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Standard 15 - approval and payment of medical, hospital and rehabilitation services

Prompt approval and payment for medical, hospital and rehabilitation services ensures workers can remain focused on their recovery and helps to maintain the integrity of the scheme.

Approval and payment of medical, hospital and rehabilitation services

Principle: Prompt consideration will be given to approving medical, hospital and rehabilitation services and payment will be made as soon as practicable after services are invoiced.

 ExemptionsBenchmarks
S15.1 Before making a decision about approval for services, insurers must determine:
  • whether the service provider is appropriately qualified to provide the service;
  • whether the proposed fees are appropriate and/or consistent with Workers Compensation Fees Orders; and
  • whether the services requested align to appropriate billing/payment codes.
Evidence on claim file.
S15.2 When approving services from workplace rehabilitation providers, insurers must ensure that services are consistent with the Nationally Consistent Approval Framework for workplace rehabilitation providers and the NSW Supplement. Evidence on claim file.
S15.3 Insurers must review service provider invoices prior to payment and ensure:
  • rates and items billed align with approvals;
  • rates do not exceed the maximum amount prescribed by any relevant Workers Compensation Fees Orders; and
  • invoices contain all relevant information, including application of GST or input tax credits where appropriate.
Evidence on claim file.