GOV-040419
Make cover or funding decision :: Make PIC funding deci-
sion v121.0
NOTE What if you need to seek internal guidance ?
Summary
Review the 'Standards for Seeking Guidance'
and make sure they are met before proceeding
Objective
to 'Seek Internal Guidance (Claims Assess-
Standardised process for claims assessment
ment)'. If you request guidance, once received
return to this process.
Background
PROCESS Seek Internal Guidance (Claims
A funding request is received, and a Treatment & Support
Assessment)
Assessor must make a decision on the request to ensure a
timely experienced for the client.
Standards for Seeking Guidance
Global
g Record assessment information and update Eos, if appli-
[Out of Scope]
Process
cable.
Owner
PIC | Pre-assessment task template
Global
[Out of Scope]
h Determine if you can make a decision.
Process
NOTE What if the claim is for Treatment Injury (in-
Expert
cluding TI Fatal), Treatment Injury Mental
Variation
[Out of Scope]
Injury or FACS and you are unable to make a
Expert
decision?
Post or email (if verified) the appropriate
Procedure
acknowledgement letter to the client taking into
consideration whether a time extension is re-
1.0 Complete pre-assessment checks
quired yet. Refer to letter and form guidance.
Cover Assessor, Specialist Cover Assessor, Treatment
NOTE What if it is a request for surgery and you are
and Support Assessor
unable to make a decision?
a Complete pre-assessment checks.
Send the ELE01 letter to the client and Lead
Provider. Create a 'Follow up Cover' task, update
Pre-assessment checklist
the target date to the cover decision due date.
b Check how you use Recovery Admin before proceeding.
Transfer the task to the 'Northern SC - Funding
Application' queue.
Claims Assessment - How do I use Recovery Admin
NOTE What if you are able to make a decision?
c Familiarise yourself with the client and claim. Refer to the
Go to '6.0 Issue decision'.
Familiarise yourself with client and claim guidance.
PIC | Familiarise yourself with client and claim
d Determine eligibility for cover or funding. Refer to the
2.0 Contact Client
linked information for guidance.
Cover Assessor, Specialist Cover Assessor, Treatment
and Support Assessor
Independence allowance eligibility criteria Policy
a Determine if you need to contact the client. Refer to client
AI Act 1998, Schedule 1, Part 4, Clause 61
conversation guidance.
https://anzlaw.thomsonreuters.com/Document/I8b624b78022911e99495db3043f758b0/View/FullText.html?originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)&comp=wlnz
PIC | Initial client conversation guidance
Lump sum eligibility criteria Policy
NOTE What if you don't need to contact the client at
AC Act 2001, Schedule 1, Part 3, Clause 61
this point?
https://anzlaw.thomsonreuters.com/Document/Iee0acc6a6e0f11e8b22785ae5ff38a3b/V
Go to '3.0
iew/FullText.html?originationContext=documentto
Assess Claim'. Return to '2.0 Contact
c&transitionType=CategoryPageItem&contextData=(sc.Default)&comp=wlnz
Client' if required.
NOTE What if you determine the claim or request
doesn't meet the eligibility criteria?
b Contact the client or ATA by phone.
Go to Activity 6.0 Issue Decision.
NOTE What if you are unable to contact the client?
e Refer to the Claims Assessment Traffic Light for consid-
1) Leave a voice message, if possible
eration, if applicable.
2) Send text: "Kia Ora, ACC attempted to call
Claims Assessment Traffic Light
you to discuss your claim. Please call us on
f Check you have the delegation to make a decision with-
0800 101 996 [insert ext if applicable] so we can
out seeking internal guidance. (Go to the 'Explanations'
gather some information from you. Ngā mihi
tab, second tab from the left) and refer to the guidance
[insert Name]"
on the landing page for this claim or request type.
3) Update the master task and change the target
Delegations Framework
date to a maximum of two working day (one
NOTE What if the claim for cover is for MICPI/WRMI
working day if this is more appropriate for the
or TIMI?
client) from today’s date..
Even though the Delegations Framework states
'must seek guidance' this is referring to the Psy-
4) Attempt to contact the client a second time.
chiatric Assessment report only. Guidance is not
Then refer to the Client Call Attempts instructions
required at this point in the process. Continue
if you are unable to make contact.
this process.
What to say in a voicemail message
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Make cover or funding decision :: Make PIC funding decision
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Page 2 of 6
GOV-040419
Create and send text
PIC | Guidance for requesting clinical records
Claims Assessment - Client Call Attempts
NOTE What if you determine you need clinical
c
records?
Confirm you are speaking with the right person by asking
ACC's identity check questions.
If you are making a decision on a Treatment
Injury (including FACS & TIMI), WRGP, Hearing
Identity Check Policy
Loss or General Cover (including MI) claim, go to
NOTE If a client mentions self-harm or suicide
'Request Clinical Records (Cover)' process, oth-
follow the response conversation guide.
erwise go to 'Request Clinical Records (without
RA)' process. If this is for a Dental Claim, and
notes are required from a dental provider, email
Respond to a Caller Who Has Disclosed Thoughts of
or call the Vendor directly to request the infor-
Self-harm or Suicide
mation. Once received continue this process.
d Check the client's details match the Eos Party record.
d Consider if you need internal guidance.
NOTE What if you need to verify the client's email
PIC | Guidance on when to seek internal guidance
address?
NOTE What if you determine you need internal guid-
Refer to 'Activity 5.0 Update Client Party
ance?
Record'. Once completed return to this process.
Review the 'Standards for Seeking Guidance'
PROCESS Update Client Party Records
and make sure they are met before proceeding
Send an Email from Eos
to 'Seek Internal Guidance (Claims Assess-
ment)'. If you request guidance, once received
NOTE What if client details are incorrect on their
return to this process.
Eos party record?
PROCESS Seek Internal Guidance (Claims
Update client details.
Assessment)
NOTE What if the client's name has changed?
Standards for Seeking Guidance
Refer to the Change client's legal name Policy.
e If you are an SCA consider if you need External Clinical
Change clients legal name Policy
Advice.
e In Eos, record the conversation as a contact on the claim.
NOTE What if you determine you need External
Clinical Advice?
NOTE What if the client wishes to withdraw the
claim?
Go to 'Seek External Clinical Advice'. Once re-
ceived, return to this process.
Go to 6.0 Issue Decision task (f).
PROCESS Seek External Clinical Advice
NOTE What if you determine a decision can made
following the conversation with the client?
f Update assessment information.
Go to '6.0 Issue Decision', unless you are waiting
PIC | Pre-assessment task template
for guidance.
g Determine if you can make a decision.
NOTE What if you have determined a client is eli-
NOTE What if you are an SCA and will require addi-
gible for a Whole Person Impairment Assess-
tional medical information or internal or
ment?
external advice to assess the claim?
Contact client to advise decision. Record this as
In Eos, generate the ACC2184 Cover decision
a contact on the claim.
tool to guide your analysis when requesting
advice.
NOTE: If the client is in prison, consider the
practicalities of arranging an assessment prior to
f In Eos, generate and send letters and documents, if
issue a decision. For guidance refer to 'Clients in
applicable.
Prison Policy.
NOTE What if the claims is for Mental Injury caused
by Physical Injury, Work Related Mental
Go to 6.0 Issue decision task (f).
Injury or Treatment Injury Mental Injury
Clients in Prison Policy
claim?
Send CVR13 / ACC4244 / PSYIS02 / ACC6300
NOTE What if you are able to make a decision?
to the client and CVR14 / ACC4245 to the Pro-
Go to '6.0 Issue Decision'
vider. In addition to this for WRMI claims send
NOTE What if you are unable to make a decision?
CVR15 to Employer.
Check if the timeframe to make a decision needs
to be extended. Go to 'Extend Cover Decision
Timeframe' process. Consider if you need to ar-
3.0 Assess claim
range an external assessment. If yes go to '5.0
Cover Assessor, Specialist Cover Assessor, Treatment
Arrange External Assessment'
and Support Assessor
a Check if there are open tasks on the claim that you can
NOTE: This excludes Permanent Injury Compen-
action and complete.
sation requests as there are no legislative time-
frames to make a decision, send PIC03.
b Check consideration factors for this claim or request type.
PROCESS Extend Cover Decision Time-
Refer to the linked consideration factors for guidance.
frame
PIC | Confirm cover considerations
c Check if you need to request clinical records. Refer to the
PROCESS
Request Clinical Records (Cover)
linked guidance for when to request clinical records.
Cover Assessor, Specialist Cover Asses-
sor, Treatment and Support Assessor
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Make cover or funding decision :: Make PIC funding decision
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Page 3 of 6
GOV-040419
NOTE What if the claim is Treatment Injury Mental
PROCESS
Request Clinical Records or Infor-
Injury?
mation (without Recovery Admin)
You must send the client for a Mental Injury
Cover Assessor, Specialist Cover Asses-
Assessment. Go to 5.0 Arrange External Assess-
sor, Treatment and Support Assessor
ment.
NOTE What if an external assessment is not re-
quired?
4.0 Assess additional information
Go to '6.0 Issue Decision'.
Cover Assessor, Specialist Cover Assessor, Treatment
and Support Assessor
a Review additional information received.
5.0 Arrange External Assessment
b Determine whether you are able to make a decision and
Cover Assessor, Specialist Cover Assessor, Treatment
that the client meets the eligibility criteria. Refer to the
and Support Assessor
linked information for guidance.
a Determine assessment type.
Independence allowance eligibility criteria Policy
NOTE What if you determine a ENT Specialist
AI Act 1998, Schedule 1, Part 4, Clause 61
assessment is required?
https://anzlaw.thomsonreuters.com/Document/I8b624b78022911e99495db3043f758b0/V
Go to
iew/FullText.html?orig
Arrange Ear Nose &
inationContext=documentto
Throat (ENT) Assess-
c&transitionType=CategoryPageItem&contextData=(sc.Default)&comp=wlnz
ment. Once this process has been completed
Lump sum eligibility criteria Policy
return to this process.
AC Act 2001, Schedule 1, Part 3, Clause 61
PROCESS Arrange Ear Nose & Throat
https://anzlaw.thomsonreuters.com/Document/Iee0acc6a6e0f11e8b22785ae5ff38a3b/View/FullText.html?orig
(ENT)
inationContext=documentto
Assessment
c&transitionType=CategoryPageItem&contextData=(sc.Default)&comp=wlnz
NOTE What if you have determined a client is eli-
NOTE What if you determine a Standalone
gible for a Whole Person Impairment Assess-
Workplace Assessment (WSA / SWA) maybe
ment?
required?
Contact client to advise decision. Record this as
Go to Set up Standalone Workplace Assess-
a contact on the claim.
ment. Once this process has been completed
return to this process.
NOTE: If the client is in prison, consider the
PROCESS Set Up Standalone Workplace
practicalities of arranging an assessment prior to
Assessment
issue a decision. For guidance refer to 'Clients in
NOTE What if you determine a Comprehensive
Prison Policy.
nursing assessment maybe required?
Go to Arrange Comprehensive Nursing Assess-
Go to 6.0 Issue decision task (f).
ment (CNA). Once this process has been com-
Clients in Prison Policy
pleted return to this process.
PROCESS Arrange Comprehensive Nurs-
NOTE What if you need to request additional clin-
ing Assessment (CNA)
ical records and/or reports?
If you are making a decision on a Treatment
NOTE What if you determine a Whole Person
Injury (including FACS & TIMI), WRGP or Gen-
Impairment (WPI) Assessment maybe re-
eral Cover (including MI) claim, go to 'Request
quired?
Clinical Records (Cover)' process, otherwise go
Go to Arrange Whole Person Impairment
to 'Request Clinical Records (without RA)'
Assessment. Once this process has been com-
process. Once received continue this process.
pleted return to this process.
PROCESS Request Clinical Records
PROCESS Arrange Whole Person Impair-
(Cover)
ment Assessment
NOTE What if you are able to make a decision?
NOTE What if you determine a Mental Injury
Go to '6.0 Issue Decision'.
Assessment maybe required?
Go to Arrange Mental Injury Assessment for
NOTE What if you are unable to make a decision at
Cover. Once this process has been completed
this point?
return to this process.
Review the 'Standards for Seeking Guidance'
PROCESS Arrange Mental Injury Assess-
and make sure they are met before proceeding
ment for Cover
to 'Seek Internal Guidance (Claims Assess-
ment)'. If you request guidance, once received
NOTE What if you determine a Medical Case Review
return to this process.
(MCR) Assessment maybe required?
PROCESS Seek Internal Guidance (Claims
Go to Arrange Medical Case Review (MCR)
Assessment)
Assessment. Once this process has been com-
pleted return to this process.
Standards for Seeking Guidance
PROCESS Arrange Medical Case Review
NOTE What if you believe based on guidance and/or
(MCR) Assessment :: Standard
new information for a TI claim it needs to be
upstreamed to a Specialist Cover Assessor?
NOTE What if you determine a Neuropsychological
Assessment maybe required?
Go to 'Treatment Injury and Additional Treatment
capability matrix'.
Go to Assess and Arrange Neuropsychological
Assessment. Once this process has been com-
Treatment Injury capability matrix
pleted return to this process.
c Update assessment information.
PROCESS Assess and Arrange Neuropsy-
chological Assessment
PIC | Pre-assessment task template
b Determine if you can make a cover decision.
d Check if an external assessment is required.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Make cover or funding decision :: Make PIC funding decision
Uncontrolled Copy Only : Version 121.0 : Last Edited Thursday, 5 June 2025 8:40 pm : Printed Tuesday, 24 June 2025 12:56 pm
Page 4 of 6
GOV-040419
NOTE What if you are unable to make a decision at
NOTE What if you are accepting cover for a MICPI
this point?
claim (including Treatment Injury) and there
Review the 'Standards for Seeking Guidance'
is already an accepted claim for the asso-
and make sure they are met before proceeding
ciated physical injury?
to 'Seek Internal Guidance (Claims Assess-
Go to Identify and Link Duplicate Claims :: Not
ment)'. If you request guidance, once received
triggered by information requirement, Nintex
return to this process.
Process Manager to establish if you need to dup-
PROCESS Seek Internal Guidance (Claims
licate the claims
Assessment)
PROCESS Identify and Link Duplicate
Claims :: Not triggered by infor-
Standards for Seeking Guidance
mation requirement
h Close 'Follow up Cover' task, if applicable.
6.0 Issue decision
i Create or update Purchase Order, if applicable.
Cover Assessor, Specialist Cover Assessor, Treatment
and Support Assessor
Create Purchase Order | Claims Assessment
a Check if the client is being managed in a Recovery Team
j In Eos, generate decision letter. Refer to linked Commu-
or by a Third Party Administrator.
nication guidance and templates.
NOTE What if the client is being managed?
PIC | Communication guidance and templates
Consider the impact when you are issuing a
NOTE What if you are approving a work related
decision. You may need to discuss with the
injury including Hearing Loss, WRGP & MI
Recovery team member who is best delivering
If there is a liable employer listed on the claim
this decision to the client.
create and send the appropriate employer deci-
b Review decline decision client conversation guidance.
sion notification letter.
PIC | Decline decision client conversation guidance
For PICBA claims this can be auto generated
NOTE What if you are approving or declining an
from the general tab, cover details.
Additional Treatment funding request?
NOTE What if you are approving a surgery request
Don't contact the client unless the client has re-
and embedding into an email?
quested contact. Go to task (f).
Confirm the email address has been validated
before proceeding.
NOTE What if you have determined a client is eli-
NOTE What if cover has been accepted?
gible for a Whole Person Impairment Assess-
Contact the client if there are entitlements pend-
ment?
ing or client has requested contact. If not go to
Go to Arrange Whole Person Impairment
task (f).
Assessment.
c Contact the client or ATA by phone to discuss decision.
PROCESS Arrange Whole Person Impair-
ment Assessment
NOTE What if you are unable to contact the client?
1) Leave a voice message, if possible
k Check if there is written guidance on the claim if you are
2) Send a text requesting they call us: - Kia Ora,
issuing a decline decision.
ACC attempted to call you to issue a decision on
NOTE What if clinical advice was obtained for a de-
your claim. We have sent this information via
cline decision?
[insert post/email]. Please call us on 0800 101
Send the written guidance transcript located in
996 if you have questions. Ngā mihi [insert
the documents tab in Eos with the decline letter.
Name]
3) Create a contact to record attempted client
l Check you have a valid email address or valid physical
contact. Go to task (f).
address for the client and send to client via their pre-
ferred method of communication.
Create and send text
Send an Email from Eos
What to say in a voicemail message
d
NOTE What if you don't have either of these?
Confirm you are speaking with the right person by asking
ACC's identity check questions.
Save the decision letter on the claim.
Identity Check Policy
NOTE What if you are sending decision letter/s by
post for a Treatment Injury claim
e In Eos, record the details of the conversation as a contact
Request Recovery Administrator to send a letter
on the claim.
(using the NGCM – Send Letter task)
f Create a contact to capture decision rationale with
Reason as 'Contact with Internal Party', select 'Internal'
m Check if there are open tasks for support and/or entitle-
as Direction and select 'Other' as Method of Contact.
ments.
Refer to linked Decision Rationale templates for content
to use in the description.
NOTE What if there are open tasks for treatment
and/or support?
NOTE What if you are an SCA and have completed
Refer to the queue matrix to determine where to
an ACC2184?
send the task.
Go to task (g).
Work type queue matrix
PIC | Decision rationale templates
n Run the EMD, if applicable.
g Update Eos, including cover status.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Make cover or funding decision :: Make PIC funding decision
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Page 5 of 6
GOV-040419
NOTE What if you are accepting a Treatment Injury
NOTE What if you received hard materials and want
Fatal claim?
to have them destroyed?
Don't run the EMD. In Eos, create a 'Follow up
Go to 'Authorise Destruction of Physical Claim
Fatal' task. Add 'handshake' details to the task.
Documents that are Digitised' process
Transfer to Accidental Death Claims department
PROCESS Authorise Destruction of Phys-
queue as HIGH priority.
ical Claim Documents that are
NOTE What if you are accepting a hearing loss
Digitised
claim (including treatment injury hearing
NOTE What if you received hard materials and want
loss)?
to return them to the Provider?
Don't run the EMD for claims if Hearing Loss is
Go to 'Prepare and send client information by
the only injury. Transfer the claim to applicable
courier' process.
Actioned Cases department queue.
PROCESS Prepare and Send Client Infor-
mation by Courier
NOTE: If you are accepting a Treatment Injury
Hearing Loss claim, transfer the claim to the
Hearing Loss - Assessment queue with the
master task as HIGH priority with the following at
Timeframes
the top of the description "Please add HL indi-
cator and send HL decision/entitlement letter to
None Noted
client via [delete one post/email]. Please then
close task and transfer claim to [delete one TC -
actioned cases/{appropriate recovery team}
department queue]"
NOTE What is you are accepting or declining the
physical injury of a Treatment Injury claim
where mental injury assessment is required?
If the physical injury is accepted and the client
has no pending entitlements check the Mental
Injury claim is in the Cover Assessment - Mental
Injury Triage department queue and create a
High Priority Follow Up Cover task in this queue.
Transfer the Treatment Injury claim to TIC - Ac-
tioned Cases
If the physical injury is accepted and the client
has pending entitlements transfer the Mental
Injury claim to the appropriate Recovery Team
department queue (Supported or Partnered
Recovery) and create a High Priority NGCM -
Cover Decision Required task in this queue.
Transfer the Treatment Injury claim to the same
department queue as above.
If the physical injury is declined SCA to initiate
the TIMI process for the assessment of the
mental injury. Go to Make cover or funding deci-
sion :: Make TIMI cover decision
Identify engagement model and transfer claim
NOTE What if you are declining cover?
Transfer the claim to the actioned cases queue
for this claim type or to Actioned Cases - Regis-
tration.
o Check the EMD has streamed the claim correctly.
NOTE What if it hasn't been streamed correctly or
you need to manually stream the claim?
Manually stream the claim to actioned cases
queue or Recovery Team identified by the EMD.
If directing the claim to a Recovery Team, check
there is a NGCM - Client Welcome Conversation
task on the claim. If not, manually create this
task prior to transferring.
p Check if hard materials were needed to inform your deci-
sion.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Make cover or funding decision :: Make PIC funding decision
Uncontrolled Copy Only : Version 121.0 : Last Edited Thursday, 5 June 2025 8:40 pm : Printed Tuesday, 24 June 2025 12:56 pm
Page 6 of 6
GOV-040419
Independence Allowance Eligibility Criteria Policy v13.0
Summary
2.0 Impairment assessment and whole person
impairment rating
Objective
a To determine the whole person impairment rating of a
When a client submits an application for an independenc
e
client, the client must have an impairment assessment.
allowance (IA) assessment or reassessment, you must check
Types of impairment assessment
their eligibility.
b To be eligible for an initial impairment assessment, the
client must meet the criteria listed in the following busi-
Owner
[Out of Scope]
ness rule, which includes having medical certification of a
permanent an impairment.
Expert
[Out of Scope]
Eligibility to an initial impairment assessment
Policy
c An impairment assessment can only be completed by an
impairment assessor who meets the criteria in the busi-
1.0 Eligibility for an independence allowance
ness rule below.
a Clients may be eligible for an independence allowance if
Requirements for an assessor to perform an impair-
their claim has all of the following:
ment assessment
• an accepted cover decision
• a whole person impairment rating of over 10%
d In some situations the whole person impairment rating
• either:
must take into account any previous whole person
— a date of injury before 1 April 2002
impairment ratings. See the following business rule.
— a date of last event (where relevant) prior to 1 April
Determining the whole person impairment rating by
2002
taking into account a previous rating
NOTE What if the injury was willfully self-inflicted?
Refer to the 'Ineligibility if Suicide or Wilfully Self-
inflicted Injury' Policy. The claim will need to be
3.0 Medical certification of permanent and stable
considered for disentitlement. If the injury meets
impairment
the criteria in the policy and disentitlement hasn't
a A person must be considered to have medical certi-
previously been considered - guidance should be
fication of a permanent impairment for an independence
sought from Technical Services.
allowance entitlement if a medical practitioner supplies
PROCESS Ineligibility if Suicide or Wilfully
the relevant information to ACC. The relevant information
Self-inflicted Injury
is listed in the business rule below.
NOTE What if the injury was sustained while
Information needed to confirm medical certification of
committing a crime?
a permanent impairment for an independence allow-
Refer to the 'Injured Committing Crime Policy'.
ance
The claim will need to be considered for disen-
titlement. If the injury meets the criteria in the
b The ACC554 Application medical certificate form is used
policy and disentitlement hasn't previously been
to capture the relevant information needed.
considered - guidance should be sought from
ACC554 LSIA Medical certificate
Technical Services.
PROCESS Injured Committing Crime
ACC554 required method for supplying medical
Policy
information for an impairment assessment
c
NOTE What if I need to seek guidance from Tech-
You must decline the client's application if the information
nical Services on disentitlement?
provided on the ACC554 Application medical certificate
does not meet the criteria for assessment.
Refer to the 'Seek Internal Guidance' process
PROCESS Seek Internal Guidance
See Accident Insurance Act 1998, Schedule 1, part 4,
b See the full list of independence allowance eligibility cri-
clause 59.
teria in the business rule below.
Single independence allowance eligibility require-
ment
4.0 Reassessment
c See also the transitional provisions for lump sum entitle-
a See the 'Independence Allowance Reassessment Policy'
ments in the AC Act 2001, Schedule 1, part 3, clauses 55
and 55a.
Independence Allowance Reassessment Policy
AC Act 2001, Schedule 1, Part 3, Clause 55
https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM105411.html?search=ts_act%40bill%40regulation%40deemedreg_Accident+Compensation+Act+2001_resel_25_a&p=1
AC Act 2001, Schedule 1, Part 3, Clause 55a
https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM1663927.html?search=ts_act%40bill%40regulation%40deemedreg_Accident+Compensation+Act+2001_resel_25_a&p=1
Lump sum checklist.doc
ACC > Claims Management > Manage Client Payments > Operational Policies > Independence Allowance & Lump Sum > Independence allowance > Independence Allowance
Eligibility Criteria Policy
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Page 1 of 2
GOV-040419
5.0 Overseas clients
a Clients based overseas are eligible to have their impair-
ment assessed or reassessed for an IA if:
• they meet the standard eligibility criteria
• the medical practitioner completing the ACC554 medical
certificate meets both the following criteria:
— holds registration in the country in which they are
practising
— holds a medical degree from a medical school ap-
proved by the New Zealand Medical Council. This in-
cludes universities listed in the WHO World Directory of
Medical Schools.
b Financial help for an impairment assessment overseas or
for travel to New Zealand for an impairment assessment
must be approved by the Technical Services team and
must be cost effective. See the following business rule.
Impairment assessment extended discretion request
6.0 Deceased clients
a Estates may be eligible to receive payments for de-
ceased clients. Different rules apply depending on when
a client has died, the support applied for, and the stage in
the support process. Refer to IA deceased clients.
Deceased Client Policy
7.0 Functional limitations profile (FLP) IA
a When American Medical Association (AMA) assessments
were introduced in 1997, clients receiving FLP IA were
required to be reassessed under AMA. Prior to the FLP
payments being stopped, ACC was obliged to both ask
the client to submit an application to be assessed under
AMA (an ACC554 Medical Certificate) and subsequently
warn the client that if they did not comply to this request,
their independence allowance would be stopped. When
the payment was stopped, a final letter should have been
issued informing the client of this.
b If the above steps were not followed at the time of the
suspension, the client may be eligible to receive arrears
of the FLP IA. To determine if arrears should be paid and
from what date, a referral must be made to technical ser-
vices via the 'Seek Internal Guidance' process.
Seek Internal Guidance
c If technical services recommend that FLP IA arrears be
paid, an impairment assessment must be completed to
determine the client's eligibility for AMA IA, and the client
warned that if they do not comply with the reassessment,
their FLP entitlement will be suspended. See the 'Make
Functional Limitations Profile Independence Allowance
Payments' process for instructions.
Make Functional Limitations Profile Independence
Allowance Payments
d Alternatively, the FLP IA arrears may be paid following an
impairment assessment, at the time of the AMA IA eligi-
bility decision. This presents a simpler pathway - both
paying the FLP IA arrears and moving to AMA IA in one
go - but it also may not be appropriate to delay payment
of the FLP arrears depending on the client's financial
circumstances. Either pathway can be chosen as is seen
fit - use discretion.
Timeframes
None Noted
ACC > Claims Management > Manage Client Payments > Operational Policies > Independence Allowance & Lump Sum > Independence allowance > Independence Allowance
Eligibility Criteria Policy
Uncontrolled Copy Only : Version 13.0 : Last Edited Wednesday, 6 December 2023 11:59 am : Printed Tuesday, 24 June 2025 12:56 pm
Page 2 of 2
GOV-040419
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GOV-040419
Independence Allowance Reassessment Policy v12.0
Summary
NOTE Examples
• The initial assessor indicates that an improve-
ment is likely in one year and recommends a
Objective
reassessment at that time
When we deem a client eligible for a reassessment that
they re-
• Recent medical information confirms an
quest, or we request a client is reassessed, a medical practi-
improvement has occurred
tioner carries out the assessment using the American Medical
Association Guides to the Evaluation of Permanent Impairment,
b If we have no information to suggest a change but we
Fourth Edition (the AMA Guides) and The ACC User Handbook
would like to check, we can ask that the client arrange for
to AMA4.
an ACC554 medical certificate to be completed. The pro-
vider who completes the ACC554 medical certificate
must have the opportunity to review the previous assess-
Owner
[Out of Scope]
ment so they can decide whether the impairment level
has changed since the last assessment.
Expert
[Out of Scope]
Policy
3.0 Reassessments leading to suspension
1.0 Client reassessment requests
a We can suspend a client’s independence allowance (IA)
payments if we make a reasonable request and the client
a A client is eligible for an impairment reassessment for an
fails to comply. This may include having the ACC554
independence allowance if they provide medical certi-
completed or attending an assessment.
fication that their permanent impairment is likely to have
changed since the date of assessment.
See Managing non-compliance.
Information needed to confirm medical certification of
an impairment changing [for reassessment of an
Managing non-compliance
independence allowance entitlement]
Independence allowance payment suspension for
ACC554 LSIA Medical certificate
non-compliance
b The client may not request a reassessment if they have
Reinstating independence allowance payment after
requested a reassessment in the last 12 months
compliance
Client reassessment request for an independence
allowance entitlement
c If an injury was certified as likely to have an impairment
Timeframes
but is unstable within 52 weeks of the injury occurring,
and we receive a further medical certificate certifying this
None Noted
injury is now stable, this is not considered a reas-
sessment and therefore not subject to the 12 month or 5
year restrictions.
The client is eligible for a reassessment of their whole
person impairment (WPI) even if we receive certification
of change to only one of the injuries.
d See Accident Insurance Act 1998, Schedule 1, part 4,
clause 61.
Accident Insurance Act 1998, Schedule 1, part 4,
clause 61.
https://anzlaw.thomsonreuters.com/Document/I8b624b78022911e99495db3043f758b0/View/FullText.html?transitionType=Default&contextData=(sc.Default)&VR=3.0&RS=cblt1.0
2.0 ACC reassessment requests
a ACC can request an impairment assessment for IA only if
all the following criteria are met:
• there are reasonable grounds to believe the impairment
may have decreased since the last assessment, and
• the client has not had an impairment reassessment in
the last 12 months that the client requested, and
• the client has not had an impairment reassessment in
the previous 5 years that ACC requested
ACC reassessment request for an independence
allowance entitlement
ACC > Claims Management > Manage Client Payments > Operational Policies > Independence Allowance & Lump Sum > Independence allowance > Independence Allowance
Reassessment Policy
Uncontrolled Copy Only : Version 12.0 : Last Edited Wednesday, 6 December 2023 11:53 am : Printed Tuesday, 24 June 2025 12:58 pm
Page 1 of 1
GOV-040419
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GOV-040419
Lump Sum Eligibility Criteria Policy v8.0
Summary
Requirements for an assessor to perform an impair-
ment assessment
Objective
d In some situations the whole person impairment rating
When a client submits an application for a lump sum ass
ess-
must take into account any previous whole person
ment or reassessment we must check their eligibility.
impairment ratings. See the following business rule.
Determining the whole person impairment rating by
Owner
[Out of Scope]
taking into account a previous rating
Expert
[Out of Scope]
Policy
3.0 Medical certification of permanent and stable
impairment
1.0 Eligibility to a lump sum entitlement
a A person must be considered to have medical certi-
a Clients may be eligible for a lump sum if their claim has
fication of a permanent impairment for a lump sum
all of the following:
entitlement if a medical practitioner supplies the relevant
• an accepted cover decision
information to ACC. The relevant information is listed in
• a whole person impairment rating of over 10%
the business rule below.
• a date of injury (or date of last event where relevant) is
Information needed to confirm medical certification of
on or after 1 April 2002
a permanent impairment for a lump sum entitlement
NOTE What if the injury was willfully self-inflicted?
b The ACC554 Application medical certificate form is used
Refer to the 'Ineligibility if Suicide or Wilfully Self-
to capture the relevant information needed.
inflicted Injury' Policy. The claim will need to be
considered for disentitlement. If the injury meets
ACC554 LSIA Medical certificate
the criteria in the policy and disentitlement hasn't
ACC554 required method for supplying medical
previously been considered - guidance should be
information for an impairment assessment
sought from Technical Services.
PROCESS Ineligibility if Suicide or Wilfully
c You must decline the client's application if the information
Self-inflicted Injury
provided on the ACC554 does not meet the criteria for
assessment.
NOTE What if the injury was sustained while
committing a crime?
See AC Act 2001, Schedule 1, part 3, clause 57.
Refer to the 'Injured Committing Crime Policy'.
The claim will need to be considered for disen-
AC Act 2001, Schedule 1, part 3, clause 57.
titlement. If the injury meets the criteria in the
policy and disentitlement hasn't previously been
https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM105415.html
considered - guidance should be sought from
Technical Services.
PROCESS Injured Committing Crime
4.0 Client under 16 with a mental injury
Policy
a If a client is under 16 years of age and has cover for per-
NOTE What if I need to seek guidance from Tech-
sonal injury that is a mental injury, we must not assess
nical Services on disentitlement?
their eligibility for lump sum compensation for the mental
Refer to the 'Seek Internal Guidance' process
injury until the client turns 16, unless we are satisfied that
there are compelling reasons for assessing eligibility ear-
PROCESS Seek Internal Guidance
lier.
b See the full list of lump sum eligibility criteria in the busi-
ness rule below.
5.0 Reassessment
Lump sum eligibility requirements
a
c
See Lump sum reassessment.
See also the transitional provisions for impairment entitle-
ments in the AC Act 2001, Schedule 1, part 3, clauses 54
Lump sum reassessment Policy
and 55.
https://go.promapp.com/accnz/Process/e38cf259-ba39-4af3-8182-cf5058c855b2?force=False#
2.0 Impairment assessment and whole person
6.0 Overseas clients
impairment rating
a Clients based overseas are eligible to have their impair-
a To determine the whole person impairment rating of a
ment assessed or reassessed for a lump sum if:
client, the client must have an impairment assessment.
• they meet the standard eligibility criteria
b
• the medical practitioner completing the ACC554 medical
To be eligible for an initial impairment assessment, the
certificate meets both the following criteria:
client must meet the criteria listed in the following busi-
ness rule, which includes having medical certification of a
- holds registration in the country in which they practise
permanent and stable impairment.
- holds a medical degree from a medical school approved
Eligibility to an initial impairment assessment
by the New Zealand Medical Council. This includes
c
universities listed in the WHO World Directory of Medical
An impairment assessment can only be completed by an
Schools.
impairment assessor who meets the criteria in the busi-
ness rule below.
ACC > Claims Management > Manage Client Payments > Operational Policies > Independence Allowance & Lump Sum > Lump Sum > Lump Sum Eligibility Criteria Policy
Uncontrolled Copy Only : Version 8.0 : Last Edited Friday, 27 October 2023 11:33 am : Printed Tuesday, 24 June 2025 1:00 pm
Page 1 of 2
GOV-040419
b Financial help for an impairment assessment overseas or
for travel to New Zealand for an impairment assessment
must be approved by the Technical Services team and
must be cost effective. See the following business rule.
Impairment assessment extended discretion request
7.0 Deceased clients
a Estates may be eligible to receive payments for de-
ceased clients. Different rules apply depending on when
a client has died, the type of support applied for, and the
stage in the request process. Information is available at:
lump sum deceased clients
Deceased client Policy
https://go.promapp.com/accnz/Process/ceda722c-753b-424c-9bb3-432a7125d2aa
Timeframes
None Noted
ACC > Claims Management > Manage Client Payments > Operational Policies > Independence Allowance & Lump Sum > Lump Sum > Lump Sum Eligibility Criteria Policy
Uncontrolled Copy Only : Version 8.0 : Last Edited Friday, 27 October 2023 11:33 am : Printed Tuesday, 24 June 2025 1:00 pm
Page 2 of 2
GOV-040419
Lump Sum Reassessment Policy v14.0
Summary
NOTE Example: Previous lump sum payment under
AC Act 2001
• A client is assessed as having a whole-person
Objective
impairment percentage (WPI) of 30%. The client
When we deem a client’
s request for reassessment eligible, or
has previously received an AC Act lump sum for
we request a client is reassessed, a medical practitioner car-
a 15% impairment. The dollar value relating to
ries out the assessment using the American Medical Association
the current total WPI of 30% is $15,492. The cur-
Guides to the Evaluation of Permanent Impairment, Fourth Edi-
rent dollar value of the previous 15% impairment
tion (the AMA Guides), and The ACC User Handbook to AMA4.
is $5,544. Subtracting $5,5448 from $15,492
gives $9,948.
Owner
[Out of Scope]
• The client is now eligible for a payment of
Expert
[Out of Scope]
$9,948. These figures are based on indexation
values at 1 July 2011.
Policy
Amount of lump sum when a previous lump sum
payment has been made
1.0 Client reassessment requests
Lump Sum Payment Rates Policy
a A client is eligible for an impairment reassessment for a
lump sum if they provide medical certification, eg an
ACC554, that states their permanent impairment is likely
4.0 Previous independence allowance and '72/'82
to have increased since the date of assessment.
Act lump sum injuries not included in lump sum
Information needed to confirm medical certification of
assessment
an impairment increasing [for reassessment of a
lump sum entitlement]
a Any reassessments for AC Act 2001 lump sum will not in-
clude injuries which are already compensated for under
b A client is not eligible to have more than one reas-
the independence allowance, or by lump sums paid for
sessment in any 12 month period.
loss of physical function under the Accident Compen-
Client reassessment request for a lump sum entitle-
sation Act 1972 or the Accident Compensation Act 1982.
ment
b However, if the AC Act 2001 lump sum assessment
c However if the ACC554 states that:
covers new injuries with the same body site as an injury
compensated for by independence allowance or '72/'82
• one or more of the injuries that were certified as unst-
Act lump sum, the impairment assessor may require
able are now certified as stable. This is not considered a
information about these injuries to inform apportionment.
reassessment and is therefore not subject to the 12
month restriction
• the client has a new injury that meets the eligibility cri-
teria. This may be assessed within 12 months of the last
assessment.
d See AC Act 2001, Schedule 1, part 3, clause 61(4).
AC Act 2001, Schedule 1, part 3, clause 61(4)
https://www.westlaw.co.nz/maf/wlnz/app/document?docguid=Ifd6788133b3d11e18eefa443f89988a0&isTocNav=true&tocDs=AUNZ_NZ_LEGCOMM_TOC&startChunk=1&endChunk=1
2.0 Reassessed amount
a When a client has been reassessed and is found to have
an increased degree of impairment, we use the sub-
traction method to determine any additional lump sum
amount.
The increase in impairment does not have to reach 10%
for a further lump sum payment to be made. The total
whole person impairment (WPI) percentage, including
any impairment from injuries previously assessed, must
be greater than 10%.
3.0 Subtraction method
a Any AC Act 2001 lump sum payment previously made
must be adjusted for indexation before being subtracted
from the current lump sum amount payable. This differs
from a previous independence allowance (IA), where the
percentage impairment on which the compensation was
based is subtracted.
ACC > Claims Management > Manage Client Payments > Operational Policies > Independence Allowance & Lump Sum > Lump Sum > Lump Sum Reassessment Policy
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Page 1 of 2
GOV-040419
NOTE Example: Previous independence allowance
and '72/'82 Act lump sum injuries not in-
cluded in lump sum assessment
• A client injured their shoulder in May 1982. ACC
accepted a claim for the injury and in July 1983
the client received a $4,760 lump sum for the in-
jured shoulder under Section 78 of the AC Act
1982.
• In January 1997, the client suffered injuries to
their back and pelvis. They went on to be as-
sessed for, and receive, an IA for the combined
impairment effects of their injuries. The com-
bined WPI was assessed at 38%. ACC sub-
tracted 28% on which the lump sum for the
shoulder injury was previously paid, and the
client received an IA for 10% impairment.
• In April 2002, the client was assaulted and lost
the vision in one eye. The client applied for a
new Act lump sum and was referred for assess-
ment. The client’s permanent impairment level
from the April 2002 eye injury was assessed as
25%. The client qualified for a lump sum pay-
ment for 25% impairment. Please note: If the
previous injury involved impairment to the same
body site as the current lump sum assessment,
then apportionment may have to be applied.
• No deduction is made of the impairment rating
from the old Act lump sum as the shoulder injury
occurred before 1 April 2002 and is not included
in the lump sum assessment. No deduction is
made either for the compensation paid for the
1997 back and pelvis injuries, as again these oc-
curred before 1 April 2002, and so were not in-
cluded in the lump sum assessment. IA con-
tinues to be paid for these other injuries as long
as the reassessment shows they are still eligible.
ACC > Claims Management > Manage Client Payments > Operational Policies > Independence Allowance & Lump Sum > Lump Sum > Lump Sum Reassessment Policy
Uncontrolled Copy Only : Version 14.0 : Last Edited Monday, 25 November 2024 2:50 pm : Printed Tuesday, 24 June 2025 1:01 pm
Page 2 of 2
GOV-040419
Process a Permanent Injury Compensation application v21.0
NOTE What if the vendor requires more than one
Summary
hour of ACC554 or 30 pages of COPY?
Contact the provider for an explanation to con-
Objective
firm the need
To process a Permanent Injury Compensation application and
If the request seems excessive or unreasonable,
to determine if a client is eligible for a Whole Person Impairment
consult with a team leader
assessment.
b Check the Remote Claims status of the claim.
Background
NOTE What if the claim is a Remote Claim?
On receipt of a Permanent Injury Compensation application
Ensure that you are logged into Eos under a
from a client, we must first confirm that the application has been
Remote Claims user profile before opening or
completed correctly, and then determine if the client is eligible
performing any action on the claim.
for a Whole Person Impairment assessment.
c Check whether the client is in prison by checking the ad-
Owner
[Out of Scope]
dress or imprisonment indicator.
Expert
[Out of Scope]
NOTE What if the client is in prison?
For lump sums, both the assessment and pay-
Procedure
ment are discretionary with separate consid-
eration for each. Use the decision making prin-
1.0 Check claims status and application documents
ciples located under Clients in Prison policy to
Treatment and Support Assessor
determine whether or not to proceed.
a Check the ACC554 Medical Certificate and confirm the
Assessments for independence allowance
client's doctor has completed all relevant sections for a
assessment are not discretionary, however there
first assessment or reassessment.
are practical considerations around arranging an
NOTE What if the ACC554 Medical Certificate is not
assessment. There is a possibility of a lower
completed by a medical practitioner?
impairment rating if the assessment takes place
The Accident Compensation Act 2001 defines a
in prison, particularly for mental injury claims.
medical practitioner as a health practitioner who
ACC can suggest to the client that the assess-
—
ment be deferred until they are released. If a
(a) is, or is deemed to be, registered with the
client does decide to proceed with an assess-
Medical Council of New Zealand as a practitioner
ment, Independence Allowance cannot be paid
of the profession of medicine; and
until the client’s release from prison.
(b) holds a current practising certificate.
PROCESS Arrange Whole Person Impair-
ment Assessment
If the person who signed the certificate does not
Clients in Prison Policy
meet these criteria, proceed to 10.0: Determine if
impairment assessment is appropriate.
NOTE What are the relevant sections for a first
2.0 Check cover is adequate
assessment for an injury?
Treatment and Support Assessor
All of Section 2
a Check that the injuries which have been applied for on
NOTE What are the relevant sections for a reas-
the ACC554 are covered adequately under the claim.
sessment for an injury?
NOTE What if the ACC554 is for an application esca-
Injury and claim details of Section 2
lated via the rapidly deteriorating process
All of Section 3
with held cover?
NOTE What are the relevant sections if the previous
The application should not be declined. Instead,
assessment was deferred?
request a placeholder referral from an impair-
All of Section 2
ment assessor in the PIC Assessor List with
As it is not technically a reassessment, Section 3
'Referral Type' of 'Rapidly Deteriorating'. This
is not relevant
can be done via email and ensures that the client
remains eligible for an assessment even if they
NOTE What if the provider or the provider invoicing
pass away prior to the cover decision.
team require a purchase order for payment
for the ACC554?
Until the decision is issued, you will need to
Create and authorise a purchase order for the
manage the application at claim level. This is be-
vendor in question from the 'General + QE' tab
cause a PIC subcase can not be added to a held
using the codes ACC554 and COPY.
or declined claim.
ACC554 LSIA Medical certificate
If the injury is accepted - proceed to step 3.0.
Creating purchase orders using general + QE
Add a new entitlement to a claim and add to an
If the injury is declined - see "What if the
existing PO
ACC554 is for an injury which has been consi-
dered for cover, but formally declined by ACC?".
PIC Assessor List
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NOTE What if the ACC554 is for an injury which has
NOTE What if the ACC554 is for an injury for which
not yet been considered for cover by ACC?
cover is currently 'deemed' but not formally
An ACC554 medical certificate is not a claim for
accepted?
cover. However, it may be reasonable or neces-
• Injuries with 'deemed' cover cannot be as-
sary to clarify or update cover before an impair-
sessed for Permanent Injury Compensation until
ment assessment can proceed. If this is the
a formal cover investigation has been completed,
case:
and the 'deemed' cover is formally accepted.
• Decline the application and send the client a
• If the claim is currently managed by a specific
'PIC08 Decline assessment - Client' letter, in-
Recovery Partner or Recovery Coordinator,
cluding a copy of the 'deemed' cover decision for
create a 'NGCM - Cover Decision Required' task
the injury in question.
on high priority with today's date, and edit the
Deemed Cover and Entitlements Policy
description to contain details of the additional
diagnosis to be investigated and the date and
NOTE What if I am processing an application where
method via which the request was received.
a client applies for Mental Consequences as
Then transfer the task directly to the managing
an injury?
staff member.
Refer to the 'Mental Injury Policy'
PROCESS Mental Injury Policy
• If the claim is currently managed by a Recovery
Team, create a 'NGCM - Cover Decision Re-
quired' task on high priority with today's date,
and edit the description to contain details of the
3.0 Check accredited employer status
additional diagnosis to be investigated and the
Treatment and Support Assessor
date and method via which the request was re-
a In Eos, check the accredited employer status of the
ceived. Then transfer the task to the queue for
claim.
the recovery team managing the claim (i.e. As-
sisted, Supported, or Partnered Recovery).
NOTE What if the claim is not an accredited em-
ployer claim?
• If the claim is currently in an 'Actioned Cases'
Proceed to step 4.0.
department, create a 'Follow up Cover' task on
b In Eos, confirm the end of the contracted management
high priority with today's date, and edit the
period.
description to contain details of the additional
diagnosis to be investigated and the date and
NOTE What if the contracted management period
method via which the request was received.
has not ended?
Then transfer the task to the 'Cover Assessment
Proceed to step 3.0d
- General Cover' queue to be investigated by the
NOTE What if the contracted management period
Cover Assessment team.
has ended, and claim management has been
transferred to ACC?
It may also be appropriate depending on the
circumstances to ask the client to withdraw their
Proceed to step 4.0
application, or decline the impairment assess-
NOTE What if the contracted period has ended, and
ment application in the interim until the cover
claim management has not been transferred
investigation is being completed - use discretion
to ACC?
to choose the appropriate pathway:
Contact [email address] to request
that the claim file be returned to ACC.
• If the client agrees to withdraw their application
while the cover investigation takes place, you
c In Eos, determine if the accredited employer has Full Self
may close the application and send a 'PIC11
Cover (FSC) or a Partnership Discount Plan (PDP) at the
Unable to proceed with application - Client' letter
date of injury.
NOTE What if the accredited employer has Full Self
• If the cover assessment is going to take an
Cover (FSC)?
indefinite amount of time, or it's unlikely the
The employer is liable for lump sum compen-
injury in question will attract cover, you may wish
sation. As such, the application should be treated
to close the application and send the client a
as an accredited employer claim.
'PIC08 Decline assessment - Client' letter, noting
that the client can contact the Permanent Injury
NOTE What if the accredited employer has a Part-
Compensation team again if they attract cover in
nership Discount Plan (PDP)
future.
The employer is not liable for lump sum compen-
PROCESS Assess Cover for an Additional
sation. As such, the application should not be
Injury or Change in Diagnosis
treated as an accredited employer claim.
PIC11 Unable to proceed with application - Client
d Generate and send the accredited employer a 'PIC04
Info request - Third Party' letter along with an 'ACC557
PIC08 Decline assessment - Client
Accredited Employer's accident details for lump sum
NOTE What if the ACC554 is for an injury which has
application' to complete.
been considered for cover, but formally de-
PIC04 Info request - Third Party
clined by ACC?
• Decline the application and send the client a
ACC557 Accredited Employers Accident Details for
'PIC08 Decline assessment - Client' letter, in-
Lump Sum Application
cluding a copy of the declined cover decision for
the injury in question.
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NOTE What if the provider or the provider invoicing
b In Power BI, generate a '4.09 Lump Sums and Indepen-
team require a purchase order for payment
dence Allowance Payment Report' which will show the
for the ACC554?
client's compensation history for Lump Sum / Indepen-
Create and authorise a purchase order for the
dence Allowance entitlements. Save the document to a
vendor in question from the 'General + QE' tab
secure location as you will need to upload this to Eos
using the codes ACC554 and COPY.
later.
Creating purchase orders using general + QE
Power BI ACC Operational Reports
Add a new entitlement to a claim and add to an
NOTE What if the 4.09 Lump Sums and Indepen-
existing PO
dence Allowance Payment Report shows that
the client has received Independence Allow-
ance - Functional Limitations Profile pay-
4.0 Check application documents
ments in the past which were stopped, and
they are not receiving any Independence
Treatment and Support Assessor
Allowance payments currently?
a Check that all of the required application documents have
Refer to the Make Functional Limitations Profile
been returned fully completed.
Independence Allowance Payments procedure.
NOTE What documents are required from the
PROCESS Make Functional Limitations
client?
Profile Independence Allowance
• A completed 'ACC554 LSIA Medical certificate'.
Payments
A medical practitioner must have signed and
Lump sum eligibility requirements
dated this document and stamped it to identify
their practice.
Determining the whole person impairment rating by
taking into account a previous rating
• A completed 'ACC6300 Authority to collect
Minimum impairment threshold percentage
medical and other records'. This must be signed
and dated by the client.
Lump sum election requirements
Definition of "Medical Practitioner"
Independence allowance election requirements
https://www.legislation.govt.nz/regulation/public/2019/0194/latest/LMS89661.html
Definition of combined impairment rating
NOTE If applicable, what documents are also re-
Deceased client eligibility for independence allow-
quired from an accredited employer?
ance
• A completed ACC557 Accredited Employers
accident details for lump sum application'.
Deceased client eligibility for lump sum
• Any corresponding medical information from
Single independence allowance eligibility require-
the employer claim file.
ment
NOTE What if the client has a rapidly deteriorating
Criteria for combined independence allowance eligi-
condition?
bility for a person who has received an old lump sum
The assessment process can commence without
the need for a 'ACC554 LSIA Medical certificate'.
Refer to Clients with rapidly deteriorating condi-
6.0 Determine if client has outstanding overpay-
tions Policy for more information.
ments
Clients with rapidly deteriorating conditions Policy
Treatment and Support Assessor
NOTE What if the required application documents
a Check the clients overpayment summary for outstanding
are missing or incomplete?
overpayments.
If the client has a rapidly deteriorating condition
NOTE What if the client has outstanding overpay-
the ACC554 is not required (see What if the
ments?
client has a rapidly deteriorating condition?).
Contact Payments (for Eos debt) or Collections
and Recoveries (for Oracle debt) and confirm
Depending on what information is missing, deter-
whether the overpayment should be recovered if
mine whether to contact the client, the GP, or if
the client is eligible for PIC.
applicable, the accredited employer, and send
them the appropriate letter (either a 'PIC03 Info
View overpayment information
request - Client', or a PIC04 Info request - Third
Party') to obtain the necessary information.
7.0 Check if client has a duplicate party/deleted
In the first instance, the information request
party ID
should be send to the client, the GP, or if appli-
Treatment and Support Assessor
cable, the accredited employer's verified email
address. Should there not be a verified email ad-
a In Eos, complete Party Searches as follows:
dress, the request should be sent via NZ Post.
- Initials of the clients first and last name with date of birth
- Initials of alternate names indicated in forms and med-
PIC03 Info request - Client
ical records with date of birth
PIC04 Info request - Third Party
- NHI number
- IRD number
- Consider reasonable alternative names e.g. nicknames
and English/non-English versions
5.0 Generate payment report
Treatment and Support Assessor
NOTE What if there is a duplicate ID?
a In Eos, locate the client's Party ID.
Create an Action Client Duplicate task and com-
plete the requested fields, this will route to the
correct queue automatically
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NOTE What if there is a deleted party ID which still
d Upload the '4.09 Lump Sums and Independence Allow-
has claims/documents?
ance Payment Report' you previously generated to the
Create an Action Client Duplicate task and com-
Permanent Injury Compensation subcase using the
plete the relevant fields, this will route to the cor-
'Lump Sums and Independence Allowance Payment 4.09
rect queue automatically.
Report' document type and add 'LS/IA Payment Report'
in the text box.
Upload an Electronic Document in Eos
8.0 Set up Permanent Injury Compensation sub-
case
Treatment and Support Assessor
9.0 Determine entitlement type and create assess-
a In Eos, determine the appropriate ACC45 that the claim
ment instance
should be managed from. This claim will be used to admi-
Treatment and Support Assessor
nister all Lump Sum / Independence Allowance activities,
a In Eos, complete the 'Determine Entitlement Type' E-
including the subcase.
form. When saved, Eos will generate an Impairment
NOTE What if there is a sensitive claims component
Assessment instance in Eos for the relevant entitlement
to the assessment?
type.
Manage the request on the sensitive claim, or
Update Permanent Injury Compensation Entitlement
where multiple sensitive claims exist, the 'master'
Details
claim, i.e. the oldest claim or claim where
assessment previously applied.
NOTE What if an assessment has already been
completed and a reassessment is required?
NOTE What if client has been assessed for this
You can create a reassessment instance in Eos
entitlement previously?
by using the 'copy' function on the previous
• If new request is lump sum then work on the
assessment instance. Refer to the 'Use copy
same claim as previous. If the previous lump
function to create reassessment ' system step.
sum payment was paid through Pathway you will
need to capture the assessment details on the
Use copy function to create reassessment
PIC subcase prior to the reassessment. See the
'Migrate Lump Sum details paid through Path-
way' system steps linked below.
10.0 Determine if impairment assessment is appro-
• If new request is for combined Independence
priate
Allowance then work from the same claim as
Treatment and Support Assessor
previous.
• If new request is for a single Independence
a Review the application and determine if it meets the cri-
Allowance then work from the claim the ACC554
teria for a Whole Person Impairment assessment or reas-
is for, i.e. the previously assessed claim if this is
sessment based on what kind of payment is being
to be assessed this time.
claimed.
Identify Claims for Rapidly Deteriorating Clients
Previously-assessed injuries must be included in
a reassessment of the entitlement.
NOTE What is the criteria for a Lump Sum?
Assessment:
Migrate Lump Sum details paid through Pathway
• the injury has cover
NOTE What if the client has not been assessed for
• the impairment is certified as permanent
this entitlement previously?
• the injury is certified as stable or 24 months
If the request is for one physical claim always
have passed since the date of injury
manage on the applicable claim.
Reassessment:
If the request is for multiple claims choose a
• the medical practitioner has certified that there
claim that:
is an increase in impairment since the previous
• relates to the highest impairment, or
assessment
• is currently managed, or
• If the client has had a reassessment previously,
• has had surgery, or
at least 12 months has passed since the last
• is the oldest claim listed.
reassessment
b Set up the Permanent Injury Compensation subcase on
Lump sum eligibility criteria Policy
the appropriate claim.
Lump Sum Reassessment Policy
Add or edit a rehabilitation action
Accident Compensation Act 2001, Schedule 1, Part
NOTE What if multiple claims need to be included in
3, Clause 61
the assessment?
https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM105421.html
• Link the additional claims to the subcase
Linking a Claim to PIC Subcase
NOTE What if the automatic injury description from
the injury code is not accurate?
• Edit the Injury Details with the correct descrip-
tion
Update Injury Details on a PIC Subcase
c In the Permanent Injury Compensation subcase, start the
'Pre-Assessment' task.
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NOTE What is the criteria for Independence Allow-
NOTE What if the client is eligible for an impairment
ance?
assessment?
Assessment:
Proceed to 'Arrange Whole Person Impairment
• the injury has cover
Assessment'
• the medical practitioner has certified that there
Eligibility to an initial impairment assessment
is impairment
• the injury is certified as stable or 12 months
Client reassessment request for a lump sum entitle-
have passed since the date of injury
ment
Reassessment:
Client reassessment request for an independence
• the medical practitioner has certified that there
allowance entitlement
is either an increase or decrease in impairment
ACC reassessment request for an independence
since the previous assessment
allowance entitlement
• If the client has had a reassessment previously,
at least 12 months has passed since the last
Information needed to confirm medical certification of
reassessment
a permanent impairment for a lump sum entitlement
Independence allowance eligibility criteria Policy
Required method for supplying medical information
for an impairment assessment
Independence Allowance Reassessment Policy
Extended discretion request
AI Act 1998, Schedule 1, Part 4, Clause 61
b In the Permanent Injury Compensation subcase close the
https://anzlaw.thomsonreuters.com/Document/I8b624b78022911e99495db3043f758b0/View/FullText.html?originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)&comp=wlnz
'Pre-Assessment' task.
NOTE What if additional medical / psychology notes
or assessment are required before a decision
can be made?
PROCESS
Arrange Whole Person Impairment
Determine what information you require, and
Assessment
from who, then follow the relevant process.
Treatment and Support Assessor
Use the PIC04 Info request - Third Party' letter
instead of the MD01 and MD02 letters.
Timeframes
Generate and send a 'PIC03 info request -
Client' letter to notify the client of the delay.
None Noted
PROCESS Request Clinical Records
Create a purchase order
PIC03 Info request - Client
PIC04 Info request - Third Party
ACC2386 DHB request for copy of notes - Vendor
NOTE What if the client is not eligible for a Whole
Person Impairment assessment?
• Contact the client and explain the decision.
• Send the client a 'PIC08 Decline assessment -
Client' letter.
• If applicable, send the accredited employer a
'PIC09 Decline assessment - Accredited Em-
ployer' letter.
• you must update the 'Description' on the 'Over-
view' tab to "Not eligible - (and the reason)"
• update the impairment assessment status to
'Declined' . Refer to the system step 'Decline
Whole Person Impairment Assessment'.
• determine claim ownership.
• close the task
• this process ends
PIC08 Decline assessment - Client
PIC09 Decline assessment - Accredited Employer
Decline Whole Person Impairment Assessment
Information needed to confirm medical certification of
a permanent impairment for an independence allow-
ance
Information needed to confirm medical certification of
an impairment increasing [for reassessment of a
lump sum entitlement]
Information needed to confirm medical certification of
an impairment changing [for reassessment of an
independence allowance entitlement]
ACC > Claims Management > Manage Client Payments > Manage Permanent Injury Compensation > Process a Permanent Injury Compensation application
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Assess Eligibility for Lump Sum / Independence Allow-
ance and Election Offer v11.0
NOTE What is the eligibility criteria for indepen-
Summary
dence allowance?
The client must have
Objective
• a degree of whole-person impairment of 10% or
To review the client's Impairment Assessment and determine
more, and
the client's eligibility for a lump sum or independence allowance.
• one of the following is true:
- a covered personal injury that has a date of
Owner
[Out of Scope]
accident before 1 April 2002, or
- a covered personal injury with a date of acci-
Expert
[Out of Scope]
dent on or after 1 April 2002 that is subject to the
transitional limits of clause 55, or
Procedure
- a covered personal injury with a date of acci-
dent on or after 1 April 2002 that is eligible for
PROCESS
Arrange Whole Person Impairment
election
under clause 55A
Assessment
Treatment and Support Assessor
Refer to the weblink below for further information
about independence allowance assessments
PROCESS
Arrange Whole Person Impairment
Independence allowance - Accident Insurance Act
Assessment peer review
1998, Schedule 1, Part 4, Clause 58
Treatment and Support Assessor
https://anzlaw.thomsonreuters.com/Document/I8b624c75022911e99495db3043f758b0/View/FullText.html?originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)&comp=wlnz
NOTE What if the client has impairment relating to
multiple independence allowances?
1.0 Make eligibility decision
You need to consider whether 'U V ACC' policy
Treatment and Support Assessor
applies and whether the client would benefit from
a In the Permanent Injury Compensation subcase start the
combining these impairments. See the 'Transi-
'Post Assessment' task.
tional Provisions and Combining Whole Person
Impairment to Determine Independence Allow-
b Determine the client's eligibility for a lump sum or
ance' policy linked below.
independence allowance using the relevant criteria
PROCESS Transitional Provisions and
below.
Combining Whole Person
Identify Claims for Rapidly Deteriorating Clients
Impairment to Determine
Independence Allowance Policy
NOTE What is the eligibility criteria for a lump sum?
The person must have:
NOTE What should I do if the client is eligible to re-
• a covered personal injury with a date of acci-
ceive an election option offer under Clause
dent on or after 1 April 2002
55A?
• the injury is not subject to the transitional limits
Go to step 2.0.
of clause 55
Certain persons may elect to receive either lump
• survived that injury for more than 28 days; and
sum or independence allowance
is alive when assessed
https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM1663927.html
• a degree of whole-person impairment of 10% or
more
NOTE What should I do if the client is not eligible?
In Eos generate and send the relevant decline
The client is not entitled to Lump Sum payment
letter(s).
in respect of personal injury suffered before 1
April 2002, or any subsequent consequences of
PIC13 Decline PIC - Client
any such personal injury.
PIC15 Decline PIC - Accredited Employer
Refer to the weblink below for further information
PIC19 Decline election - Client
on lump sum compensation for permanent
Lump sum eligibility requirements
impairment.
Determining the whole person impairment rating by
Lump sum compensation for permanent impairment
taking into account a previous rating
http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM105410.html
Minimum impairment threshold percentage
Transitional limits on eligibility for lump sum entitle-
ments
Lump sum election requirements
http://www.legislation.govt.nz/act/public/2001/0049/latest/DLM105411.html
Independence allowance election requirements
Lump Sum Reassessment Policy
Definition of combined impairment rating
Deceased client eligibility for independence allow-
ance
Deceased client eligibility for lump sum
Single independence allowance eligibility require-
ment
Criteria for combined independence allowance eligi-
bility for a person who has received an old lump sum
ACC > Claims Management > Manage Client Payments > Manage Permanent Injury Compensation > Assess Eligibility for Lump Sum / Independence Allowance and Election
Offer
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Timeframes
PROCESS
Set Up a Lump Sum / Independence
Allowance Payment
None Noted
Treatment and Support Assessor
PROCESS
Adjust or Stop a Lump Sum /
Independence Allowance payment
Treatment and Support Assessor
2.0 Offer election option
Treatment and Support Assessor
a Use the Comparison Calculator supplied by Actuarial
Services every 6 months to generate the information to
populate the ACC4214 Choice of Entitlement form.
NOTE What information do you need to complete an
Election Calculation:
- Claim number
- Payment from date (date of lodgement in most
cases)
- Impairment Rating
NOTE Where can the calculator be found?
\\ACCfiles\Data\Public\Calculators\Comparison
Calculator
b Generate and send the client a 'PIC16 Approve election -
Client' letter, including the information from the election
calculator in the attached ACC4214 Choice of Entitlement
form.
PIC16 Approve election - Client
c Create a 'Follow up election form' task and set the target
date 30 days in the future to allow the client sufficient
time to reply.
NOTE What if the client does not reply within 30
days?
Generate and send a 'PIC17 Election reminder -
Client' letter to the client.
Update the target date for the 'follow up election
form' task allowing another 30 days to respond.
PIC17 Election reminder - Client
NOTE What if the client does not respond within 60
days?
The client automatically receives an Indepen-
dence Allowance. Follow the 'Confirm Election
Option decision' system step to confirm payment
of the 3 monthly Independence Allowance in
Eos.
Confirm Election Option decision
d Once the client responds to the election eligibility letter,
follow the 'Confirm Election Option decision' system step
to confirm the election decision in Eos and then generate
and send the client a 'PIC18 Election confirmed - Client'
letter.
Confirm Election Option decision
PIC18 Election confirmed - Client
Lump sum and independence allowance payee
Election Eligibility Criteria Policy
PROCESS
Set Up a Lump Sum / Independence
Allowance Payment
Treatment and Support Assessor
ACC > Claims Management > Manage Client Payments > Manage Permanent Injury Compensation > Assess Eligibility for Lump Sum / Independence Allowance and Election
Offer
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Document Outline
