. Update as necessary and
tor to let them know.
click
‘Save’.
If in doubt, or specified by the provider, contact
NOTE Why is it important to correctly update the
the provider to confirm capacity.
booking schedule?
If the maximum referrals has not been reached
It is vitally important that the tool is updated and
and there is no wait-list, the provider has capac-
that requests that have been received are re-
ity to receive a referral.
moved from the list. This allows users of the tool
to accurately assess the work load of providers.
NOTE What if you can’t confirm the provider has
This will enable visibility to your colleagues of
capacity to receive a referral?
referrals sent, when ECA is due, referrals on the
Select the next appropriate provider with the
waiting list and when provider has capacity so
right specialty and sub-specialty.
that another referral can be released.
NOTE What do you do if all providers with the re-
NOTE How do you manage urgent referrals when
quired specialty and sub-specialty are at full
other referrals are on the waiting list with a
capacity?
provider?
1) Extend the due date of the task, aligning it to
Contact the Specialist Cover Assessor who re-
when the soonest expected due date for receipt
quested the referral and work together to enable
of an ECA from the identified providers this will
the referral to be placed at the top of the waiting
keep the referral delay to a minimum.
list queue.
2) Record a rationale in the task as to why you
are extending the task due date this will help
This should involve discussions with other Spe-
identify
cialist Cover Assessors to agree priority based
through reporting if additional ECA providers
on each client situation, and to enable Specialist
need to be recruited and added to the list.
Cover Assessors to update clients on the status
3) Go to step b.
of their referral and expected timeframes.
NOTE What do you do if there are no ECA providers
NOTE What if this is a mesh claim?
on the Provider details tab with the required
In the task sub specialty will be noted as mesh. If
speciality and/or subspecialty?
a specialist s noted, find them in the ECA list. If
• Email your Client Service Leader with the issue
no specialist is noted, filter by Mesh in sub - spe-
and they will escalate to
cialty (pending ECA tool update)
[email address] for resolution.
• Extend the due date of the task out to three
days to follow up resolution and record reasons
6.0 Create purchase order
why the task due date is extended. This infor-
Recovery Administrator
mation will be extracted for reporting as part of
improving the ECA service.
a In Eos, create a Purchase Order for the ECA referral by
referring to the details in the e-form.
b Update the booking schedule recording the relevant de-
tails in the appropriate fields against the confirmed se-
NOTE What do you add to the purchase order?
lected provider.
• In 'General Q+E' tab select 'Cover Assessment'
under Rehabilitation Action, 'Treatment Injury-
Cover' under
intervention, and 'Non-Contracted' under Pur-
chase Method.
• On Select Ent - select ECA01
• Enter 10 units for quantity approved and set
frequency as 'Quarter'
Create a purchase order
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GOV-027796 Appendix 1
b Add the vendor to the purchase order, as identified in the
NOTE For Recovery Administrators: What do you
ECA booking schedule and Provider details, ensuring the
do next if the referral task only requested a
vendor is also added as a participant on the claim.
Purchase Order creation and approval due to
c
hard copy clinical material needing to be sent
Approve the purchase order.
by the Specialist Cover Assessor with the
NOTE What if the purchase order requires a higher
referral?
delegation?
1) Ensure you have edited the TI40 as much as
Save the purchase order and create and send a
you can and save the document as Incomplete.
Request Authorisation Task from within the pur-
2) Create a General Task and record that the
chase order and send to a Recovery Leader for
purchase order has been approved and the
approval.
referral is ready to
be completed.
Refer to the link below.
3) Add the purchase order number to the task
description.
Request Authorisation for a Purchase Order -
4) Transfer the General Task to the referral re-
System Steps
quest creator.
NOTE What if you get a 'Limited Payment' error
5) Close the Medical Assessment Referral task.
message when authorising the purchase
order?
Go to step 8 (the Specialist Cover Assessor will
Change the limited payment indicator.
complete the rest of this activity).
b Link the referral to the document group 'External Clinical
1) In Eos, go to the 'Validations' tab, select 'Edit'
Advice'.
and update the Limited Payment List Indicator to
'No'.
c Perform privacy checks using the Inbound and Outbound
2) Select 'OK'.
Document checks.
3) Go back to the purchase order to authorise.
NG SUPPORTING INFORMATION Inbound and
Outbound Document Checks
Once you have authorised the purchase order,
remember to change the Limited Payment List
d Check the provider's preference for receiving the referral.
Indicator to 'Yes'.
If the providers preference is by email and the request is
not associated with hard copy material, Recovery Admin-
istrator to ensure the provider's email address has been
7.0 Create and send referral documents
verified.
Recovery Administrator, Specialist Cover Assessor
Update the Booking schedule in the Treatment Injury
a Create and edit the TI40 External Clinical Opinion Re-
Referral tool with the date the referral is sent.
quest - Vendor letter (do not complete the document until
sent to the vendor - this will allow the vendor to edit the
NOTE What if the email address has not been veri-
document and enter their findings), populating with the
fied?
extra information noted in the ECA task. Ensure you
Go to (NGCM) Verify Provider and Vendor email
check that all relevant information within the task has
addresses process.
been captured.
PROCESS Verify an Existing Provider,
Vendor or Facility Email Ad-
ADMIN TEMPLATE - External clinical advice.docx
dress
NOTE When would a Specialist Cover Assessor
Treatment Injury ECA Referral tool
complete this activity?
Only when hard copy clinical material is to be
e Create email using the requests and referrals template
sent.
and attach the referral and document group.
Emailing from Eos using a template - System Steps
Recovery Administrators will complete the TI40
as much as possible and save the document as
NOTE If you are unsure contact the ECA provider
Incomplete. Upon receipt of the General Task
directly.
from Recovery Administration, the Specialist
Cover Assessors will then edit the rest of the
NOTE What if the document is too large to email?
document through to completion and send the
referral documents, ensuring all steps outlined in
Break it up in chunks, if required.
this activity are completed.
NOTE What if the request is urgent?
State this clearly in the email.
NOTE What if the referral documents need to be
sent via courier?
Recovery Administrators - Refer to the process
link below (NGCM) Prepare and Send Client
Information by courier.
Specialist Cover Assessors - Refer to the Infor-
mation link below Sending medical material to
External Clinical Advice
PROCESS Prepare and Send Client Infor-
mation by Courier
Sending medical material to External Clinical Advice
f Complete a final dispatch check to ensure the client and
vendor details are correct.
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GOV-027796 Appendix 1
g Send the email or courier to the ECA provider. Use the
NOTE How do you contact the ECA provider to
email address provided under the Treatment Injury ECA
follow up on the report?
Referral tool.
1) You can contact the provider by email or
NOTE What if the TI ECA provider requests an
phone call and advise the ECA provider that the
update to their details or availability?
report is due back to ACC.
2) Check if referral has been received by them.
Pass the information on to
3) Ask the provider what the expected timeframe
[email address] (Attn: Kristina Bueno)
for ACC to receive this report.
to have the Provider list in the TI ECA Referral
4) Document this clearly in the contacts of the
tool updated.
claim with the follow heading: ECA PROVIDER
h After sending the incomplete TI40 letter to the vendor,
CONTACTED and write within the contact the
save the document as complete this will allow the docu-
agreed timeframe to receive the report.
ment to be edited by the vendor (to convert the document
5) Alter the 'NGCM - Admin Request Task' to re-
into a non-editable pdf).
flect the new agreed timeframe or three further
i
weeks and place back in the queue.
Close the assigned task and create a new "NGCM -
Admin Request" task, edit the task description with "ECA
NOTE What if the provider can’t complete the refer-
Follow Up" Provider Name and Due Date. Set the due
ral?
date for three weeks’ time and put back into the queue.
1) Make note and close follow up task.
j Check that you have correctly updated the Booking
2) Mark as report received in booking tool and
Schedule in the Treatment Injury ECA Referral Tool
note that the provider declined the referral.
(locate the entry with your clients name and the vendor
3) Call specialist cover assessor and ask them to
who has been previously selected under point 5.0), with
make a new task and make mention to not refer
the date the referral was sent to the vendor and then cal-
to previous provider OR indicate an alternative
culate a six week ECA report due date (first follow up on
provider.
ECA referral at 6 weeks then 4 weekly after that).
4) Consider if the provider’s availability needs to
be changed due to reason of the declined of ser-
NOTE Specialist Cover Assessors sending the
vices.
referral will need to update the spreadsheet
with the date referral sent and ECA due date.
NOTE What if the ECA provider is not responding to
follow ups?
If you experience repeated difficulty commu-
nicating with the provider, eg provider is not res-
ponding to a mix of emails and phone calls after
8.0 Follow up request for external clinical advice
three attempts, it is reasonable to engage the
Recovery Administrator, Specialist Cover Assessor
task creator to determine if the referral should be
a Upon receipt of the NGCM - Admin Request task, per-
cancelled and a new referral sent to another
form a check of the documents on the claim to confirm
ECA provider next on the list who has capacity to
the requested information has been received.
receive the referral.
NOTE What if the ECA has been received?
NOTE What if the ECA provider indicates a lengthy
1) Update the Booking schedule in the Treatment
delay and they haven't commenced the
Injury ECA Referral tool with the ECA received
review?
date.
ECA Providers are very good at advising delays
2) Close the "NGCM - Admin Request" task.
or that they are unable to undertake the work.
3) Create "NGCM - Action Attached Documen-
Some examples of this are, taking leave, or
tation" task and tick the box "Assign this work to
experiencing an increased workload in their rou-
me" at
tine practice (outside of ECA) and therefore
the bottom left of the EOS page so that you can
unable to provide reports. If this occurs, inform
make edits. Select next.
the Specialist Cover Assessor and determine if
4) Write in task description "ECA received from
the referral should be cancelled and a new refer-
Dr (enter name and specialty)", then allocate
ral sent to another ECA provider next on the list
task to
who has capacity to receive the referral.
case owner/Specialist Cover Assessor.
NOTE For how long should you continue following
5) Check if there is another referral on the wait-
up for the ECA report?
ing list for that provider that can now be sent to
the
You should continue to follow up the ECA report
ECA. If so, locate the referral task, change the
for as long as required until the ECA report has
due date to today's date, and record in the task
been received.
description that the provider can now receive the
referral.
NGCM - Admin Request tasks for follow up of
6) Change the task to high priority so that the
the ECA report should never be closed unless
task can be allocated and actioned same day.
the report has been received or you have been
advised by the Specialist Cover Assessor that
b Contact the ECA provider to follow up on the report if the
follow up is no longer required.
ECA has not been received.
c Extend the NGCM Admin Request to reflect the earlier of
the new agreed timeframe or three further weeks and
place back in the queue.
d In the Booking Schedule, add in the comments field that
follow-up has occurred and the expected new date of re-
ceipt of the ECA report.
ACC > Claims Management > Manage Claims > Gather Additional Information or Advice > Seek External Clinical Advice
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GOV-027796 Appendix 1
NOTE Do not change the initial six week ECA due
PROCESS
Make cover or funding decision ::
date recorded in the Booking Schedule as
Make Treatment Injury cover deci-
changing due dates will incorrectly inform
sion
provider service level agreement monitoring
Cover Assessor, Specialist Cover Asses-
occurring in another part of the business.
sor
e Receive the ECA report or the Alert: You Have Mail task
notification from the Inbound Document Management
Team that the ECA report has been attached to the claim,
open and review the document.
NOTE What if you are a Specialist Cover Assessor
and you receive the ECA report directly from
the provider and upload it yourself?
Do not cancel the NGCM - Admin Request follow
up task - update the task requesting the admin
team to update the ECA booking tool and
change the target date and priority level. This will
allow the admin team to close the task after the
ECA booking tool has been updated to avoid
delays for other clients on the waitlist.
f Perform Privacy and Relevancy checks on the received
report.
NG SUPPORTING INFORMATION Inbound and
Outbound Document Checks
9.0 Review report
Specialist Cover Assessor
a Review the report to ensure there are no clinical issues
and that it is complete.
NOTE What if there are quality clinical issues or
completeness concerns?
You are encouraged to deal directly with the Pro-
vider where you can, particularly if the concerns
are around the completeness of the report, omis-
sions or redactions.
However, where the quality of a report potentially
falls below expectation and there may be a need
to provide feedback to the ECA, these situations
can be referred to a Clinical Advice Manager for
consideration. The team will help you by re-
viewing the report and where necessary talking
with the ECA Provider.
If you have any concerns relating to the quality of
any ECA reports, please email the case and a
summary through to [email address].
PROCESS Address Treatment Injury ECA
Performance Issue
10.0 Determine next steps
Specialist Cover Assessor
a Review ECA report and determine next steps.
b Contact the client and confirm you are speaking with the
right person by asking ACC's identity check questions.
Identity Check Policy
c Discuss the report and next steps.
d In Eos, add a contact as a record of the conversation.
e Go to 'Assess Cover for Treatment Injury Claim' step 5.0
Review additional information.
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GOV-027796 Appendix 1
Arrange Medical Case Review (MCR) Assessment v84.0

Linked Process
Create or Update Recovery Plan
11.0
Determine next steps
10.0
Review report
9.0
Receive confirmation of appointment
8.0
Create and send referral documents
7.0
Create purchase order
5.0
Request assessment referral
6.0
Review referral task
3.0
Identify and confirm vendor
4.0
Action request to identify potential vendor (if required)
2.0
Contact client and explain the need for an assessment
Linked Process
Create or Update Recovery Plan
1.0
Determine whether Medical Case Review is required
Assistant
Assistant
Administrator
Assessor
Recovery
Recovery Coordinator
Recovery Partner
Cover
Recovery
Recovery Coordinator
Recovery Partner
Recovery
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GOV-027796 Appendix 1
Arrange Medical Case Review (MCR) Assessment v84.0

NOTE Who will identify the need for an MCR?
Summary
The need for an MCR will be identified as part of
written guidance from Recovery Support.
Objective
To clarify diagnoses and the cause of a client’s injury or current
Where there are clinical questions, or where re-
condition and get recommendations for further investigations,
quired for medicolegal reasons and Clinical Ser-
treatment or rehabilitation.
vices or the treating practitioner are unable to
address these, written guidance from Recovery
To create and send a medical assessment referral in order to
Support will confirm and support the need for ob-
provide the most appropriate support for our clients throughout
taining an independent expert opinion from a
their recovery.
non-treating specialist. The written guidance will
include tailored questions for the MCR provider
Background
to respond to.
Medical Case Reviews (MCR) are used to obtain an opinion
from a non-treating practitioner or a second opinion from a suit-
For how to obtain written guidance, refer to Seek
ably qualified assessor.
Internal Guidance.
PROCESS Seek Internal Guidance
Key features:
• Only ACC can refer for an MCR
NOTE What do you need to consider when deemed
• An MCR can be used to help determine cover and ongoing
cover exists?
entitlements
Refer to the Deemed Cover and Entitlements
• The provider must be a non-treating practitioner who is a med-
Policy for considerations to determine client
ical specialist
entitlement eligibility while in deemed cover
• The provider may order tests or investigations if necessary
period.
for them to be able to provide an opinion. They can also make
recommendations for tests or investigations.
Deemed Cover and Entitlements Policy
• MCRs are purchased either under the Clinical Services con-
NOTE What if the client has not granted ACC au-
tract or by letter of agreement where the provider does not hold
thority to collect medical and other records?
this contract.
See step 2a below
Owner
[Out of Scope]
NOTE What if the MCR request has come from a
Review Specialist?
Expert
[Out of Scope]
If the MCR is being requested by a Review Spe-
cialist as the result of a review hearing or reso-
Procedure
lution agreement then you do not need to Seek
Internal Guidance. Review Specialists have dele-
PROCESS
Create or Update Recovery Plan
gation to authorise an MCR without referring to
Recovery Assistant, Recovery Coor-
Clinical Advice. This may be the result of an
dinator, Recovery Partner
overturned or revoked decision.
NOTE What are the different types of MCR you can
refer a client for?
1.0 Determine whether Medical Case Review is re-
• Standard
quired
• Complex
Cover Assessor, Recovery Assistant, Recovery Coor-
NOTE When would you refer for or agree to a re-
dinator, Recovery Partner
quest for a complex MCR?
a Confirm client's eligibility for the Medical Case Review
• the client’s injury is of unusual complexity
(MCR) assessment.
• there are co-morbidities that appear to be af-
NOTE You must Seek Recovery guidance from a
fecting the client’s recovery from injury
Clinical Advisor before arranging an MCR.
• the review or assessment will be undertaken in
two parts while results of investigations are ob-
tained.
NOTE What if the request/referral is to a specialist
NOTE When would you use an ‘exceptional code’ in
who is the treating practitioner or will
MFP?
become the treating practitioner?
This is usually initiated after discussion with the
In this case MCR codes are not appropriate.
provider. The ‘complex’ code plus an hourly rate
payable under the Clinical Services Contract (all
If the provider holds the clinical services contract
codes are in MFP). ie large volume of reading re-
then they need to bill under this using the stan-
quired, complex injury/non injury factors.
dard codes which do not need prior approval.
Identify Claims for Rapidly Deteriorating Clients
If the provider does not hold the clinical services
b Ensure current medical notes are on file so they can be
contract then consult the "manage non con-
sent to the MCR assessor.
tracted purchasing" process. (see activity 3.0 for
how to confirm if they hold the clinical services
NOTE What if the current medical notes are not on
contract.)
file?
You will need to obtain these before the referral
Seek support from your Team Leader and
is sent to the provider. Refer to (NGCM) Request
Engagement and Performance Advisor if the pro-
Clinical Records.
vider continues to request MCR codes.
PROCESS Request Clinical Records
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GOV-027796 Appendix 1
NOTE What if you need clarification of an answer
NOTE What else do you need to discuss with the

following the MCR assessment?
client?
Following the initial MCR assessment, you may
• that the specialist may suggest a telehealth (vir-
need to clarify something in the report or have a
tual) assessment if it is clinically appropriate - the
follow up a question from Recovery Support. In
client must give their consent for this, otherwise
this case ensure you use the PO code MEDR.
it should be in person. Explore any concerns
about a potential virtual assessment and confirm
Send an NGCM - Admin Request Task to Recov-
their agreement/disagreement at this point.
ery Admin to update the PO.
• ask what their availability is to attend the
NOTE What if you require a supplementary report
assessment, do they have a preferred time
following the MCR assessment?
during the day?
Following the initial MCR assessment, you may
be required to request a supplementary report.
• we will send the appointment details through to
This may be because you have additional ques-
them
tions for the assessor.
• that there is no cost for the appointment, that
1) Use the PO code CSM3 and specify the
we can contribute or arrange travel
number of hours required.
2) Send an NGCM - Admin Request Task to
• they are welcome to have a support person
Recovery Admin to update the PO.
accompany them
NOTE What if the client needs requires a second
MCR assessment?
• the specialist will send us a report which we will
Following the initial MCR assessment, you may
send to appropriate parties. Confirm they are
be required to request a additional MCR assess-
happy for the report to be sent to the key parties,
ment. This may be due to receiving new medical
including their GP and record this in your con-
information.
tact.
Follow the same steps below as arranging the
• make them aware that some providers will ask
initial MCR and ensure you use the appropriate
to review the referral documents before ac-
contracted or non-contracted purchase order
cepting the referral and confirming they can
code. Go to 2.0 Contact client and explain need
undertake the assessment. Explain that this is to
for assessment.
assist the provider in deciding whether they are
the right clinician for the client, and that any pro-
NOTE What if you are assessing a Work Related
viders that do not accept the referral will be
Gradual Process (WRGP)?
asked to delete the referral documents. Confirm
Refer to the Medical Case Review Providers list
that they are informed of this process, consent to
to identify who can conduct this type of assess-
the referral documents being shared and note
ment for WRGP claims. See link to the Te Wha-
this in the client contact record.
riki page below
WRGP | Medical Case Review Providers
Ensure your client understands the purpose of
the assessment and the possible outcomes.
NOTE What if you are booking an MCR with an
2.0 Contact client and explain the need for an
Occupational Physician via the Vocational
assessment
Medical Services (VMS) Centralised Booking
Cover Assessor, Recovery Assistant, Recovery Coor-
System spreadsheet?
dinator, Recovery Partner
Some Occupational Physicians hold the Voca-
tional Medical Services (VMS) contract to con-
a Check that the client has granted ACC the authority to
duct an MCR, if you use these assessors they
collect medical and other records.
can be booked using the VMS Centralised Book-
NOTE What if the client has not granted ACC au-
ing System spreadsheet. Follow the steps below
thority to collect medical and other records?
when booking an assessor via the VMS spread-
You will need to consider if authority is needed.
sheet:
Refer to (NGCM) Obtain Client Authority to Col-
• Open the VMS Centralised Booking System
lect Information.
and identify the provider, for information and
guidance refer to VMS Centralised Booking
PROCESS Obtain Client Authority to Col-
System.
lect Information
• Create a reminder action to notify the client of
b Contact the client and confirm you are speaking with the
appointment details the day prior to the appoint-
right person by asking ACC's identity check questions.
ment.
• In Salesforce, add a contact as a record of the
Identity Check Policy
conversation.
c Explain that you are referring them for the assessment,
• Add the agreed intervention to the Recovery
the purpose and any potential implications, as well as
Plan.
what their rights and responsibilities are.
• Go to step 5.0
Group VMS SharePoint site
Medical Case Review and Medical Single Discipline
Assessment Service Page
Client Legislative Rights and Responsibilities Policy
Client choice of providers Policy
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GOV-027796 Appendix 1
NOTE What if the client does not agree to partic-
NOTE What if you already know which vendor you

ipate or does not want a telehealth assess-
want to use?
ment if that has been suggested?
Go to activity 5 if they are contracted or
Find out why the client does not want to partic-
Use the steps in the note below ("What if you
ipate and consider their reasoning and alter-
need to refer to a non-contracted provider and
natives. Go to (NGCM) Seek Internal Guidance if
how do you confirm the price?" ) for non-
you are unsure how to proceed. If the client
contracted vendors
wants to be seen in person, let the assessor
know.
NOTE How do you know if a vendor is contracted or
PROCESS Seek Internal Guidance
non-contracted?
d In Salesforce, (or EOS if your role does not use Sales-
You can use the Service Contracts and Con-
force) add a contact as a record of the conversation.
tracted Providers - MFP spreadsheet to confirm
whether a vendor holds the clinical services con-
e Add the agreed intervention to the Recovery Plan.
tract. (see link below). Change the yellow box to
NOTE How do you update the Recovery Plan?
show Clinical Services and search within the
Go to (NGCM) Create or Update Recovery Plan
green vendor column.
PROCESS Create or Update Recovery
Plan
Remember that some specialists work under
multiple vendors so you may need to contact
NOTE What if you are a cover assessor and there is
them directly to confirm whether they hold the
no Recovery Plan?
clinical services contract and if so which vendor
Add an EOS task to remind yourself to follow up
ID.
on the report if it has not been received in a
Service Contracts and Contracted Providers - MFP
timely manner amending the date once you have
spreadsheet
confirmation of the assessment date.
NOTE What if you need to refer to a non-contracted
vendor and how do you confirm the price?
3.0 Identify and confirm vendor
Send the vendor the "SMR15 - Medical case
Cover Assessor, Recovery Assistant, Recovery Coor-
review non-contracted agreement - vendor letter"
dinator, Recovery Partner
once discussion and agreement is made on
rates.
a Contact the vendor to check they are able to take the
referral
Amend the letter to include the relevant service
NOTE How do you find potential vendors?
codes and the price of the assessment. Service
Go to Activity 4.0c and 4.0d for ways to locate
codes for non contracted MCR's can be found in
suitable vendors.
the link below NG GUIDELINES Purchase Order
Details - Medical Case Review. Remove the
NOTE What if you would like Recovery Adminis-
client's address from the top if it has prepo-
tration to find or confirm a vendor for you?
pulated and add MCRD as the service code for
Send an NGCM - Admin Request Task to Recov-
the disbursements line.
ery Administration
What is the price? Offer the same rate as a con-
Enter the following information into the task:
tracted MCR - See CSM codes on page 5 of the
"Clinical Services Schedule" linked below.
"Find Vendor for MCR"
• Type of provider eg neurologist, orthopaedic
If there is excessive relevant information and the
(and body area eg spinal) or pain specialist
vendor requests additional reading time it would
• The questions you want them to address and a
be appropriate to use MCR13 (Exceptional rate)
brief summary of the client and the relevant
to cover this. These requests do not need to be
background
approved by Elective Services.
• any special client requests/needs eg if the
client prefers a morning or afternoon appoint-
Any requests for a rate higher than the contract
ment, the date range, if the client can travel and
must be referred to the Portfolio Manager in the
if so, how far.
Provider Service Delivery.
• timeframe for the report if urgent
• which type of referral this is - complex or stan-
Email [email address] and use the
dard (for definitions see page 24 of "Clinical Ser-
subject "Approval for exceptional non contracted
vices Service Schedule linked below.)
MCR/MSDA".
• confirm your client is aware that supporting
information may be sent to the vendor prior to
The signed letter of offer MUST be returned prior
the referral being accepted.
to sending a referral task to Recovery Admin.
Create your relevant document group and note
Clinical Services Service Schedule (Service Codes
the name of it in your task (this is so Recovery
and Pricing)
Admin can send it if a provider requests to see
NG GUIDELINES Purchase Order Details - Medical
the referral documents prior to accepting the
Case Review
referral.)
See Activity 5 a-d for how to create and name
the relevant document group.
Ensure your client is aware that the documents
may go out prior to the referral.
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GOV-027796 Appendix 1
NOTE How do you create the SMR15 letter from out-
NOTE What if a suitable contracted vendor cannot

side the purchase order?
be identified?
From the Documents tab at ACC45 claim level,
Refer to the Medical Council of New Zealand’s
complete the following:
Register of Doctors and the Dental Council’s
• Add Document
Register of Oral Health Practitioner to search for
• From the "search" tab, enter SMR15 in the
potential providers with the required specialty in
document type field and click search
the links below.
• Select SMR15 Medical Case Review non-
Medical Council of New Zealand’s Register of Doc-
contracted agreement - vendor and click OK
tors
• Add the client's NHI number to this letter
• Codes are MCR11 (standard) or MCR12 (com-
https://www.mcnz.org.nz/registration/register-of-docto
plex)
Dental Council’s Register of Oral Health Practitioner
• Use the rates as instructed in the note above
https://www.dcnz.org.nz/practitioners
SMR15 Medical Case Review non-contracted agree-
d Contact potential vendors (local first) to check their
ment - vendor
availability either by sending the Medical Case Review
NOTE What if the vendor wants to see the referral
and Medical Single Discipline Assessment - Vendor
documents prior to accepting it?
Email Template or by phone.
Some vendors may request information about
Medical Case Review and Medical Single Discipline
the referral prior to accepting it. Confirm that the
Assessment - Vendor Email Templates
client has given consent for supporting infor-
mation documents to be sent to potential ven-
NOTE How long do you hold on to the task?
dors.
Try additional vendors, until you do have a re-
sponse
If you would like Recovery Administration to do
Hold on to the task till the end of the day to allow
this for you, create an NGCM Admin task stating
time for responses.
the action required. Note the Vendor ID & Name,
NOTE What if the vendor requests supporting infor-
email address or physical address (if the docu-
mation prior to accepting the referral?
ments need to be couriered) and the document
Some may ask to see supporting information
group needing to be sent.
before they will accept the referral or sign the
SMR15. Generally, this is because they want to
Ensure the email address is verified and able to
confirm if they are the right clinician for this
be emailed out of EOS. Recovery Administration
client.
will only send supporting information if consent
has been given and the vendor makes this re-
This information can be sent to potential vendors
quest.
via email or couriered as a final option.
b Add the vendor as a participant on the claim once they
confirm they can undertake the assessment and have re-
Confirm the client has provided consent for the
turned their signed letter of agreement where they are
information to be released (the Recovery Team
non-contracted. Then go to activity 5.0 Request Assess-
Member will note this in the task).
ment Referral.
Email vendors using the email template link
NOTE How do you manage participants on a claim?
below.
The Recovery Team Member must ensure all
known participants are loaded on the claim and
Recovery Team Members should have named
then removed when they are no longer relevant.
the relevant document group in the task. If this is
For information on how to manage participants,
not included and the vendor is requesting this
refer to Manage Participants (Eos Online Help).
follow the process as per Activity 6.0
Manage Participants (Eos Online Help)
Medical Case Review and Medical Single Discipline
Assessment - Vendor Email Templates
4.0 Action request to identify potential vendor (if re-
e Close the NGCM – Admin Request task once the ven-
quired)
dors have been identified.
Recovery Administrator
a
NOTE TIP: If potential vendors have been identified
Following the task assignment in Salesforce, navigate to
in the task description copy this before you
Eos and select 'Do Task' from your task queue.
close the task.
b Review the NGCM Admin Task and ensure it contains the
following information:
• Type of provider
f Create a Contact Party (Case Owner) Task to the Recov-
• Standard or complex
ery Team Member/Team.
• Client injury history
• Referral questions
In the task description enter the following
• Client consent (if given) for supporting information to be
‘Potential Vendors Identified’
sent
• Vendor names and dates available (include if the
• Name of the document group
vendor is suggesting telehealth (virtual) assessment) or
• Client's location or distance they can travel
• No vendors available
If this is not included follow the process as per Activity
If the request to arrange an MCR is urgent change the
6.0.
priority to ‘High’ before transferring the task back to the
Recovery Team Member/Team
c Use the MCR MSDA provider search tool to search for
potential vendors with the required specialty.
MCR MSDA provider search tool
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GOV-027796 Appendix 1
5.0 Request assessment referral
NOTE What if you find information that needs to be
Cover Assessor, Recovery Assistant, Recovery Coor-
redacted?
dinator, Recovery Partner
Send an email to Recovery Administration
a Find all the documents that need to be sent along with
([email address]) and include the
the referral.
document to be redacted plus your redaction
instructions, before adding the document to the
NOTE What if the signed letter of agreement has not
document group.
been received for a non-contracted service?
NGCM - Redact information from PDF documents
The process cannot proceed to referral without
the signed letter of offer being returned from the
c Create a referral-specific document group with today's
vendor. The Recovery Team member is respon-
date and name it 'Medical Case Review'.
sible for ensuring this is returned.
d Add the documents to the group.
NOTE What documents should be considered?
NOTE What if there are documents from other
It is important that you send only the relevant
claims that are relevant to the assessment?
information to the specialist. Consider the ques-
Create a bulk print of all documents on the other
tions you are asking them to answer.
relevant claim and complete mandatory fields
and description
• A current medical certificate
• Open PDF document from email link
• Schedule relevant to the client's function
• File the PDF away to the relevant claim
• Schedule of Claimant Injuries (if deemed appli-
• Repeat these steps if there is relevant docu-
cable)
ments on multiple relevant claims
• Most recent/current Back to Work, Stay at
Work, Standalone Workplace Assessment Re-
The PDF should also be renamed to identify
ports
which claim number the information came from,
• GP notes
so it is included/printed in further referrals or
• Specialist notes
copy files. e.g. Medical records and reports from
• Imaging results
claim: 100XXXXXXXX
• Physio notes
• All medical notes and any relevant vocational
This will ensure the notes remain on the correct
notes eg a Standalone Workplace Assessment if
claim but a copy can accompany the referral,
the specialist has been asked to consider s103
while clearly identifying which claim they belong
• Any written guidance information from Recov-
to.
ery Support
• Signed ACC6300 or ACC6300D Authority to
Please do not create a bulk print on one claim
collect medical and other records. NOTE: If
and then move it to another claim, renaming it
verbal consent was provided please note this in
and using it in a referral for advice as it will not
the task eform for Recovery Admin.
appear in any file copy subsequently used.
Manage document groups
NOTE What do you do if you don't have all the infor-
mation to complete the referral?
e Generate a Medical Assessment referral task for Recov-
If you require further information, refer to Gather
ery Administration for a 'Medical Case Review'.
Additional Information or Advice.
Referring Tasks to Recovery Administration - Prin-
Once you have requested the required infor-
ciples
mation, create a reminder action and set the
target date for when you expect to receive the
NOTE How do you generate and send a referral task
information.
to Recovery Administration?
Go to NGCM Create a Referral Task.
NOTE What if the document group created is larger
than 250 pages?
NOTE What do you do if Mental Injury Claim infor-
This may indicate that there is irrelevant infor-
mation needs to be sent with a Referral from
mation being included. We should only be send-
a Physical Injury Claim?
ing the relevant documents to the assessor so
In Eos, manually transfer the Referral Task gen-
please discuss what can be redacted with your
erated to the Recovery Administration depart-
Team Leader prior to sending it to Recovery
ment with the Sensitive Claims Administrator
Administration.
Role
Gather Additional Information or Advice
Creating Manage Referral Tasks - System Steps
b Perform privacy checks on documents.
NOTE What do you need to check?
Check documents:
• are relevant to the referral
• do not contain any third party information
• do not contain any other information that needs
to be withheld.
For details on what checks you need to complete
before sending documents out, refer to NG SUP-
PORTING INFORMATION Inbound and Out-
bound Document Checks.
NG SUPPORTING INFORMATION Inbound and
Outbound Document Checks
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GOV-027796 Appendix 1
NOTE What information do you need to include in

the referral task?
7.0 Create purchase order
• Type of MCR (standard/complex)
Recovery Administrator
• Vendor
a In Eos, create a purchase order for the MCR referral.
• Address for clinic/appointment (if known)
• If non contracted confirm that the signed
Create a purchase order
SMR15 (letter of agreement) is on file
NG GUIDELINES Purchase Order Details - Medical
• Recommendations from Recovery Support, in-
Case Review
cluding any questions
• Reason for the referral
b Identify and select the vendor as specified by the Recov-
• Vendor's delivery method (email/courier)
ery Team Member.
• Provide the correct service code. Refer to the
NOTE What if you need to locate the vendor via the
Purchase Order guidelines linked below
VMS Booking sheet?
• The client's NHI number
• Confirm whether or not the client has con-
Once selected add the vendor as a 'Vendor' -
sented to telehealth if this was requested
participant in Eos.
• Details of care indicators if applicable
Group VMS SharePoint site
• In the VMS box write NA if it not a vocational
assessment.
c Locate the vendor via the Geographic Location search,
once selected add the vendor as a 'Vendor' participant in
NG GUIDELINES Purchase Order Details - Medical
Eos.
Case Review
d Approve the purchase order.
f Complete all the mandatory fields and any additional
information to be included in the referral form including
NOTE What if the purchase order requires a higher
questions received via written guidance from Recovery
delegation?
Support.
Save the purchase order. Create and send a Re-
quest Authorisation task to a Recovery Leader
Identify Claims for Rapidly Deteriorating Clients
for a purchase order approval.
NOTE What if your client has a Care indicator?
You need to clearly outline this in the e-form.
Refer to the link below.
Request Authorisation for a Purchase Order -
Refer to Disclosure of Care Indicator Information
System Steps
to Third Parties Policy for more information on
how information is disclosed.
NOTE What if you get a limited payment error mes-
sage when authorising the purchase order?
Disclosure of Care Indicator Information to Third Par-
If you have received a request to amend a pur-
ties Policy
chase order or create a purchase order for client
g Review "When to use ‘high’ priority indicator on the tasks
reimbursements, change the limited payment
sent to Recovery Administration" rules to determine prior-
indicator.
ity of the task.
1) In Eos, go to the 'Validations' tab, select 'Edit'
When to use ‘high’ priority indicator on the tasks sent
and update the Limited Payment List Indicator to
to Recovery Administration
'No'.
NOTE What if your scenario meets the 'high' priority
2) Select 'OK'.
rule for this task?
3) Go back to the purchase order to authorise.
• If your scenario meets the priority rule for this
task, change the priority indicator to 'high'.
Once you have authorised the purchase order
• If your scenario doesn't meet the priority rule
and notified the vendor please remember to
for this task, leave the priority indicator at 'low'.
change the Limited Payment List Indicator to
'Yes'.
6.0 Review referral task
8.0 Create and send referral documents
Recovery Administrator
Recovery Administrator
a Following the task assignment in Salesforce, navigate to
Eos and select 'Do Task' from your task queue.
a Create an ACC7395 referral document for the MCR
assessment.
b Review the task to ensure it has all the information you
need to proceed.
ACC7395 Referral for medical single discipline
assessment or medical review - PO - vendor
NOTE What if the referral is for a non-contracted
service?
b Populate with extra information noted on the referral task.
Ensure you have checked that all the relevant information
The process cannot proceed to assessment
within the task has been captured.
without the signed letter of offer (SMR15) being
returned from the vendor. The Recovery Team
NOTE What does a quality ACC7395 look like?
member is responsible for this so if it's not linked
Refer to Admin Template - Referral for medical
to the task then you should follow the note
single discipline assessment or medical review
below.
Admin Template - Referral for medical single discip-
NOTE What if you don't have all the information you
line assessment or medical review
need?
c Ensure you have completed the document (to convert the
If required information is missing from the task,
document into a non-editable pdf).
or you need guidance on working within the
Administration Team, refer to the link below.
d Link the referral to the document group 'Medical Case
Review'.
Principles of Working in the Administration Team
ACC > Claims Management > Manage Claims > Gather Additional Information or Advice > Arrange Medical Case Review (MCR) Assessment
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GOV-027796 Appendix 1
e Perform privacy checks using Inbound and Outbound
SMR12 Medical case review appointment - client

Document checks
SMRIS02 Medical case reviews - client
NG SUPPORTING INFORMATION Inbound and
l in Salesforce, close the assigned referral task.
Outbound Document Checks
f Call the vendor to confirm how they want to receive the
referral documents (if email, ensure it is verified and if
9.0 Receive confirmation of appointment
they prefer documents to be emailed separately or as a
Cover Assessor, Recovery Assistant, Recovery Coor-
bulk print).
dinator, Recovery Partner
NOTE What if the Provider and/or Vendor email ad-
a Receive confirmation of the appointment from the pro-
dress has not been verified?
vider and file the email away to Eos.
Go to Verify Provider and Vendor email ad-
dresses process.
NOTE What if the vendor is unable to accept the
referral?
PROCESS Verify an Existing Provider,
Vendor or Facility Email Ad-
If the vendor is unable to accept the referral,
dress
resubmit the request with a new vendor.
NOTE What if the vendor has been booking via the
NOTE What are the timeframes?
VMS booking sheet?
• A vendor who has agreed to provide the MCR
Update the VMS booking sheet with the date the
must perform a clinical examination within eight
referral is sent.
business days of receiving a referral, unless oth-
erwise agreed by ACC
VMS Centralised Booking System Service Page
g Generate a Bulk Print of the “Medical Case Review”
• If they are unable to meet the eight day time-
Document Group by following the system steps below.
frame to see a client, you can negotiate a time-
frame which is acceptable to both parties
Print documents
h Generate the Bulk Print Index.
• The vendor must provide a copy of the report to
the case owner within eight business days from
NOTE How do you generate the Bulk Print Index?
the date of the clinical examination.
• Click properties
NOTE What if the client refuses or fails to attend
• Click view contents less
and/or participate in the MCR?
• Right click convert to PDF
• Save to desktop
If the client refuses or fails to attend or take part
• Upload to Claim using document type VCF006
in the MCR you should find out why. In some
• Label as Bulk Print Index
cases, you may need to consider the non com-
• Delete file from desktop
pliance process. Refer to the Policy below.
PROCESS Decline Entitlement when Client
i If email is the preference, create email using the requests
is Non-compliant Policy
and referrals template and attach the referral and bulk
print and save the bulk print to desktop and attach to the
NOTE What if the client wants to change to appoint-
email. Use the email address as confirmed by the vendor.
ment date?
Contact the vendor and discuss and confirm new
NGCM - FINAL Emailing from Eos using a Template
appointment details.
- System Steps
NOTE What if you identify the documents you're
sending exceed 10MB?
10.0 Review report
Use Adobe Pro to
Cover Assessor, Recovery Assistant, Recovery Coor-
Reduce file size:
dinator, Recovery Partner
• Select Optimize PDF
a Receive notification that the MCR report has been at-
• Select Reduce File Size
tached to the claim.
Or
Split document
NOTE What if there are quality clinical issues or
• Select organize page
concerns?
• Select Split
If you have any concerns relating to the clinical
• Select Split by File Size (up to 10MB)
quality of any VMS reports, please email the
The document will save in the same location and
case through to [email address]. You
the original document and will be name PART1,
are encouraged to deal directly with the vendor
PART2 (depending in the size of the file being
where you can, particularly if the concerns are
split).
around the completeness of the report or omis-
j Send the referral to the vendor.
sions.
NOTE What if the Vendor requires the documents to
However, the clinical quality team are particularly
be sent via courier?
interested regarding any reports which lack clin-
Go to Prepare and Send Client Information by
ical quality. Not only will the clinical quality team
Courier process.
help you by reviewing the report with the
PROCESS Prepare and Send Client Infor-
Engagement and Performance Management
mation by Courier
team (EPM) talking with the vendors, learnings
will be provided to all Providers through the reg-
k Send the appointment and information sheet to the client
ular newsletters.
via the preferred contact method. Ensure they contain the
relevant dates/times/locations where these are available
b Perform Privacy and Relevancy checks on the received
and ensuring any vendor phone numbers are not per-
report.
sonal ones.
ACC > Claims Management > Manage Claims > Gather Additional Information or Advice > Arrange Medical Case Review (MCR) Assessment
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GOV-027796 Appendix 1
NG SUPPORTING INFORMATION Inbound and
NOTE What if the client requests that the report is

Outbound Document Checks
changed or incorrect?
A client can request that information held by ACC
is changed or updated if it is factually incorrect
11.0 Determine next steps
(ie: wrong DOB, incorrect name spelling etc). If it
Cover Assessor, Recovery Assistant, Recovery Coor-
is the opinion of an assessor or provider, the
dinator, Recovery Partner
client can supply a 'statement of correction' to
a
ACC which is then included with the report. This
Follow the advice and recommendations in the MCR. If
means that any time the report is sent out, the
the report answers your questions clearly then act on
statement of correction must be sent as well.
those answers and in these cases there is no need to
seek internal clinical advice. The only exception to acting
Refer to Managing a client’s request to change
on the recommendations of the report without any further
personal information
advice is if the next step is a section 117 suspension or
revocation of cover, then seek advice from Technical Ser-
Managing a client’s request to change personal infor-
vices.
mation
NOTE What if the MCR report is not clear?
d Provide a copy of the report to the client, their GP (ensur-
Seek guidance from your Team Leader initially,
ing the client has given permission) and any other stake-
escalating to Practice Mentor if required. If you
holders as you consider appropriate or if internal advice
are still not clear what the next steps are then
was sought then also as recommended by recovery sup-
seek internal guidance to confirm.
port.
e In Salesforce, add a contact note as a record of the
The referral for guidance must explicitly state
conversation.
what exactly in the report you need assistance
understanding.
f Update the Recovery Plan with the outcome of the inter-
vention.
NOTE Refer to (NGCM) Seek Internal Guidance.
PROCESS Seek Internal Guidance
PROCESS
Create or Update Recovery Plan
NOTE What if you need clarification of an answer
Recovery Assistant, Recovery Coor-
following the MCR assessment
dinator, Recovery Partner
Following the initial MCR assessment, you may
need to clarify something in the report or have a
follow up a question from Recovery Support. In
this case ensure you use the PO code MEDR.
Send an NGCM - Admin Request Task to Recov-
ery Admin to update the PO.
NOTE What if you require a supplementary report
following the MCR assessment?
Following the initial MCR assessment, you may
be required to request a supplementary report.
This may be because you have additional ques-
tions for the assessor. Ensure you use the PO
code CSM3 and specify the number of hours re-
quired. Send an NGCM - Admin Request Task to
Recovery Admin to update the PO.
NOTE What if the client needs requires a second
MCR assessment?
Following the initial MCR assessment, you may
be required to request an additional MCR
assessment. Follow the same steps as arranging
the initial MCR and ensure you use the appro-
priate contracted or non-contracted purchase
order code. Go to 2.0 Contact client and explain
need for assessment.
b Contact the client and confirm you are speaking with the
right person by asking ACC's identity check questions.
Identity Check Policy
c Discuss the report, the outcome of the guidance and the
next steps. Consider if a face-to-face meeting is required.
NG GUIDELINES Client Face to Face Meetings
ACC > Claims Management > Manage Claims > Gather Additional Information or Advice > Arrange Medical Case Review (MCR) Assessment
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