GOV 029160 Appendix.pdf

GOV-029160 Archived July 2021 (No longer used)
Claim validation framework: guide
Treatment Injury Cover Assessment Centre
April 2019

GOV-029160 Archived July 2021 (No longer used)
Self-validation guide
April 2019
Purpose
This guide supports proficient1 Treatment Injury Cover Specialists2 ‘Cover Specialists’ to issue cover
decisions without the need for validation, be it managerial or through the peer review process - so long
as certain claim requirements have been met.
Framework
The Treatment Injury Cover Assessment Centre, over time, has developed a set of business rules
related to claim validation for treatment injury claims. This guide now formalises these rules and builds
upon them by adopting a framework, which is structured, logical, and timely.
Our framework recognises where information clearly supports issuing a decision and the level of clinical
complexity is low, we entrust our proficient Cover Specialists to issue a decision which is: accurate, well-
considered, and timely.
Where internal or external medical opinion is sought (or the injury event is not on the self-validation –
injury event list), this signals that clinical complexity or how the treatment injury provisions apply to the
claim is not straightforward. As such it makes sense to discuss the claim at a decision-validation forum.
This’l  ensure the decision issued is accurate, well-considered, and timely.
Figure one: our framework for claim validation
Self-
Approach
Peer review
CCP
validation
Five Ws and a
Five Ws and a
Five Ws and a
1.Analysis
H: yes
H: yes
H: yes
Injury is not on
Injury is on self-
self-validation
validation list
list; or,
High-risk and/or
2.Action
high-cost: yes
No internal or
Internal or
external medical
external medical
opinion needed
opinion needed
3.Outcome
Peer review
CCP validation
Self-validation
validation
1 Proficiency means: the Team Manager is confident the Cover Specialist can consistently meet the requirements of the role and can self-
validate (e.g. the degree of confidence will be determined by a Team Manager’s understanding of their team member’s performance, the
quality marking they do and from regular coaching).
2 All of whom are qualified healthcare professionals.
Accident Compensation Corporation
Page 2 of 5

GOV-029160 Archived July 2021 (No longer used)
Self-validation guide
April 2019
A high certainty approach to self-validation
To self-validate a proficient Cover Specialist must be able to confidently answer the following questions
(five Ws and a H):
• What happened (the claimed injury)?
• Where did it happen (the anatomical location)?
• Why did it happen (the cause)?
• How did it happen (context: was the injury necessary or ordinary)?
• When did it happen (date of injury)?
• Who was involved (a registered health professional)?
And:
• the treatment injury event is on the self-validation – injury event list; and,
• no medical opinion (internal or external) was needed; and,
• the claim is not considered high-cost and/or high-risk.
Where all these requirements are met, a Cover Specialist can issue a decision without the need for
validation, i.e. managerial validation or peer review. This approach only applies to proficient Cover
Specialists. Proficiency is determined by Team Managers.
If the injury event is not on the validation guide or medical opinion (internal or external) was needed, then
the claim will need to be validated at Peer Review, unless it is considered high-cost and/or high-risk.
What high-cost and high-risk means
If a claim is considered high-cost and/or high-risk it must be referred to Complex Claims Panel (CCP) for
decision validation. CCP ensures consistent, accurate and well-considered decisions are issued, and
where a claim is covered, ACC has a better understanding as to what assistance we can offer our client.
High-cost means:
• the claim may be coverable as a treatment injury; and
• there is clear evidence that the treatment injury has resulted in significant disability, which will
require ongoing support.3
Where the claimed treatment injury event or the decision has the potential to attract attention externally,
this is considered high-risk.
Noting points – for the triage team
1. The ACC2184 does not need to be completed if the claim is an accept decision (and on the self-
validation guide) – the key information will be captured by completing the Eos treatment injury
decision tabs. A contact must be added outlining the rationale for the decision for entitlement
purposes.
2. However, if the decision is a decline or partial accept then the ACC2184 and Eos treatment
injury tabs need to be completed.
Managerial sign-off
Date: 24/04/2019
3 If unsure a Cover Specialist can seek direction from their Team Manager.
Accident Compensation Corporation
Page 3 of 5

GOV-029160 Archived July 2021 (No longer used)
Self-validation guide
April 2019
Self-validation – injury event list
Self-validation – injury event list
The claimed injury (event) is…
And there…
Accept
Decline
Allergic/anaphylactic reaction resolved with no
√
√
other injuries
Acute sprain, with clear evidence and strong
√
√
temporal link (< 10 days) to treatment
Back strain following normal vaginal delivery
√
Bladder neck stenosis, urethral stricture, urethral
was no other treatment for the
damage from straightforward TURP
underlying prostate condition or
√
complicating patient factors
Blisters/infected blisters from cryotherapy
are no underlying health
√
√
conditions
Burns
√
√
Cellulitis
√
√
Contact dermatitis
√
√
Dental injury with clear evidence and strong
√
temporal link (< 10 days) to treatment
Diagnosed and identified nerve injury
is a direct causal link to treatment
and no relevant underlying health
√
√
condition or similar
pathophysiology, i.e. Carpal
Tunnel Syndrome
Adverse reaction to vaccination
√
√
Extravasation
√
√
Early failure of joint replacement due to technical
is clear evidence confirming a
√
factors, e.g. metallosis
physical injury and treatment

cause
Fat atrophy secondary to steroid injections
√
Foreign body/retained equipment with need to
√
surgically remove
Foreign body/retained equipment with no need to
surgically remove and there is no injury, excluding
√
surgical mesh
Fractures during/following straightforward surgeries
√
√
Accident Compensation Corporation
Page 4 of 5

GOV-029160 Archived July 2021 (No longer used)
Self-validation guide
April 2019
Haematoma/bleeding/contusion
are no underlying health
√
√
conditions
Iatrogenic organ damage/injury/perforation
caused by straightforward procedure/surgery/
√
√
IUCD
Jadelle implant migration requiring surgical removal
√
√
Lacerations/abrasions
√
√
Perineal tears following normal or instrumental
√
√
vaginal delivery
PICBA claims
√
Post-operative deep vein thrombosis (DVT) –
are no underlying health
√
excluding orthopedics
conditions
Post-operative pulmonary embolism (PE)
are no underlying health
√
conditions
No post-operative pulmonary embolism (PE),
√
confirmed by imaging
Pressure injury
√
√
Scarring following a minor straightforward
are no underlying health
√
procedure
conditions
Swallowing of dental files and there is no injury
√
Thrombophlebitis
√
√
Wound infection/abscess
are no contributing factors such
as a dirty treatment procedure
√
√
i.e. surgical drainage of an
abscess
Wrong medication – no injury
√
Wrong medication – with injury
√
Accident Compensation Corporation
Page 5 of 5

GOV-029160
BUSINESS RULE
Enterprise Business Rules Portal
Criteria for a valid overseas practising certificate for providers Business
Rule
who caused a treatment injury
Rule Purpose
To ensure that New Zealand residents receive the appropriate cover for a treatment injury that occurs
while they are overseas.
A practising certificate of an overseas health care provider that provided treatment [causing a treatment injury] must be
considered to be valid if all of the following are true:
the practising certificate is issued by a registration authority from the country the treatment [causing the treatment
injury] occurred
at least one of the following is true:
the registration authority has a record of the practising certificate in an online register
a copy of the practising certificate is provided to ACC
the practising certificate specifies all of the following:

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an expiry date that is after the date of the treatment [causing the treatment injury]
at least one of the following:
a full name exactly the same as the full name of the health care provider
a professional registration number exactly the same as the professional registration number of the health
care provider
Business Terms
Practising certificate Health care provider [causing a treatment injury] Treatment injury
Treatment [causing a treatment injury] Registration authority
Tags
Cover TIO
Related Policy
Cover criteria for treatment injury Policy
Other Data 
Owner
Approvers
Reviewers
[Out of Scope]
[Out of Scope]
[Out of Scope]

GOV-029160
[Out of Scope]
Feedback
Approval Date: 16/12/2021

GOV-029160
BUSINESS RULE
Enterprise Business Rules Portal
Cover acceptance criteria for a treatment injury claim when the Business
Rule
treatment occurred in New Zealand but the resulting treatment
injury is identified overseas
Rule Purpose
To ensure that New Zealand residents receive the appropriate cover for a treatment injury that occurs
while they are overseas.
A personal injury caused by a treatment injury to a person seeking or receiving treatment [for the symptoms of that
treatment injury] at an overseas location may receive an accepted cover decision only if all of the following are true:
the injury meets the criteria for acceptance of cover for all of the following:
a personal injuryy
a treatment injury
the treatment [causing the treatment injury] occurred at a location within New Zealand

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the health care provider [causing that treatment injury] was a New Zealand registered health professional on the
date that treatment was provided
the person sought or received treatment [for the symptoms of the treatment injury] while overseas
the person was ordinarily resident in New Zealand on the date of the treatment injury
Business Terms
Personal injury Health care provider [causing a treatment injury] Cover Treatment injury
Treatment [causing a treatment injury] Treatment [for the symptoms of a treatment injury]
Ordinarily resident in New Zealand New Zealand Registered health professional
Date of injury [for a treatment injury]
Tags
Cover TIO
Related Policy
Cover criteria for treatment injury Policy
Other Data 
Owner
Approvers
Reviewers

GOV-029160
[Out of Scope]
[Out of Scope]
[Out of Scope]
Feedback
Approval Date: 16/12/2021

GOV-029160
BUSINESS RULE
Enterprise Business Rules Portal
Cover acceptance criteria for a treatment injury claim when the Business
Rule
treatment occurred overseas
Rule Purpose
To ensure that New Zealand residents receive the appropriate cover for a treatment injury that occurs
while they are overseas.
A personal injury caused by a treatment injury to a person at an overseas location must receive an accepted cover
decision only if all of the following are true:
the personal injury meets the criteria for acceptance of cover for all of the following:
a personal injury
a treatment injury
the date of the treatment [causing the treatment injury] is on or after 1 July 2005
the treatment [causing the treatment injury] occurred at a location not in New Zealand

GOV-029160
the overseas health care provider [causing that treatment injury] was not a New Zealand registered health
professional on the date that treatment was provided
the person that received the treatment [causing the treatment injury] was ordinarily resident in New Zealand on the
date on which that treatment occurred
the treatment [causing the treatment injury] was within the scope of practice of the overseas health care provider
providing that treatment
that overseas health care provider holds qualifications within that scope of practice
there is a registration authority for that scope of practice in New Zealand
that registration authority confirms those qualifications as being equivalent to New Zealand qualifications for that
scope of practice via one of the following methods:
online documentation provided by that registration authority
written confirmation from that registration authority
the overseas health care provider [causing the treatment injury] holds a practising certificate that meets the criteria
for being a valid overseas practising certificate for that treatment provider
Business Terms
Personal injury Practising certificate Health care provider [causing a treatment injury] Cover
Treatment injury Treatment [causing a treatment injury] Ordinarily resident in New Zealand
New Zealand Registration authority Registered health professional Scope of practice
Accepted cover decision
Tags
Cover TIO

GOV-029160
Related Policy
Cover criteria for treatment injury Policy
Other Data 
Owner
Approvers
Reviewers
[Out of Scope]
[Out of Scope]
[Out of Scope]
Feedback
Approval Date: 16/12/2021

GOV-029160
REFERENCE
Determining overseas equivalent of Registered Health Professional
[Out of Scope]
Published 6/12/2023
Introduction
Cover Assessors and Specialist Cover Assessors obtain the necessary information to determine if an overseas treatment
provider meets the requirement of Section 22(4)(a) of the Accident Compensation Act 2001 (the Act):
'the treatment is given by a person who has qualifications that are the same as or equivalent to those of a registered
health professional' (emphasis added)
In other words, whether or not the overseas treatment provider has qualifications that are the same as or equivalent to
those of a Registered Health Professional (RHP) in New Zealand.
In New Zealand, RHP under the Act means that all practitioners from each occupational group are registered with their
relevant regulatory authority and have an up-to-date practising certificate, in accordance with the Health Practitioners
Competence Assurance Act 2003 (HPCA Act 2003). These professional requirements predominately relate to educational

GOV-029160
achievements and continuing competency which act as a mechanism to ensure that patients are not placed at undue risk of
harm. As a result it offers assurance that individual practitioners are suitably qualified, and fit to practice in their chosen
field.
It would be difficult to conclude that individual overseas treatment providers who work within a comparable health system
overseas are not the equivalent to a New Zealand RHP. Given that individual overseas treatment providers are largely
subjected to the similar types of professional standards and on going professional development that are in place in New
Zealand.
Where a country’s health system is not considered comparable to New Zealand’s there may still be evidence to show that
the overseas treatment provider would provide the same or equivalent treatment to those of a RHP in New Zealand, based
on their educational achievements and continuing competency.
As with all claims, this information is a guide only and ACC staff must consider all claims on their individual merit, in relation
to the relevant information or case law that may be available.
It is ACC’s role to determine whether the overseas treatment provider meets the criteria of Section 22(4)(a), with information
from a New Zealand registration organisation as required. You may need clinical advice in the form of External Clinical
Advice (ECA) about the personal injury and the treatment.
DO NOT request advice from an ECA to tell us whether there is overseas equivalence in application of Section 22(4)(a) - an
ECA is not in a position to make that decision. The determination about overseas equivalence is a legal decision made by
ACC. If at anytime you are uncertain whether the overseas treatment provider is equivalent then please discuss the claim
with your Team Leader, and consider seeking internal guidance from a Technical Specialist.
Method

GOV-029160
Step 1:
Claim for a treatment injury is received that relates to treatment provided overseas.
Note: First determine if the client is ordinarily resident in New Zealand
Step 2:
Send request to the overseas treatment provider asking the following questions, this is in addition to the usual questions
relating to the treatment injury event:
What is the name of the body that you are registered with?
What is your registered qualification in full and where was this gained?
Have you ever had registration in New Zealand? If so, please provide the dates of that registration.
Please provide a copy of your current practicing certificate or registration certificate.
Step 3:
Once the above information is received, consider the following:
For all overseas treatment providers
What health qualifications does the practitioner have?
When and where were the qualifications gained?
Is the educational facility internationally recognised?
Is the practitioner registered with a national/regional authority whose role and function is similar to the New Zealand
equivalent?
Do they have a current practising certificate?
Is there evidence of continuous professional development that is of reputable standard?
If not current registered, does the practitioner have a recently issued certificate of good standing (or verification)
from a regulatory authority whose role and function is similar to the New Zealand equivalent?

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Is there any other information that supports RHP equivalency?
Do they have current or previous registration as a registered health professional in New Zealand?
And
It is important to review the relevant registration organisation criteria for all new claims, because the information can
be updated from time to time. Make a note in the claim as to when the qualifications were checked e.g.
MCNZ website checked dd/mm/yyy.
Contact the relevant registration authority to clarify whether they consider the qualifications to be equivalent to
those of a New Zealand RHP if you are unsure.
So, where would we go for information/resources to help us identify an overseas equivalent RHP? A logical start point is to
view the information in each occupational group's relevant New Zealand regulatory authority. For example, medical
treatment would be the concern of MCNZ. The table below gives examples showing how you might approach occupational
group's relevant regulatory authority; see 'Examples: handy information/resources about some RHP occupational groups'.
Examples: handy information/resources about some New Zealand RHP occupational groups
Medical Practitioner
Nurse/Nurse Practitioner
Physiotherapist
Pharmacist
Dentist/Clinical Dental Technician/Dental Technician/Dental Hygienist/Dental Therapist

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Medical Laboratory Science Practitioner
Optometrist
Podiatrist
Midwife
Occupational Therapist
Medical Raditation Technologist
Step 4:
If you determine that the overseas treatment provider meets the provisions of section 22(4)(a) - continue to assess claim for
cover.
Step 5:
If you are unable to determine if the provisions of section 22(4)(a) and have followed all the steps above and made the
relevant enquiries, seek internal guidance from a Technical Specialist.
Step 6:
Technical Specialist may seek further internal guidance to progress the claim.

GOV-029160
Contact the relevant registration authority to clarify whether they consider the qualifications to be
equivalent to those of a New Zealand Registered Health Professional if you are unsure.
Page Details
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Topic
ACC: Rehabilitation and Treatment
Information Type
Guidance
Relates To
Internal

link to page 21

GOV-029160
REFERENCE
Comparable country for overseas claim - treatment injury
Introduction 
ACC receives a small but regular number of treatment injury claims that relate to treatment provided outside New Zealand.
Most of these claims are about medical treatment. Cover Assessors and Specialist Cover Assessors obtain the necessary
information to determine if treatment overseas meets the requirement of Section 22(4)(b) of the Accident Compensation
Act 2001 (the Act):
'the personal injury would be personal injury caused by [treatment] if the treatment were given by or at the direction of
the equivalent of a registered health professional and the person suffered the injury in New Zealand' (emphasis added)
In other words, there is a 'comparison' between the treatment that was provided outside New Zealand to if that treatment
was provided in New Zealand.
In this page. medical treatment is used as an example to highlight the style of thought-process/approach needed to
compare treatment in another country. Other health practitioner groups e.g. the Midwifery Council of New Zealand will

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compare other countries differently than countries compared by Medical Council of New Zealand (MCNZ).
Not all Regulatory Authorities in New Zealand have publicly available lists of comparable countries. Regulatory
Authorities can be asked if an overseas country is comparable to New Zealand. In countries that are not identified to be
comparable, factors related to the individual overseas treatment provider's educational achievements and continuing
competency need to be taken into account to determine whether the threshold for equivalency has been met and in
context of the precise location of where the treatment took place in the overseas country. This type of approach should be
applicable to all health practitioner groups that are defined as a Registered Health Professional under the Accident
Compensation Act 2001 (the Act).
For example, medical [practice] treatment overseas: is the country
'comparable'?
MCNZ list the following 'comparable' countries [this list is only for: medical [practice] treatment overseas countires]:
Australia
Austria
Belgium
Canada
Czech Republic
Denmark
Finland
France
Germany
Greece

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Iceland
Israel
Italy
Norway
Portugal
Republic of Ireland
Singapore
Spain
Sweden
Switzerland
The Netherlands
United Kingdom
United States of America
What if the medical [practice] treatment was in a 'comparable' country?
We require a copy of the overseas health professional's current practicing certificate.
What if the medical [practice] treatment was not in a 'comparable' country?
Further information is required about the individual overseas medical professional, precisely where (not just identifying the
country - precisely where in that country too) the treatment took place and the treatment that happened.
Note: cover is not declined solely on the basis that medical treatment was not in a 'comparable' country. There still does
need to be further assessment to determine if the overseas medical professional (in the 'non-comparable' country) meets
the requirement of Section 22(4)(a) of the Act:

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'the treatment is given by a person who has qualifications that are the same as or equivalent to those of a registered
health professional' (emphasis added)
Further information: see in Te Whariki page 'Determining overseas equivalent of Registered Health Professional'.
How do we think about determining 'equivalency' of overseas treatment in a 'non-comparable' country?
Using medical treatment as an example.
Medical treatment in a country not on the MCNZ list of comparable countries:
Example 1 - meets the criteria for equivalency:
Malaysia not on the MCNZ list of comparable countries.
The treatment was at a private hospital (with internet website) in Kuala Lumpur.
The overseas medical professional evidenced:
Practising certificate from the Malaysian Medical Board.
Overseas medical professional's curriculum vitae published on a website.
Certificates (were in the last 2-5 years) from courses/workshops and conferences in Asia Pacific and Australasia
regions.
Delegates and tutors/presenters at the conferences were practising in comparable country health systems.
Overseas medical professional had done a lot of international travel.
Medical treatment in a country not on the MCNZ list of comparable countries
Example 2 - does not meet the criteria for equivalency:

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India - not on the MCNZ list of comparable countries.
Cannot find hospital in the internet - no website.
The overseas medical professional:
No evidence of a practising certificate.
No curriculum vitae.
No evidence of recent continuous professional development.
Page Details
Content Owner
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Relates To
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