Applications and Timeframes for Support Decisions [ Histor-
ical ] v14.1
Summary
4.0 Relevant type of support
a Always consider requests for assistance in terms of the
Objective
relevant type of support, e.g. a client may ask ACC to buy
Refer to this guidance when managing requests for support.
them a car but the relevant type of support is Transport
This page outlines the types of support available to clients, and
for Independence.
informs you what constitutes a request for support, who can
apply for support, and the timeframes we follow when consi-
dering requests for support.
5.0 Requests for types of support we do not pro-
vide
1) Support available to clients
a
2) Who can apply for support?
In some cases, ACC receives inquiries regarding sup-
3) General enquiries or requests to change support are not re-
ports we do not provide, such as gardening. In most
1982
quests for support
cases, clarification on what assistance we provide is suffi-
4) Relevant support
cient, and a decline letter with review rights is not re-
5) Requests for types of support we do not provide
quired.
6) Verbal applications
b Should the client insist on this assistance, or formally re-
Act
7) Timeframes for decisions on support
quest the service, item or support, consideration should
8) Lodgement date for support claims
be given to any relevant type of support that would meet
9) Record the date the request is received
their need. For example, offering the client home help in-
10) Unable to make support decision within timeframe
stead of gardening.
11) Review on the grounds of unreasonable delay
c If the client continues to insist that ACC provide the ser-
Owner
vice, item, or support, then ACC should consider the re-
fusal of the item as a decision. A decline letter with review
Expert
rights should be issued.
Policy
6.0 Verbal applications
1.0 Types of support available to clients
a Verbal applications must be:
a
Information
Types of support available to clients include:
• requests for a specific type of support, e.g. housing
• rehabilitation, comprising treatment, social rehabil-
modifications or transport for independence
itation, and vocational rehabilitation
• recorded in the appropriate system with the date of the
• lump sum compensation for permanent impairment aris-
application.
ing from injuries occurring on or after 1 April 2002
• independence allowance, for impairment arising from
b You must acknowledge the request for entitlement, and
injuries before 1 April 2002
advise the client of their rights under the Code of ACC
• weekly compensation
Claimants’ Rights (the ACC Code). See Working with the
• support for fatal injuries, e.g. funeral grant, survivors
Code of ACC Claimants’ Rights
Official
grant, childcare, weekly compensation.
Code of ACC Claimants’ Rights (the ACC Code).pdf
Working with the Code of ACC Claimants rights
2.0 Who can apply for support?
the
a Applications for support can be made by:
7.0 Timeframes for decisions on support
• clients
• treatment providers, in respect of treatment costs
a ACC has a legislative requirement, as well as obligations
• legal guardians of clients, e.g. parents of children
under the ACC Code, to make every decision regarding a
• family members authorised by the client
claim in a timely manner. This includes decisions on sup-
• advocates and lawyers authorised to act on the client’s
port.
behalf.
b
under
ACC regards 21 days as a reasonable timeframe for the
b If a client has suffered cognitive impairment due to their
majority of decisions on support.
injury, the immediate family may apply for assistance on
their behalf.
8.0 Lodgement date for claims for support
a A claim for support is lodged on the later date of either:
3.0 General enquiries or requests to change sup-
• when the cover decision is made, or
port are not requests for support
• the client applies for the support.
a If a client asks what assistance is available from ACC,
this does not constitute a claim for support.
9.0 Record the date the request is received
Released
b Requests for a change to the current level of support are
not requests for support.
a Record the date the claim for support was lodged, to:
• ensure we make decisions in a timely manner
• allow arrears to be paid, if applicable (we sometimes
pay arrears for rehabilitation)
• allow for subsequent checking if required.
ACC > Claims Management > Manage Claims > Operational Policies > Treatment and Rehabilitation > Social rehabilitation > Applications and timeframes for entitlement
decisions > Applications and Timeframes for Support Decisions
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10.0 Unable to make decision on support within
timeframe
a If a client has a covered injury, but it is unlikely that we
can make a decision on a requested type of support
within 21 days of the claim being lodged, we must con-
tact the client about the reason for the delay and send
the ENT01 Further information required (30K) letter to the
client acknowledging the application advising that more
time is required to process the application.
ENT01 Agreement to extend time (unable to issue
decision)
11.0 If no cover decision
1982
a If a client requests a new type of support but their injury
does not yet have a cover decision, send the ENT05
Cover decision pending (31K) letter advising the appli-
cation will be processed if the cover is awarded.
Act
ENT05 Cover decision pending
12.0 Review on the grounds of unreasonable delay
a A client may apply for a review of any delay that they be-
lieve is unreasonable in processing a claim for support.
b What is considered unreasonable will depend on all the
circumstances of the case.
c If the reviewer believes that we have not made a decision
within a reasonable timeframe, they may direct us to
make a decision on the claim within a specified time-
frame, or they may make the decision for us.
Information
d Under Accident Compensation Act 2001, section 135(2)
(g) a client can only make an application for review on
the grounds of unreasonable delay after 21 days have
passed since the date on which the claim for support was
made. However, we cannot refuse to send the matter to
review if fewer than 21 days have passed.
Accident Compensation Act 2001, section 135(2)(g)
Official
How to apply for review
http://www.legislation.govt.nz/act/public/2001/0049/lat
the
Timeframes
None Noted
under
Released
ACC > Claims Management > Manage Claims > Operational Policies > Treatment and Rehabilitation > Social rehabilitation > Applications and timeframes for entitlement
decisions > Applications and Timeframes for Support Decisions
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Assess Loss of Potential Earnings (LOPE) - Physical
Injury [ Historical ] v12.1
Outputs
1982
6.0
Request setup of LOPE payments
Act
eekly
Linked Process
Assess a Backdated W Compensation Request
Linked Process
Seek Internal Guidance
Information
5.0
Receive and review the occupational assessment report
4.0
Create purchase order
Official
Linked Process
Arrange Section 105 Medical Assessment
3.0
Review task
the
2.0
Arrange s105 Occupational Assessment
under the Official Information Act 1982
under
riggers & Inputs
T
1.0
Assess LOPE eligibility
Released
Administrator
Recovery Coordinator
Recovery Partner
Recovery
ACC > Claims Management > Manage Claims > Manage Vocational Interventions / Supports > Assess Loss of Potential Earnings (LOPE) - Physical Injury
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Page 1 of 4
Assess Loss of Potential Earnings (LOPE) - Physical
Injury [ Historical ] v12.1
Loss of Potential Earnings Policy
Summary
NOTE What do you need to consider when the
entitlement request is received and deemed
Objective
cover exists?
Determine eligibility for Loss of Potential Earnings (LOPE) Pay-
Refer to the Deemed Cover and Entitlements
ments for a client with a Physical Injury.
Policy for considerations to determine client
Background
entitlement eligibility while in deemed cover
Who LOPE is for?
period.
All clients who are potential earners should have their eligi-
Deemed Cover and Entitlements Policy
bility for Loss of Potential Earnings checked. The definition of a
potential earner is a claimant who, at the time of sustaining their
b Determine Eligibility:
1982
injury they were either:
• What period the client is claiming for?
• Is less than 18 years of age on the date they are considered to
• Identify clinical and other records that support these pe-
be a potential earner
riods of incapacity
OR
• Assist in confirming (passive) the injury occurred prior to
• in full-time study or training that was continuous since before
the age of 18.
Act
reaching 18 years of age
eg “confirm the injury occurred prior to the age of 18.” .
NOTE What if the records are not on the claim?
Loss of Potential Earnings (LOPE) assessment for a Physical
Refer to the Request Clinical Records process.
Injury Claim requires a Recovery Team Member to first assess
PROCESS Request Clinical Records
the client's eligibility against a set of criteria, then investigate
their inability to work. This may include the following assess-
NOTE What if there is no ACC18 Medical Certificate
ment types:
that supports the claim?
Check clinical and other records can be used to
1) Section 105 Occupational Assessment. This is purchased by
support backdated periods of incapacity in the
following the Initial Occupational Assessment (IOA) process.
absence of ACC18 Medical Certificate.
The purpose of this assessment is to provide supporting infor-
mation to subsequent assessors so that they can determine
c Determine if the client has been engaged in any full-time
whether there is now, or has been at some time in the past,
study for the period which they are claiming for, or if the
Information
incapacity from engaging in work types for 30+ hours based on
client was engaged in full time study prior to the age of
their skills, training and education.
18 (or 16 under the 1972 and 1982 Act), until they sus-
tained their injury.
2) Section 105 Medical Assessment. This assessment is to
NOTE What if the client did engage in full-time
determine how the injury has been (retrospectively) or is cur-
study?
rently affecting the client's ability to work. This assessment is
Send a request for information to the confirmed
only used in cases of doubt about incapacity, or when it appears
education provider to obtain confirmation of the
likely that there is no longer any incapacity and that entitlement
course, including course dates.
will be declined. Contact Recovery Support to confirm before
Official
omitting referral for this assessment.
d Confirm that the client meets all eligibility criteria for Loss
of Potential earnings.
Upon receipt of relevant information, the Recovery Team
NOTE What if you are unsure if the client meets the
Member may consult with Recovery Support to determine
the
eligibility criteria?
whether the client is or has in the past been unable, because of
his or her personal injury, to engage in work for which he or she
Go to Seek Internal Guidance
is suited by reason of experience, education, or training, or any
PROCESS Seek Internal Guidance
combination of those things.
NOTE What if the client does not meet the eligibility
criteria?
The intention behind Loss of Potential Earnings (LOPE) is to
provide an income for young adults who, as a result of their
Decline the request. Go to Issues Recovery
under
injury, are unlikely to gain paid employment or will face signif-
Decision.
icant challenges securing paid employment. The value of Loss
PROCESS Issue Recovery Decision
of Potential Earnings payment is set by ACC and fixed relative
to the adult minimum wage. LOPE starts when the person is a
young adult and in many cases continues until they're eligible
2.0 Arrange s105 Occupational Assessment
for National Superannuation.
Recovery Coordinator, Recovery Partner
a In Eos, generate a Vocational Rehabilitation referral task
for a 'Initial Occupational Assessment'. For further infor-
mation refer to Referring Tasks to Recovery Adminis-
tration - Principles.
Owner
Released
Expert
NOTE What if client is not able to engage in s105
Assessment?
Procedure
If the client is non-verbal or behavioural reasons
is unable to engage in s105 Occupational
1.0 Assess LOPE eligibility
Assessment, request clinical written guidance.
Recovery Coordinator, Recovery Partner
Referring Tasks to Recovery Administration - Prin-
a Review the eligibility criteria for LOPE payments.
ciples
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Creating Manage Referral Tasks - System Steps
Purchase Order - Handy Hints on how to create and
b
edit POs
Complete the mandatory fields in the e-form.
b Identify and select a contracted provider in the client's
NOTE What information is required?
geographic area.
• Purchase order code: VIO105 Vocational
Independence Occupational Assessment Loss of
NOTE What if this is a re-referral?
Potential Earnings Section 105 assessment (one
Update the original Purchase Order with the new
unit)
Provider and continue with this process.
• Investigation Period: Incapacity start and to
NOTE What if a preferred provider has been spe-
date eg May 1996 to present
cified in the task?
• Vendor preference (if applicable)
• Reason for the referral.
Select the vendor from the Contracted Suppliers
tool below. Go to task (c).
If your client has a care plan indicator, refer to
Contracted Suppliers Tool
'Considerations for Disclosure of Care Plan Indi-
cators' page for information about when this
c Add the selected vendor as a participant on the claim.
1982
needs to be shared.
Manage Participants (Eos Online Help)
Considerations for Disclosure of Care Plan Indi-
NOTE What if the purchase order requires a higher
cators
delegation?
c
Act
Send the task to the Recovery Admin within 24 hours.
Refer to the system steps below.
NOTE What if the request is urgent and needs to be
Request Authorisation for a Purchase Order -
completed that day?
System Steps
Call Recovery Administration, provide the claim
d Select 'Add documents' and generate the ACC6278 refer-
number and request the task is completed today.
ral for Loss of Potential Earnings Occupational Assess-
NOTE What if the request is required in the future?
ment.
If the support is required in the future, set a re-
e Add additiona information received in the task to the
minder task for the future date when the support
referral. For guidance refer to the ACC6278 - ACC refer-
will be required.
ral for Occupational Assessment. Obtain ACC7416 from
the link below as this document cannot be generated
When the reminder task is due return to Activity
from Eos yet.
2.0 Arrange s105 Occupational Assessment.
Admin Template - ACC6278 Initial Occupational
Information
Review the contract timeframes and SLAs as
Assessment
specified in the service page.
ACC7416 Loss of Potential Earnings Occupational
Assessment
f Perform privacy checks on the documents in the group.
PROCESS
Arrange Section 105 Assessment
Recovery Coordinator, Recovery Partner
NOTE These must not contain any injury or medical
information. This is crucially important as
Official
3.0 Review task
failure to observe constitutes a privacy
breach.
Recovery Administrator
a In Eos select 'Do Task' from your task queue.
NG SUPPORTING INFORMATION Inbound and
the
b Check the task provides the following information:
Outbound Document Checks
• purchase order code (VIO105)
• investigation period
Privacy Check Before Disclosing Information Policy
• vendor preference (if applicable)
NOTE Can you provide medical information?
• reason for the referral.
ACC will provide information that is relevant to
NOTE What if you receive a task for a Care Plan
the occupational assessor and the assessment
Indicator client?
that is being completed. If you are providing any
under the Official Information Act 1982
under
Refer to the page 'Considerations for Disclosure
medical information, advise the client and seek
of Care Plan Indicators' to determine what you
their consent. You should also provide a copy of
need to do with the information received.
the ACC6300 Authority to collect medical and
other records form.
Considerations for Disclosure of Care Plan Indi-
cators
g Complete the documents and convert the ACC6278 into
a non-editable PDF, leaving the ACC7416 as an editable
NOTE What if you receive a NGCM - Admin Request
word document.
task for a re-referral as the Provider is unable
to accept a referral?
h Create and send an email using 'Requests and referrals'
Go to Activity 4.0 (b).
template
Released
NGCM - FINAL Emailing from Eos using a Template
- System Steps
4.0 Create purchase order
NOTE What if there is a document group?
Recovery Administrator
Open document group and link the ACC7416
a In Eos, generate a purchase order using the purchase
and VIO03 to the group and email to the vendor.
order code VIO105 and Vocational Rehabilitation and
Independence Rehabilitation Action.
Creating purchase orders using general + QE
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NOTE What if the email is too large to send as a
NOTE What if you have declined the request for
single email?
LOPE?
Contact the vendor and ask if the referral can be
• Advise the client the reason(s) for declining the
sent by courier. If yes, confirm correct physical
LOPE request and explain their review rights.
address then go to Prepare and Send Client
Refer to the NG Principles Decision Making
Information by Courier then return to this
document to support the conversation.
process. Otherwise, send by email.
• Create and send the SPD999 Decline entitle-
PROCESS Prepare and Send Client Infor-
ment decision – client letter via the client's pre-
mation by Courier
ferred method of communication.
• Record the decision as per the Decision
i In Salesforce, close the referral task
Making Principles.
NOTE What if you are advised by a Provider they
NG Principles Decision Making
are unable to accept a referral?
Go to Activity 4.0 (b) and complete a re-referral.
Add a Non standard WC set up Eform
b In Eos, add the Setup Weekly Compensation - BDWC
task and link the non-standard WC set up eform and
1982
5.0 Receive and review the occupational assess-
ACC6217 (if applicable) to the task.
ment report
Add a Weekly Compensation setup task (Eos online
Recovery Coordinator, Recovery Partner
help)
Act
a Receive report.
Link a document to a task in Eos
b Review report to check that details are correct to claim.
c Confirm entitlement for loss of potential earnings based
on clinical and other records, certified incapacity and the
Timeframes
assessments available. This must be done via seeking
technical written guidance.
Activity
Incl.
Active
Wait
d Determine if you need to arrange a s105 Medical Assess-
Time
Time
ment.
Arrange Section 105 Assessment
NOTE When would you not need to arrange a s105
Medical Assessment?
-
-
If the available medical information shows symp-
Seek Internal Guidance
toms so severe as to make any form of gainful
Information
employment unsustainable (e.g. in long-term
-
-
hospitalisation; housebound; safety risks to self
or others and/or major cognitive dysfunction)
Assess a Backdated Weekly Compensation Request
then speak with Recovery Support (Medical Ad-
visor) who may advise omitting a s105 Medical
-
-
Assessment.
PROCESS Seek Internal Guidance Official
e Consider Backdated Weekly Compensation Process and
whether an ACC6217 needs to be completed.
the
PROCESS
Seek Internal Guidance
Recovery Coordinator, Recovery Partner
PROCESS
Assess a Backdated Weekly
Compensation Request
Recovery Coordinator, Recovery Partner
under the Official Information Act 1982
under
6.0 Request setup of LOPE payments
Recovery Coordinator, Recovery Partner
NOTE Is PPPR necessary before starting LOPE pay-
ments?
Visit the 'Personal and Property Orders for
Clients Policy' page to help determine this. (Link
cannot currently be shared).
a Contact to the client and to discuss details of the WC14 -
Released
Accept Application for Weekly Compensation decision
letter, answering any questions they may have.
ACC > Claims Management > Manage Claims > Manage Vocational Interventions / Supports > Assess Loss of Potential Earnings (LOPE) - Physical Injury
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Assess Loss of Potential Earnings (LOPE) - Sensitive
Claims [ Historical ] v17.3
eekly
9.0
Issue decision
Linked Process
Request Set Up of W Compensation Payments
1982
8.0
Review s105 Occupational Medical Assessment report
Act
6.0
Review s105 Initial Occupational Assessment and s105 Initial
7.0
Arrange s105 Occupational Medical Assessment if
5.0
Arrange s105 Initial Occupational Assessment
5.1
Arrange s105 Function AssessmentInformation
4.0
Assess LOPE eligibility
Official
inical and
est and
0
3
Req review earnings records
the
2.0
Contact the client or representative
under the Official Information Act 1982
under
riggers & Inputs
T
1.0
Review claim
Mental
-
Released
eam Member
Administrator
Assessor
Recovery Partner
Recovery
Injury
Recovery Partner
Cover
Recovery T
ACC > Claims Management > Manage Claims > Manage Vocational Interventions / Supports > Assess Loss of Potential Earnings (LOPE) - Sensitive Claims
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Assess Loss of Potential Earnings (LOPE) - Sensitive
Claims [ Historical ] v17.3
NOTE What do you do if the claim status is held or
Summary
declined?
You need to determine cover first. Refer to the
Objective
Assess Early Supports Plan process. You can
Determine eligibility for Loss of Potential Earnings (LOPE) Pay-
investigate cover and financial entitlements
ments for a client with a Sensitive Claim.
alongside each other to avoid delay in kiritaki ac-
cessing support.
Background
PROCESS Assess Early Supports Plan
Loss of Potential Earnings (LOPE) assessment for a Sensitive
Claim requires a Recovery Partner to first assess the client's
NOTE What if there is no ACC18 Medical Certificate
eligibility against a set of criteria, then investigate their ina-
that supports the claim?
bility to work by completing three assessments. These assess-
Ask the client to obtain current and ongoing
1982
ments must be completed in this order. However, if #2 appears
ACC18 Medical Certificate from their GP.
to demonstrate severe incapacity, confirm this with Medical Ad-
visor who may confirm omission of #3 on this occasion.
Existing clinical and other records can be used to
support backdated periods of incapacity in the
1) Section 105 Occupation Assessment. This is purchased by
absence of an ACC18 Medical Certificate.
Act
following the Vocational Independence Occupational Assess-
ment (VIOA) process. The purpose of this assessment is to pro-
Rules for Medical Certificates for Inability to Work
vide supporting information to subsequent assessors so that
Policy
they can determine whether there is now, or has been at some
d Check the claims history and check for a duplicate claim
time in the past, incapacity from engaging in work types for 30+
to determine if there are other Sensitive claims. This en-
hours based on their skills, training and education.
sures that cover is sitting on the right claim.
2) Section 105 Function Assessment (psychiatric/psycho-
NOTE What if you find a duplicate claim?
logical). If ACC has already determined the client's Personal
Link the duplicate claim. Go to Identify and Link
Injury cover through a Specialist Cover Assessment then this
Duplicate Claims :: Identify and link duplicate
assessment will determine the functional effects of the client's
Sensitive claims.
mental injury on their ability to engage in work types identified
PROCESS Identify and Link Duplicate
in the Occupation Assessment. If the client has not completed a
Claims :: Identify and link dup-
Information
recent Assessment, then they should be referred for a Specialist
licate Sensitive claims
Cover Assessment with additional questions on Function, as
e Check the Indicators tab to find out if physical file exists.
specified in the referral letter for s105 Specialist Cover Assess-
ment + Function Assessment (psychiatric/psychological)
NOTE How do you request a physical file?
Refer to the Retrieve Archived Physical Claim
3) Section 105 Occupational Medical Assessment. This assess-
Files process to request and obtain physical
ment is to determine how the injury has been (retrospectively)
files.
or is currently affecting the client's ability to work. This assess-
PROCESS Retrieve Archived Physical
ment is only used in cases of doubt about incapacity, or when
Official
Claim Files
it appears likely that there is no longer any incapacity and that
entitlement will be declined. Contact Recovery Support to con-
NOTE What if the medical/clinical records are not
firm before omitting referral for this assessment.
on the claim?
Refer to the Request Clinical Records process.
the
Upon completion of all necessary assessments, the Recov-
PROCESS Request Clinical Records
ery Partner must consult with Recovery Support to determine
whether the client is or has in the past been unable, because of
f In Eos, check the claim for medical/clinical records and
his or her personal injury, to engage in work for which he or she
Consent tab for a signed ACC6300 within the last
is suited by reason of experience, education, or training, or any
12months.
combination of those things.
NOTE DHBs require a new ACC6300 every 12
months.
under
Owner
Expert
NOTE What if there is no recent ACC6300 signed
within 12 months?
Procedure
Obtain a new ACC6300 and send to the client or
the provider. Refer to the Obtain Client Authority
1.0 Review claim
to Collect Information process.
Recovery Partner
PROCESS Obtain Client Authority to Col-
a Understand LOPE eligibility criteria.
lect Information
Loss of Potential Earnings Policy
NOTE What should you consider in the medical/
Released
b In Eos, check the claims history for medical notes to
clinical records already on the claim?
ensure that Deemed Date of Injury (DDOI) is accurate or
Check the medical records to understand:
if there is an earlier DDOI.”
• What additional medical records may be
needed to support the assessments.
c Determine Eligibility:
• What period the client is claiming for?
g Determine if the client meets the Sensitive claims criteria
• Identify clinical and other records that support these pe-
as outlined in section '1.0 Eligibility' and '2.0 Schedule 3
riods of incapacity.
of the Accident Compensation Act 2001' of the Cover Cri-
• Assist in confirming (passive) the injury or Event oc-
teria for Sensitive Claims Policy.
curred prior to the age of 18.
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Cover Criteria for Sensitive Claims Policy
ACC138 Certificate of attendance
NOTE What if the client meets the Sensitive claims
NOTE What is considered full-time study or train-
criteria?
ing?
Determine whether appropriate to organise Spe-
Refer to section '5.0 Definition of full-time study
cialist Cover Assessment and Function Assess-
or training' of the LOPE Policy.
ment before client engaging Cover and Well-
e Ensure that the client understands why ACC needs to re-
being Plan stage.
quest notes, Real Time Earnings (RTE) and Ministry of
Social Development (MSD) benefit information and that
Go to activity '6.0 Arrange s105 Function
they are aware of what period we are requesting for.
Assessment'.
NOTE Why do we need to request relevant infor-
NOTE What if you are unsure if the client meets
mation from IR and MSD?
Sensitive claims criteria.
We use the information to confirm previous earn-
Discuss the claim with your Team Leader,
ings from IR and MSD to help assess eligibility
Recovery Partner Level 2 or Practice Mentor.
and potential entitlement for LOPE.
1982
NOTE What if the client has not granted ACC au-
2.0 Contact the client or representative
thority to collect medical and other records?
Recovery Partner
Obtain verbal and written consent from the client
a
so that we can collect relevant medical or other
Determine whether you will contact the client or an Au-
Act
records. See Obtain Client Authority to Collect
thority to Act (ATA).
Information process for further guidance.
NOTE What if you need to add or update the ATA?
Refer to Obtain Authority to Act (ATA) process.
PROCESS Obtain Client Authority to Col-
PROCESS Obtain Authority to Act (ATA)
lect Information
b Contact the client or ATA by their preferred method of
f Advise the client that we may request updated clinical
communication. Advise receipt of request and explain
records. Confirm that the client is OK with this.
LOPE eligibility criteria.
NOTE What if you need to request updated clinical
NOTE Do you need to send a letter to the client to
records?
confirm receipt of entitlement request?
Ask the client for their relevant health provider
Only if the client requests it. To do this, generate
who we may need to obtain medical records
the 'WC41 Investigate link - client' and replace
from.
Information
'relevant pre-existing conditions you have like
NOTE What if there are no notes available or you
arthritis’ with ‘relevant pre-existing mental health
don't need to request them?
conditions you have’.
After completing the tasks below, go to activity
WC41 - Investigate link - client
4.0 Determine LOPE eligibility.
c Confirm with the client what periods to investigate LOPE
NOTE What if there are other relevant claims on
for.
file?
Ask the client if there are other relevant claims
NOTE How do you confirm the client LOPE claim
Official on file where we may obtain relevant information
period?
from and refer to Prepare and Complete Sen-
Review clinical and other records that may sup-
sitive Claims Document Release activity 2.d,
port these periods of incapacity and assist in
note 3.
confirming the client's injury occurred prior to the
the
PROCESS Prepare and Complete Sen-
age of 18.
sitive Claims Document Re-
d Determine if the client has been engaged in any full-time
lease (Provider Only)
study for the period which they are claiming for or prior to
g Advise the client that we may need to contact their em-
the age of 18 until they sustained their injury.
ployer. Confirm that the client is OK with this and that
NOTE What if the claim was lodged and accepted
they are comfortable with us discussing their claim with
under the 1972 or 1982 Act?
their employer.
under the Official Information Act 1982
under
Determine if the client was in full-time study prior
NOTE What if the client requests to not involve their
to the age of 16.
employer?
NOTE Why do we need to determine if the client has
Where there is a Sensitive claim, we must follow
been engaged in any full-time study or train-
directions by the client and not involve the em-
ing for the period which they are claiming
ployer unless requested to do so. Ensure you do
for?
not show or discuss any sensitive client infor-
As per the LOPE policy, one of the eligibility cri-
mation with the employer.
teria is the client must not be in full-time study or
h Advise client and/or ATA of the six month stand down
training that leads to the award of a qualification
period.
during the period for which they are claiming
support.
NOTE What is the six month stand down period?
Released
As per the LOPE Policy, to be eligible to receive
Loss of Potential Earnings Policy
compensation for LOPE, the client must meet all
NOTE What if the client did engage in full-time
criteria including 'have been unable to work due
study?
to the injury for more than six months'.
Send the ACC138 Certificate of attendance to
Loss of Potential Earnings Policy
the client to request information from the Univer-
sity, Polytechnic or Study Facility to obtain confir-
mation of course.
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NOTE What if the client received support from
NOTE What if the client is not registered with the
MSD?
practice?
Advise the client that ACC will reimburse MSD if
The practice may still hold notes for the client, or
they have been in receipt from MSD during any
enquire where the client is actually registered.
periods of eligibility or entitlement. Note not all
Contact that practice to see if they hold any infor-
support is reimbursed fully. If unsure speak to
mation on file.
your Team Leader or Recovery Partner Level 2.
b Request all mental health records for the periods of inca-
i Check the claim for a signed ACC165 Declaration of
pacity the client is requesting financial support for.
Rights and Responsibilities form.
NOTE How do you request clinical records?
NOTE What if there is no signed ACC165 on the
Refer to Request Clinical Records process.
claim?
PROCESS Request Clinical Records
Discuss the client’s rights and responsibilities
and confirm that the client understands these.
c Review the clinical records obtained and complete claim
Record this discussion in Salesforce and send
and client relevancy check.
an ACC165 to the client.
NOTE What do we do with the clinical information
1982
j Advise the client on the next steps and to gain further
received?
information if necessary. Refer to the process map to
Check information as it comes n. If it s not what
help give the client a high level overview of the steps we
you need or want, either return to the provider
follow when processing their request
and ask them to resend or redact the unne-
Act
cessary information and delete the unredacted
NOTE What do you need to advise the client of and
version.
what information is required?
• What will happen as part of this process in-
If unsure, check with Team Leader or Recovery
cluding information around assessments.
Partner Level 2.
• ACC may need to collect more information from
their relevant providers (list providers and get
Privacy Check Before Disclosing Information Policy
client approval to contact).
NG SUPPORTING INFORMATION Inbound and
• That we may contact their current employer to
Outbound Document Checks
gather relevant information (applicable only if
currently employed).
d Confirm the earliest DDOI based on information avail-
• Confirm with the client when and how they
able
would like to be kept up to date with progress.
NOTE What if the claim is declined or held?
• Set expectations about timeframes and com-
Information
• Do not make a decision on DDOI until cover
pleting all recommended treatment assessments
has been established.
and rehabilitation.
• In Salesforce, create a Reminder Task and
• What it would mean if there is no clear link be-
document the earliest date the client has been
tween their covered injuries and incapacity to
treated for any mental injuries;
work.
- add the consultation date (eg 15/04/2018)
- client received treatment for 'diagnosis' (eg
k In Salesforce, refer to Conduct Recovery Check-in
depression)
Conversation process to update the Recovery Check-in
- notes location (eg see pg3 of notes).
Official
task at the timeframe agreed with the client to update
• Set the due task date to the expiration date of
them on progress.
the assessment purchase order.
Conduct Recovery Check-in Conversation
NOTE What if the claim is accepted and/or clinical
the
l
records indicate an earlier DDOI?
In Salesforce, populate the Voca ional Life Area with the
relevant details and create a future dated Reminder task
Request guidance from a Psychology Advisor
to record vital information using the LOPE Sensitive
and Technical Specialist via Recovery Support.
Claims Investigation Template.
PROCESS Seek Internal Guidance
LOPE Sensitive Claims Investigation Template
e In Eos, generate the 'CVR17 Update deemed date of
injury - client' to claimant to issue a decision letter if an
earlier DDOI has been determined by Psychology Ad-
under the Official Information Act 1982
under
3.0 Request and review clinical and earnings
visor and/or Technical Specialist.
records
CVR17 Update deemed date of injury - client
Recovery Partner
NOTE On what claims would the DDOI apply?
a Request relevant medical/clinical records if the client has
DDOI would only apply to claims lodged under
given permission.
the 1992, 1998 and 2001 Acts, and not the 1972
NOTE What if you are requesting medical notes for
or 1982 Acts. There are different rules applying
a client with a Sensitive Claim?
to the dates of injury under 1972 Act, and no
Refer to 'Requesting Medical Notes for a Client
clear rule under the 1982 Act. In these two sce-
with a Sensitive Claim'.
narios, seek guidance from a Technical Spe-
cialist.
Released
Requesting Medical Notes for a Client with a Sen-
f
sitive Claim
Retrieve the earnings from IR to confirm the client was
employed during the periods of incapacity.
NOTE What do you need to do prior to making a re-
quest for any updated medical/clinical
records?
Contact the relevant health providers to confirm
that the client is registered with the practice.
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NOTE How do you obtain Inland Revenue (IR) earn-
NOTE What do you need to consider when the
ings information if the client was in employ-
entitlement request is received and deemed
ment?
cover exists?
1) Request Real Time Earnings (RTE) infor-
Refer to the Deemed Cover and Entitlements
mation to determine if the client has been in re-
Policy for considerations to determine client
ceipt of any earnings between DDOI and DOFI/
entitlement eligibility while in deemed cover
DOSI. This will also help confirm client's dates of
period.
employment. This requires client consent befo-
Deemed Cover and Entitlements Policy
rehand.
b Confirm that the client meets the eligibility criteria before
Only collect the period for the month of the con-
proceeding with the first assessment:
firmed date. For example: DDOI or DOFI/DOSI
• be a potential earner
has been confirmed as 15/03/2020. You would
• have turned 18
request period for 01/03/2020 to 31/03/2020.
• earnings are under minimum rate
Ensure that you are only requesting the RTE for
• not be in full-time study
the dates in question. Requesting information
1982
from DDOI to DOFI/DOSI is an over request and
NOTE What if you are unsure if the client meets the
a potential breach of the client's privacy.
eligibility criteria?
2) Create a ‘General Task’ with the heading RTE
Speak to your Team Leader, Recovery Partner
REQUEST’
Level 2 or Practice Mentor. Act
3) Add Reason e.g. to confirm earner status at
NOTE What if the client doesn't meet the 1-4 of the
DDOI or DOFI/DOSI
eligibility criteria for LOPE?
4) Period required
Go to 10.0c NOTE 2 to generate the decline
5) Transfer the General Task to Weekly Compen-
decision letter and communicate the decision to
sation Sensitive Claims queue.
the client.
NOTE How will you know when earnings infor-
NOTE What if the client may meet the eligibility cri-
mation is available?
teria for weekly compensation?
Client Payments will save the RTE to the claim
Consider which entitlement is more beneficial for
and return the task to advise they are now avail-
the client, i.e. LOPE weekly amount vs Weekly
able.
Compensation weekly amount.
NOTE What if IR is unable to provide RTE break-
down on backdated periods?
If unsure, speak to your Team Leader, Recovery
There are limitations to how far back IR can pro-
Partner Level 2 or Practice Mentor support.
Information
vide the breakdown of RTE. For RTE requests
PROCESS Assess Weekly Compensation
before 2000, IR may be able to provide the year
for Sensitive Claims
earnings but not the earnings by week or month.
NOTE How do you determine which financial sup-
In this case, ask the client to provide evidence of
port is more beneficial for the client?
their earnings to confirm their earner status in
Review RTE earnings to determine clients pre-
the period required.
vious earnings.
Seek Technical Guidance if unsure of information
NOTE What if the client may benefit more on
Official
received in RTE.
Weekly Compensation?
g Consider requesting MSD benefit information for the pe-
If the Weekly Compensation amount appears to
riods the client is claiming LOPE using the following
be higher, go to the Assess Weekly Compen-
instructions.
sation for Sensitive Claims process. This
the
process ends.
NOTE Why should you request benefit information
PROCESS Assess Weekly Compensation
from MSD?
for Sensitive Claims
To help determine if the client has been incapa-
citated to work if medical/clinical records are not
c Contact the client or ATA to confirm and explain what the
enough to clearly indicate this.
next steps are.
MSD Benefit Information Request Email Template
NOTE What are the next steps?
under the Official Information Act 1982
under
1) s105 Initial Occupation Assessment,
2) s105 Specialist Cover Assessment and Func-
4.0 Assess LOPE eligibility
tion Assessment, and
3) if needed, s105 Occupation Medical Assess-
Recovery Partner
ment.
a Review the eligibility criteria for LOPE payments. Refer to
the policy, guidelines on eligibility date for MI and busi-
Find out from the client at this time if the client
ness rules below.
has a vendor and/or assessor preferences ie
Loss of Potential Earnings Policy
gender, location.
d
LOPE Eligibility Date for Mental Injuries
In Salesforce add or update Agreed Interventions on the
Recovery Plan if the client agrees to the above assess-
Released
How to work out a clients date of event for a sen-
ments.
sitive claim
NOTE How do you add or update Agreed Inter-
ventions?
Refer to Create or Update Recovery Plan
process activity 2.2c.
PROCESS Create or Update Recovery
Plan
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5.0 Arrange s105 Initial Occupational Assessment
5.1 Arrange s105 Function Assessment
Recovery Administrator - Mental Injury, Recovery Part-
Recovery Administrator - Mental Injury, Recovery Part-
ner
ner
a In Eos, generate a Vocational Independence Occupa-
a Confirm that the client has completed a Supported
tional Assessment referral task for a 'Vocational Initial
Assessment/ Specialist Cover Assessment within the last
Occupational Assessment' to purchase the assessment.
two years.
Referring Tasks to Recovery Administration - Prin-
NOTE What if the client has not had a recent Sup-
ciples
ported Assessment/ Specialist Cover Assess-
ment?
Creating Manage Referral Tasks - System Steps
Arrange a Specialist Cover Assessment with
b Complete the mandatory fields in the e-form.
additional questions on Function specific to
c Provide additional information in the task if applicable.
LOPE. This is to determine the effects of the
injury on their work capacity.
NOTE What information is important to include in
the task?
Arrange this assessment using the Set Up Spe-
1982
• Expected outcome
cialist Cover Assessment and/or Function
• Vendor preference if applicable
Assessment process. You will need to start at
• Reason for the referral
activity '3.0 Create request for Specialist Cover
• Factors that may impact the assessment, e.g.
Assessment' and refer to the notes on Specialist
Act
communication difficulties or interpreter services
Cover Assessment with additional Function
• State if the client has requested CV preparation
questions for specific guidance for this assess-
• Name of document group or advise no docu-
ment type.
ments are to be sent
PROCESS Set up Specialist Cover Assess-
• If your client has a care plan indicator. Refer to
ment and/or Function Assess-
'Considerations for Disclosure of Care Plan indi-
ment
cators' page for information about when this
needs to be shared.
b Seek Medical Advisor opinion via Hotline or Rapid Advice
• The purchase order code for a LOPE IOA is
Medical (RAM) session before referring for further
VIO105. Do not use IOA02.
assessment
NOTE What can the Medical Advisor Hotline help
Additional information is found in the Partnered
with?
MI Occupational Assessment section of the Part-
The Medical Advisors may be able to determine
nered and Assisted Mental Injury Task Tem-
whether a Function Assessment is required
Information
plates.
based on the assessment and clinical/medical
Considerations for Disclosure of Care Plan Indi-
records we have on file. They can also provide
cators
comment on what clinical information we may
need to request from treatment providers eg GP,
Partnered and Assisted Mental Injury Task Template
Te Whatu Ora (DHB).
NOTE What if assessor notifies us that the client
PROCESS Seek Internal Guidance
did not attend (DNA) the assessment?
NOTE How do you organise a RAM session?
In Eos, generate an NGCM Admin Request task.
Official
Advise Recovery Admin to add one of the codes
Speak to your Team Leader to book a session.
below including quantity (1 or 2) and timeframe
c Use the Contracted Suppliers list to find a Clinical
to the current Purchase Order for the assessor.
Psychologist or Psychiatrist who holds an SCS contract
• IOADNAC - Did not attend Complex IOA
or a Clinical Psychiatric contract to undertake the s105
the
• IOADNAR - Did not attend Reassessment
Function Assessment. If possible, use a Clinician who
• IOADNAV - Did not attend CV preparation
has treated the client previously.
Note: Two DNAs per client referral
Contracted Suppliers Tool
d Call Recovery Administration, provide the claim number
and request the task is completed today if urgent.
d In Eos, generate a s105 Function Assessment referral
task.
e Review the task and create the purchase order (per-
under the Official Information Act 1982
under
formed by Recovery Administrator).
NOTE How do you create a S105 Functional Assess-
ment referral task under Sensitive Claims
NOTE How does the Recovery Administrator do
Service?
this?
1) From the ACC45 tab, press add Activity and
Refer to Assess Loss of Potential Earnings
select Request SCS Purchase Order.
(LOPE) - Physical Injury process activities '3.0
Select New Purchase Order Request.
Review task' and '4.0 Create purchase order'.
Complete template details. In Services select:
SCSFA - Function Assessment - 6 hours (In
Note the following difference with Sensitive
Total); End Date 6 months
claims purchase orders: If the ACC195 does not
SCSFAR - Function Assessment Report - 2
generate from the purchase order, open ACC195
hours (In Total); End Date 6 months
linked below, populate the blank form as neces-
Letter Info: One-off Function Assessment -
Released
sary and attach to the email to the supplier/
Vendor and One-off Function Assessment -
provider.
Client and complete details.
PROCESS Assess Loss of Potential Earn-
ings (LOPE) - Physical Injury
ACC195 - Application for Loss of Potential Earnings
Create or Update Purchase Orders | Sensitive
Claims Service
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Page 6 of 9
NOTE How do you create a s105 Function Assess-
NOTE What if the specified email address has not
ment referral task under clinical psychiatric
been verified?
contract?
Refer to Verify an Existing Provider, Vendor or
1) From the Recovery Plan sub-case, create the
Facility Email Address.
correct Admin task.
PROCESS Verify an Existing Provider,
• For clinical psychiatric contract use NGCM –
Vendor or Facility Email Ad-
Manage Referral Tasks > Mental Injury Assess-
dress
ment task.
2) Refer to the Partnered and Assisted Mental
i Send to the provider the:
Injury Task Template document to select the
• medical notes
appropriate option under 'Partnered MI Function
• assessment pack
Assessment'.
• assessment report
3) Complete all sections of the referral template.
• IBSC reports and any other types of sensitive or confi-
Ensure you instruct Recovery Admin on which
dential information.
template to add to the referral. Either:
• s105 Function Assessment, or
1982
• Cover + s105 Function Assessment
6.0 Review s105 Initial Occupational Assessment
Partnered and Assisted Mental Injury Task Template
and s105 Initial Function Assessment reports
Recovery Partner
e Review the task and create the purchase order (per-
a
Act
formed by Recovery Administrator).
In Eos, review the s105 Initial Occupational Assessment
and s105 Initial Function Assessment reports carefully
NOTE How does the Recovery Administrator do
and determine if all the questions have been answered.
this?
NOTE What if the assessor has not answered all the
To review task refer to Create and Edit Purchase
questions?
Order and Send Documents for Sensitive claims
procedure activities 1.0 Review task
Contact the assessor, request the missing infor-
mation and ask for an amended report.
To generate the purchase order, refer to Create
b Perform privacy checks on the reports ensuring all the
and Edit Purchase Order and Send Documents
details are relevant to the client.
for Sensitive claims procedure activities 2.0
Create purchase order if needed
NG SUPPORTING INFORMATION Inbound and
Outbound Document Checks
PROCESS Create and Edit Purchase
Order and Send Documents for
c Generate ACC6217 Backdated Incapacity Rationale form
Information
Sensitive Claims
complete the necessary fields and leave as 'incomplete'
f
in the claim for Medical Advisor and Technical Specialists
Create a document group and name it 's105 Function
to complete.
Assessment'.
ACC6217 Backdated incapacity rationale & referral
Manage document groups
for interest on late payment of weekly compensation
g Send relevant documents and information to the asses-
d Obtain Written guidance from Recovery Support.
sor.
NOTE What can Recovery Support assist with?
Official
NOTE How do you send above information to a pro-
vider?
• Seek guidance from Medical Advisor and Tech-
nical Specialist, to assist in determining eligibility
Refer to the Prepare and Complete Sensitive
for LOPE based on clinical and other records,
Claims Document Release (Provider Only)
incapacity and assessments available.
process.
the
If a Supported Assessment was completed, seek
PROCESS Prepare and Complete Sen-
guidance from a Psychology Advisor in addition
sitive Claims Document Re-
to Medical Advisor and Technical Specialist.
lease (Provider Only)
• Whether a s105 Occupational Medical Assess-
NOTE What documents do you need to provide?
ment is required before we issue a LOPE deci-
• Signed ACC6300 or ACC6300D Authority to
sion.
Collect Medical and other Records. If verbal con-
• If s105 Occupational Medical Assessment is
under the Official Information Act 1982
under
sent was provided note this in the task e-form for
not required, is there sufficient information to
Recove y Admin.
issue a LOPE entitlement decision. If yes, then
s105 Initial Occupational Assessment
progress to activity 10.0 Issue decision.
• Any relevant Recovery Support guidance
PROCESS Seek Internal Guidance
• Relevant clinical notes
• Any relevant reports, ie medical, psychological,
counselling reports
7.0 Arrange s105 Occupational Medical Assess-
• Any relevant assessments
ment if required
• Any relevant previous physical files
Recovery Administrator - Mental Injury, Recovery Part-
• Information on any other ACC claims that might
ner
be relevant
a Determine if you need to arrange a s105 Occupational
Released
h Contact the assessor to confirm their email address and
Medical Assessment.
cellphone number for sending the clinical records.
NOTE What if the assessor is verbally confirming
the email address?
In Salesforce, add a contact with the details of
the conversation and confirmation for privacy
reasons.
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Page 7 of 9
NOTE What if a s105 Occupational Medical Assess-
NOTE How does the Recovery Administrator do
ment is required?
this?
Refer to Arrange Section 105 Assessment
Refer to the Arrange Section 105 Assessment
process activity '2.0 Contact client and explain
procedure activities '4.0 Review task' and '5.0
need for assessment' then return to this step to
Create Purchase Order'.
continue.
PROCESS Arrange Section 105 Assess-
PROCESS Arrange Section 105 Assess-
ment
ment
NOTE When would you not need to arrange a s105
Occupational Medical Assessment?
8.0 Review s105 Occupational Medical Assessment
When Recovery Support provides guidance that
report
a s105 Occupational Medical Assessment is not
Recovery Partner
required to determine eligibility for LOPE.
a Review s105 Occupational Medical Assessment report to
determine if all relevant information has been included.
Go to activity 10.0 Issue decision.
NOTE What information should be included?1982
b In Eos, generate an Initial Medical Assessment referral to
Refer to activity '4.0 What should you expect
purchase the assessment.
from the IMA?' of the Initial Medical Assessment
NOTE How do you create a task for Recovery
(IMA) Service Page.
Administration?
Act
Initial Medical Assessment Service Page
Use ‘Add Activity’, NGCM – Manage Referral
Tasks > Medical Assessment Referrals> S105
b Seek guidance from a Psychology Advisor, Medical Ad-
Assessment and complete all sections in the e-
visor and Technical Specialist to assist in determining
form as well as the template, by transferring the
entitlement for LOPE based on clinical and other records,
information into the ‘Specific service elements’
incapacity and assessments available.
section.
NOTE What information do we need to provide?
1) Make note of any periods of incapacity based
Code: VMS03
on historical and current medical records in-
Investigation period: Incapacity start and to date
cluding benefits information collected from MSD.
eg May 1996 to present
2) Note periods of employment and earnings
Additional details: Please specify whether as-
over minimum wage.
sessing current/ongoing incapacity and/or earlier
3) Key information from assessment reports ob-
incapacity
tained such as treatment recommendations,
Information
impact of non-covered injuries.
NOTE Where can you find more details on the
PROCESS Seek Internal Guidance
Occupational Medical Assessment referral?
Refer to the Partnered MI Section105 Occupa-
tional Medical Assessment details in the Part
9.0 Issue decision
nered and Assisted Mental Injury Task Template.
Recovery Partner
Partnered and Assisted Mental Injury Task Template
a Review that we have considered the right information,
Official
c Create a document group and name it 's105 Occupa-
kept our clients informed throughout the assessment
tional Medical Assessment'.
process, and show accountability for our final decision.
Manage document groups
NG Principles Decision Making
the
d Send relevant documents and information to the asses-
b Contact the client or ATA by their preferred method of
sor.
communication to explain the decision and send decision
letter.
NOTE How do you send above information to a pro-
vider?
NOTE Refer to activities '1.0 Advise Client of a deci-
Refer to the Prepare and Complete Sensitive
sion' and '2.0 Record details from discussion
Claims Document Release (Provider Only)
with client' of the Issue Recovery Decision
under the Official Information Act 1982
under
process.
process.
PROCESS Prepare and Complete Sen-
sitive Claims Document Re-
PROCESS Issue Recovery Decision
lease (Provider Only)
NOTE What documents do you need to provide?
• Signed ACC6300 or ACC6300D Authority to
Collect Medical and other Records. If verbal con-
sent was provided note this in the task e-form for
Recovery Admin.
• s105 Initial Occupational Assessment
• Any relevant Recovery Support guidance
Released
• Relevant clinical notes
• Any relevant reports, ie medical, psychological,
counselling reports
• Any relevant assessments
• Any relevant previous physical files
• Information on any other ACC claims that might
be relevant
e Review the task and create the purchase order (per-
formed by Recovery Administrator).
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Page 8 of 9
NOTE What else do you need to discuss with the
NOTE What additional information do you need to
client?
provide in your request?
• Explain the six month stand down period.
In the non-standard e-form task that is sent to
As per the LOPE Policy, to be eligible to receive
Payments, clearly state the client has been as-
compensation for LOPE, the client must meet all
sessed and is eligible for LOPE.
criteria including 'have been unable to work due
to the injury for more than six months'.
Go to activity '3.0 Send request to Weekly
• If you need to do backdated weekly compen-
Compensation Payments team (Recovery Team
sation (BDWC), you are reliant on information
Member)' of the Request Set Up of Weekly
from third parties eg MSD or IR which means
Compensation Payments process.
there could be delays on receiving the infor-
mation required to make the financial support
calculations.
PROCESS
Request Set Up of Weekly Compen-
• If the client received support from MSD, advise
sation Payments
the client that ACC will reimburse MSD if they
have been in receipt from MSD during any pe-
Cover Assessor, Recovery Team Member
1982
riods of incapacity. Note not all support is reim-
bursed fully. If unsure speak to your Team
Leader or Recovery Partner Level 2.
Timeframes
• Explain to the client that it is essential that on-
Act
going medical certificates need to be submitted
Activity
Incl.
Active
Wait
in order for payments to continue uninterrupted
Time
Time
without delays or part payments.
• Complete the non-standard e-form in Eos that
Request Set Up of Weekly Compensation Payments
is to be sent Payments team.
-
-
Ensure you record that these points have been
discussed with the client.
NOTE What if the decision is to decline the request
for LOPE?
Discuss with your Team Leader or Recovery
Partner Level 2 how best to communicate the
decline decision to the client.
Information
Create and send the SPD999 Decline entitle-
ment decision – client (declined) letter via the
client's preferred communication channel
(phone, post or email) including the ACC255
Kōrero mai - Working Together.
Consider if the decision needs to be commu
nicated in a safe environment such as in therapy
Official
session.
This process ends.
PROCESS Issue Recovery Decision
the
SPD999 Decline entitlement decision - client
c In Eos, generate the WCO50 accept weekly compen-
sation letter, including the ACC255 working together and
FSW05 earning while on weekly compensation to send
via the client's preferred communication channel.
under the Official Information Act 1982
under
WCO50 Accept application for weekly compensation
- LOPE
ACC255 Kōrero mai - Working together
FSWC05 Earning while on weekly compensation
d Upda e Recovery Plan.
NOTE How do you create or update the Recovery
Plan?
Refer to the Create or Update Recovery Plan
process.
Released
PROCESS Create or Update Recovery
Plan
e Request set up of Weekly Compensation - LOPE pay-
ments.
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Page 9 of 9
1982
Act
Information
Official
the
under
Released
1982
Act
Information
Official
the
under
Released
Loss of Potential Earnings (LOPE) Policy [ Historical ] v19.1
Summary
3.0 Six month inability to work criterion
a Under clause 47(3) of Schedule 1 of the Accident
Objective
Compensation Act 2001, weekly compensation for LOPE
Use the following guidance to help you determine eligibility, and
is payable when a person has been unable to work due
calculate compensation, for Loss of Potential Earnings capacity
to the injury for at least six months. This means that the
(LOPE).
effective start date for support is only after the six month
period of inability to work. Once the LOPE criteria are
1) Eligibility criteria
satisfied, the support is not payable, and cannot be back-
2) Determining inability to work
dated within that initial six month period of inability to
3) Six month inability to work criterion
work. Compensation for LOPE incapacity is payable to
4) Calculating compensation
an eligible client after six months of cumulative inability to
5) Definition of full-time study or training
work. A client can become unable to work prior to reach-
1982
6) Definition: Place of education
ing age 18.
7) Definition: Qualification
8) Links to legislation
NOTE Example
Act
Owner
A child at the age of five suffers a serious car
accident resulting in significant permanent brain
Expert
damage. As their inability to work can be tested
from a period prior to the date they turned 18, by
Policy
the time the client reaches the age of 18 they are
eligible to start receiving weekly compensation
1.0 Eligibility criteria
for loss of potential earning capacity as they
have already been unable to work for six
a To be eligible to receive compensation for loss of poten-
months.
tial earning (LOPE) capacity, the client must meet all the
following criteria:
• be unable to work due to that personal injury
4.0 Calculating compensation
• is a potential earner
• have turned 18
a Any compensation payable under the Accident Compen-
Information
• not be in full-time study or training that leads to the
sation Act 2001, Schedule 1 Clause 47 will be calculated
award of a qualification, during the period for which they
as if the client had weekly earnings of under minimum
are claiming support
earner rate.
• not have weekly earnings over the minimum earner rate
• have been unable to work due to the injury for more
Compensation is payable at 80% and abatement applies,
than six months
if the person gets earnings during the period of eligibility.
A client is not eligible for compensation for loss of poten-
tial earnings if the amount of compensation for loss of
Official
Eligibility to LOPE
earnings they are eligible for is greater than the amount
Definition of a potential earner
of compensation for loss of potential earnings they are
eligible for under Clause 47 of Schedule 1.
the
2.0 Determining inability to work
Conversely, if the amount of compensation for loss of
potential earnings they are eligible for under clause 47 is
a Inability to work due to the injury, in this case, is deter-
greater than the amount compensation for actual earn-
mined as 'incapacity' under Section 105 of the Accident
ings lost from a job they are eligible for (ie eligibility for
Compensation Act 2001 by considering if the client is
loss of earnings under the Schedule), they are not eli-
unable, because of their injury, to engage in work for
gible to receive both, only compensation for loss of
which they are suited by reason of experience, education
potential earnings.
or training.
under
Compensation for loss of potential earning capacity is
Amount payable to a client who is both eligible for
payable to an eligible client after six months of cumu-
LOPE and WC-LOE Better off assessment
lative inability to work. A client can become unable to
Amount of LOPE payable to client with no post inca-
work prior to reaching age 18.
pacity earnings
Initial LOPE abatement excess calculation
Section 105 Assessment (VMS) Service Page
https://go.promapp.com/accnz/Process/3ef695e8-be4
LOPE entitlement post abatement calculation
Definition of Incapacity LOPE
WC LOPE abatement calculation
Released
ACC > Claims Management > Manage Client Payments > Operational Policies > Weekly Compensation > Eligibility > Loss of Potential Earnings (LOPE) Policy
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Page 1 of 2
5.0 Definition of full-time study or training
7.0 Definition: Qualification
a The following are all considered full-time study or train-
a In the Education Act 1989, the term ‘award’ is defined as
ing:
being a degree, diploma, certificate, or other qualification.
• a course of study, recognised as full-time by the place
Qualifications that have been approved by a recognised
of education that administers it. The course leads to a
body and are delivered by an accredited education or
qualification approved by the New Zealand Qualifications
training organisation can be found on the New Zealand
Authority and it would be likely to enhance the employ-
Register of Quality Assured Qualifications (Kiwiquals)
ment prospects or lead to an award of a qualification
• any work-related study or training which requires an
There is no specific definition in New Zealand law of what
employee to undertake the study or training for an av-
a qualification is. The Education Act does not include an
erage of no less than 30 hours per week. This leads to a
exhaustive list of all recognised qualifications. The New
qualification approved by the New Zealand Qualifications
Zealand education sector, however, has developed an
Authority and it would be likely to enhance the employ-
agreed set of definitions for qualifications. Information on
ment prospect
these definitions can be found on Kiwiquals
• any study undertaken overseas as part of a student's
continuous and uninterrupted (up until personal injury)
1982
full-time study. This applies both to foreign students who
Kiwiquals Definitions
have come to New Zealand for study who sustain an
injury while in the country, and to New Zealand students
https://www.nzqa.govt.nz/studying-in-new-zealand/un
who have undertaken part of their studies abroad.
Kiwiquals
Act
b A client is not eligible for compensation for loss of poten-
http://www.kiwiquals.govt.nz.
tial earnings during periods of full-time study or training
Full-time study for potential earners does not include full-
8.0 Links to legislation
time study or training in living or social skills
Accident Compensation Act 2001, section 105 for
determining incapacity of a client who had ceased to
ACC considers all holiday periods, eg term or semester
be in employment, was a potential earner, or had
breaks, to be part of the study, so no eligibility exists for
purchased weekly compensation
loss of potential earnings for these periods
http://www.legislation.govt.nz/act/public/2001/0049/lat
At a secondary place of education, the main qualification
Accident Compensation Act 2001, Schedule 1,
offered to students will be the National Certificate of
Clause 47 Weekly compensation for loss of potential
Educational Achievement (NCEA). The NCEA is awarded
earnings capacity
Information
to students who achieve at least 80 credits, although a
http://www.legislation.govt.nz/act/public/2001/0049/lat
student can attempt to earn more than the minimum
number of credits required for the award of the quali-
Accident Compensation Act 2001, Section 6
fication.
Interpretation
https://www.legislation.govt.nz/act/public/2001/0049/la
NOTE Example
At a tertiary place of education, a 120 credit
course is considered equivalent to one full year
of full-time study. A credit is equivalent to 10 no-
Timeframes
Official
tional learning hours, including time spent on
assessment, self-directed learning, and contact
None Noted
with teachers. This means that a part-year
course for a lower credit value can also be a full-
the
time course
Engaged in full time study of training at specific date
6.0 Definition: Place of education
a ‘Place of education’ covers the following types of insti-
under
tutions:
• a composite school, composite private school, sec-
ondary school, or special school
• an institution, such as a polytechnic, teachers college,
university or wananga
• a registered establishment as defined by Section 159(1)
of the Education Act 1989.
Definition of Place of education
Released
ACC > Claims Management > Manage Client Payments > Operational Policies > Weekly Compensation > Eligibility > Loss of Potential Earnings (LOPE) Policy
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When to Review Cover and Entitlements Policy [ Historical ] v13.1
Summary
3.0 Change of diagnosis
a If the client’s diagnosis changes, you must consider the
Objective
new diagnosis and whether ACC should still be respon-
Recovery team members are responsible for regularly reviewing
sible for cover. Eos needs to be kept up to date and
the scope of ongoing cover and whether support is still linked to
cover letters reissued if the new diagnosis is accepted by
the covered injury. Recovery team members are also respon-
ACC. Sometimes the provider will lodge the original claim
sible for the checking the initial fund code on a file when it is
with a working or suspected diagnosis, and this is up-
allocated to them.
dated when further information is received. To ensure
ACC has accurate records, the diagnosis should be up-
dated with relevant evidence. This is important because
Owner
ACC cover is linked to ongoing liability for that injury in
the future.
1982
Expert
NOTE Example
Policy
Manju fell while playing netball and hurt her
1.0 Rules
knee. She sees her GP who lodges the claim as
Act
a knee sprain. ACC accepts cover for a knee
a Each time new support is requested or considered, or fur-
sprain. Later, it is confirmed that Manju sustained
ther medical information is received for a client, you must
a meniscal tear and she will need surgery to
confirm the link to the covered injury.
repair this. Once ACC has appropriate medical
evidence, the injury on Eos is updated as menis-
You must also review cover:
cal tear, and a fresh cover letter issued to the
• if it was granted incorrectly
client.
• if the diagnosis changes
• if there is doubt around whether the effects of the injury
originally covered by ACC are the cause of the client's
current inability to carry out activities.
PROCESS
Assess Cover for an Additional
Check that the fund code is correct and include evidence
Injury or Change in Diagnosis
Information
to support this.
Timeframes
2.0 Paying for support when claim is being as-
sessed
Activity
Incl.
Active
Wait
a If a client has requested support and ACC needs to con-
Time
Time
firm responsibility for this, it is reasonable not to pay for
Assess Cover for an Additional Injury or Change in
the support until a decision has been made.
Diagnosis
Official
NOTE Example
-
-
Susan sustained a lumbar sprain lifting a heavy
box and ACC granted cover for this. Nine months
later Susan applies for weekly compensation
the
(WC) as she is unable to work because of back
pain. Due to the nature of the injury and the
length of time between the original accident and
the application for WC, it is reasonable for ACC
to assess whether the covered lumbar sprain is
the cause of her current inability to work, before
paying WC.under
b However, if a client is currently receiving support, ACC
must continue to pay for this while assessing the claim.
NOTE Example
Adam fell off his tractor and hurt his knee. Cover
was granted for a knee sprain and ACC started
to pay WC based on Adam’s inability to work as
a farmer. Three months later he is still struggling
with the injury and hasn’t returned to work. Adam
is referred for an MRI scan on his knee, which
shows a cyst that is likely to have been there for
Released
some time. The specialist considers this is now
the cause of Adam’s pain and inability to work.
ACC must keep providing support until we re-
ceive all the medical evidence and a formal deci-
sion can be made whether to cease the support.
ACC > Claims Management > Manage Claims > Operational Policies > Managing Claims at ACC > Claim management > When to Review Cover and Entitlements Policy
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Page 1 of 1
