New guidelines for claiming workers compensation in NSW

The State Insurance Regulatory Authority (SIRA) is the NSW government organisation responsible for regulating and administering the workers compensation system in NSW.

They have developed new ‘Guidelines for claiming workers compensation’ to support, inform and guide workers, employers, insurers and other stakeholders in the process of claiming workers compensation in NSW. These new guidelines will replace existing guidelines for compensation benefits, work capacity and domestic assistance. 

These new SIRA guidelines will come into effect from Monday 1 August 2016.

Our claims staff have had extensive training on these changes are ready to start implementing these changes from 1 August 2016.

The main impacting changes are summarised below:

   Changes

  How this will impact you

  Changes to the minimum requirements for initial notification of a claim
 
  • Removal of an injured worker's DOB and some employer details
  • Less information required when notifying a claim
  • Quicker and easier notification process
  Removal of Notification Only status
 
 
  • An initial decision must be made on all notifications of injury. Decisions include:
                       1. Accept liability,
                       2. Provisionally Liability,
                       3. Declinature or
                       4. Reasonable Excuse
  • Previously, a claim could be coded as “Notification Only”, however now this will be coded as “Reasonable Excuse – No requirement for weekly payments” and then can be closed.
  • For all claims under this code, the insurer must contact the employer and worker by phone or letter and must send a letter to worker which includes a Claim Form. 
  • The Notification Only coding will be phased out  from 01 August 2016.
  • To streamline the management of notification only incidents, please submit written confirmation from your employee with your notification to confirm there are no payments required and there is no action after notification.
  • A new code: “Reasonable Excuse – No requirement for weekly payments” will apply to these claims.
  • This will not impact the case management of the notification. It just requires a different coding in our system. The notification can still close, as per the current process, once we confirm there is no action or payment needed.
  • Once we have confirmed there is no action or payment after notification, we can send the required letters and close the claim.
 
  Application of reasonable excuse only applies to weekly payments
 
  • A Reasonable Excuse Status only applies to weekly payments – as per the legislation. 
  • Medical expenses etc. must be provisionally accepted and reasonably necessary expenses paid when a claim is in Reasonable Excuse. Note: This is not an admission of liability.
  • Whilst liability is being determined, a worker’s progress and recovery will not be delayed, as they will have access to immediate treatment and rehabilitation needs.
  • For example, a worker with a psychological injury will have immediate access to treatment and rehabilitation needs such as counselling and mediation to help facilitate a speedy recovery and return to work.
 
  Exemptions to treatment pre-approval
 
  Pre-approval is no longer required for the following: 
 
  • Access to any treatment within 48 hours of DOI
  • Nominated Treating Specialist: If referred by NTS; any consultations and treatment during consultations (apart from surgery) within first 3 months from DOI
  • Diagnostic investigations: If referred by Nominated Treating Doctor; X-rays within 2 weeks of DOI, US, CT scans, MRIs within 3 months of DOI when the IW has been referred to a NTS, If referred by NTS; Any diagnostic investigations within 3 months of DOI.
  • Pharmacy: medication prescribed by NTD or NTS for the injury within 1 month of DOI
  • Physical treatment (physio, chiro ex phys): 8 sessions if injury not previously treated and starts within 3 months of DOI, 3 sessions if injury not previously treated and starts after 3 months since DOI. One consultation with a different provider if injury was previously treated.
  • Psychological treatment (psychologist or counselor): Same as above.
  • Hearing needs assessment: Initial hearing needs assessment
  • Allows a worker to access reasonably necessary treatment early on in the claim without delay or administrative formalities
  • Encourages early intervention
  • Promotes early recovery and return to work

NOTE: Where possible, workers should be encouraged to attend treatment outside working hours, to support their gradual RTW and ensure there is no unnecessary disruption to their workplace.

Despite the removal of pre-approval requirements, workers and doctors still need to keep their employer and case manager up to date with treatment, and treatment still needs to be reasonably necessary as a result of the work injury.
 

 
  Reasonably necessary treatment
 
  • An approach that encourages sound decision making and reduces the requirement for further medical information that isn’t necessary
  • Case by case analysis and consideration
  • Reasonably necessary does not mean absolutely necessary
  •  Reduces unnecessary disputes
  • Quicker review, determination and application of treatment
  • Considers an individual’s needs and situation rather than the typical or traditional options available
 
  Work Capacity Assessment appointments
 
  • A worker cannot be required to attend more than 4 appointments per work capacity assessment (WCA),
  • Can only attend one appointment with the same type of medical specialist (e.g. can’t refer the worker to two orthopaedic surgeons for the same WCA)
  • Can only attend one appointment with the same type of health care professional (e.g. physiotherapist, psychologist)
  • Quicker Work Capacity Assessment
  • Shorter delay in appointments
  • Reduces unnecessary disputes
   
If you have any queries or wish to discuss these changes further please contact your EML Account Manager.
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