The State Insurance Regulatory Authority (SIRA) is the NSW government organisation responsible for regulating and administering the NSW workers compensation system. On the 10 July 2016, SIRA undertook a number of information sessions to introduce the SIRA “Guidelines for Claiming Worker’s Compensation”. These guides have been implemented to support workers, employers, insurers and other stakeholders in the process of claiming workers compensation. These new SIRA guidelines will come into effect from the 1 August 2016 and include such items as removing the need for the injured worker’s DOB, changes to claim decisions, removal of pre-approval for certain items and more.
Guidelines For Claiming Workers Compensation – The new SIRA guidelines come into effect from the 1 August 2016 and a brief summary of the changes include:
1) Removal of an injured worker’s DOB and some employer details
Less information required when notifying a claim providing a quicker and easier notification process.
2) An initial decision must be made on all notifications of injury
Decisions include:
- Accept Liability
- Provisional Liability
- Declinature
- Reasonable Excuse
- The Notification only coding will be phased out
icare has identified that this may be a significant change for some insurers and employers and are seeking information from stakeholders to implement the change.
Previously a claim could be coded “Notification Only” however this will now be coded “Reasonable Excuse, no requirement for weekly payments” and then closed. For all claims under this code, the insurer must contact the employer and worker via phone or letter and must send a letter to the worker which includes a claim form.
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. 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.
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.
4) Pre-Approval is no longer required for the following:
- Nominated Treating Specialist (within 3 months of DOI)
- Diagnostic Investigations (within 3 months of DOI)
- Pharmacy (prescribed by NTD or NTS within 1 month of DOI)
- Physical treatment – physio, chiro, ex phys (8 sessions within 3 months of DOI)
- Psychological treatment (same as above)
- Hearing Needs Assessment
- Allows a worker to access reasonable necessary treatment early on in the claim without delay or administrative formalities
Encourages early intervention and promotes early recovery and return to work.
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
5) 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
6) Quicker review, determination and application of treatment
Considers an individual’s needs and situation rather than the typical or traditional options available
7) 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
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