Providing allied health services in the NSW CTP schemes - FAQs

What are the principles of treatment?

Clinical Framework

All allied health practitioners should apply the nationally endorsed Clinical Framework for the Delivery of Health Services when treating people injured in motor accidents.

The clinical framework has been established to:

• optimise participation at home, work and in the community, and achieve the best possible health outcomes for injured people
• inform healthcare professionals of our expectations for managing injured people
• provide guiding principles for the provision of healthcare services for injured people, healthcare professionals and decision makers
• ensure healthcare services are goal oriented, evidence based and clinically justified
• assist with dispute resolution.

The five principles of the clinical framework are:

1. measure and demonstrate the effectiveness of treatment
2. adopt a biopsychosocial approach
3. empower the injured person to manage their injury
4. implement goals focused on optimising function, participation and return to work
5. base treatment on the best available research evidence.

These principles have been incorporated into the forms which allied health practitioners use to request treatment and other services for CTP claimants.

When should injured people return to work?

There is compelling Australasian and international evidence that good work is beneficial to people’s health and wellbeing and that long-term work absence, work disability and unemployment generally have a negative impact on health and wellbeing.

Injured persons should be supported to recover at work after an injury where possible. People who keep working, even if they can’t do everything at first, get better quicker than people who take a long time off work.

Under the MACA, persons injured in motor accidents are entitled to different types of vocational support, including, where eligible, vocational support programs.

Allied health practitioners should incorporate this focus into their practice by becoming familiar with The Health Benefits of Good Work, an initiative from the Australasian Faculty of Occupational and Environmental Medicine of The Royal Australasian College of Physicians (RACP).

How are decisions made about treatment, rehabilitation and attendant care services and equipment?

Under both the MACA and MAIA, CTP insurers are only obliged to pay for treatment that's considered ‘reasonable and necessary’. You need to take this into account when proposing treatment, rehabilitation and attendant care services or equipment.

The criteria for reasonable and necessary treatment are:

1. directly related to the injuries sustained in the motor accident
2. aimed at helping the injured person get back to their usual activities
3. appropriate for the type of injury
4. provided by an appropriately qualified health professional
5. cost effective.

Under the MAIA, which applies to motor accident injuries acquired on or after 1 December 2017 you also need to consider whether the injury could be considered or is considered a ‘threshold injury’ by the CTP insurer, because that will affect how long a person is entitled to services and equipment.

A service or piece of equipment considered to be reasonable and necessary in one case may not be considered reasonable and necessary in another. For example, a physiotherapy or psychology treatment might be considered reasonable and necessary for extended periods for some people, but not for others, depending on the nature of their injury and progress made.

You can find more information in the following links:

• How do I provide services to a person injured in a motor accident?
• Threshold injuries
• What forms should I use? (Eg requests for allied health services, equipment, attendant care)
• Vocational programs.

Who is covered by the CTP scheme?

Not all people injured in motor accidents are covered under the NSW CTP scheme (for example, people injured in a vehicle accident in the course of their employment may be covered by the workers compensation system instead), so it’s important you check your client's compensation status and identify the relevant insurer.

If the person was injured on or after 1 December 2017

The scheme differentiates between at fault and not at fault drivers, and also between threshold injuries and non threshold injuries.

Some injured people may also be eligible for SIRA-funded vocational support programs.

Injured people who were not at fault and have only threshold injuries are entitled to:

• Early intervention including a GP visit and two treatment sessions after notifying the insurer and obtaining approval, even if a claim has not been made yet. Access to services is at the insurer’s discretion. This early intervention may also be used after the claim form is submitted during the four-week period that the insurer has to determine liability.
• Statutory benefits (treatment and care, and weekly benefits for loss of earnings) for up to 52 weeks from the date of accident
• Limited domestic assistance (graded to match the injured person’s recovery)
• Possibility of treatment beyond 52 weeks if specific criteria are met.

If the person was not at fault and has non threshold injuries, they are entitled to:

• Early intervention
• Statutory benefits:
  • ­ Treatment and care for as long as reasonable and necessary
  • ­ Weekly benefits for loss of earnings for up to 5 years, subject to certain requirements.

If the person was not at fault and has severe injuries, they are entitled to the same as for a person not at fault with non threshold injuries, but if treatment and care expenses are ongoing 5 years after the date of accident, then the Lifetime Care and Support Authority will become the relevant insurer and will manage ongoing expenses.

If the person was at fault, regardless of injury, they are entitled to:

• Early intervention
• Statutory benefits (treatment care, and weekly benefits for loss of earnings) for up to 52 weeks from the date of accident
• Limited domestic assistance (graded to match the injured person’s recovery).

If the person was injured before 1 December 2017

If the person was not at fault, they can make a claim for a range of benefits including past and future medical treatment and rehabilitation costs, care costs and economic losses, as well as payments for pain and suffering (in some circumstances).

If the person was at fault, the Green Slip may provide limited cover, up to the first $5,000 of treatment costs and lost income incurred in the first 52 weeks after an accident.

What is a threshold injury?

‘Threshold injury’ has a legal definition under the MAIA, which applies to motor accident injuries acquired on or after 1 December 2017:

• a soft tissue injury, or,
• a threshold psychological or psychiatric injury.

Whether an injured person is deemed to have a threshold injury or not will affect their entitlements to treatment.

See this fact sheet for more information about threshold injury.

Soft tissue injury

A soft tissue injury is an injury to tissue that connects, supports or surrounds other structures or organs of the body (such as muscles, tendons, ligaments, menisci, cartilage, fascia, fibrous tissues, fat, blood vessels and synovial membranes), but not an injury to nerves or a complete or partial rupture of tendons, ligaments, menisci or cartilage.

Included as threshold (as per the Regulation) is an injury to a spinal nerve root that manifests in neurological signs (other than radiculopathy).

Threshold psychological or psychiatric injury

A threshold psychological or psychiatric injury is a psychological or psychiatric injury that is not a recognised psychiatric illness.

Included as threshold (as per the Regulation) are acute stress disorder and adjustment disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

What is my role in the CTP scheme?

Allied health practitioners should review and note the following inclusions of the Guidelines for the Provision of Relevant Services (Health and Related Services), which apply to them when working in the CTP scheme (for accidents on or after 1 December 2017):

• Part 1: Code of conduct
• Part 2: Requirements for telehealth services

As a single allied health practitioner (eg physiotherapist, psychologist, chiropractor), your role includes:

• working collaboratively and communicating in an effective and timely manner with members of the injured person’s support team (including the employer, insurer, doctor, allied health practitioner, rehabilitation provider and others providing treatment, care and support to the injured person) about the injured person's injury, treatment, and recovery
• conducting appropriate assessment, goal setting in conjunction with the injured person and providing the best treatment to help the injured person achieve their goals
• providing treatment for injuries sustained in the motor accident to enable the injured person to resume participation in pre-injury activities that have been restricted by the motor accident related injuries
• empowering the injured person to manage their injury and recovery
• monitoring progress towards the injured person’s goal (for improved capacity/function) and adjusting the treatment plan as required
• ensuring you provide any telehealth services in a manner consistent with Part 2 of the Guidelines for the Provision of Relevant Services (Health and Related Services,
• providing further information to insurers upon request.

At all times, your practices need to adhere to the code of conduct contained in Part 1 of the Guidelines for the Provision of Relevant Services (Health and Related Services), relevant professional codes of conduct and/or legislation of the relevant board or association.

Your role does not include:

• making referrals or coordinating the injured person’s return to work
• advocating for the injured person in relation to the management of their claim or coaching them through litigation or other compensation processes
• providing services that are not related to the injuries sustained in the motor accident.

How will injured people be referred to me?

The injured person will usually refer themselves. Sometimes the referral will be initiated by the person’s general practitioner or rehabilitation provider.

How do I request approval for treatment?

You should always get approval from the insurer before providing services to ensure accounts will be paid, with the following exceptions:

• initial assessment (one treatment session) – but ensure that the injured person has a CTP claim number before conducting the assessment
• if the injured person has insurer pre-approval for two early intervention treatment sessions.

Most CTP insurers now require that allied health practitioners complete an allied health recovery request (AHRR) and submit it to the insurer in order to request treatment.

This form should be provided to the CTP insurer after the first treatment on a claim (other than early intervention  treatments). This initial AHRR form completion attracts a SIRA-gazetted fee of $35.60 (plus GST). Subsequent AHRRs do not attract a fee and should be completed as part of the standard consultation cost.

At times, the insurer may request additional information to the AHRR (for example, a specific report or a rehabilitation services request). If so, you will need to discuss the payment for this with the insurer.

For more information, see what forms should I use?.

What is early intervention?

Under MAIA (that is, for injuries which occurred on or after 1 December 2018), allied health practitioners such as physiotherapists can provide up to two early intervention treatment sessions prior to the injured person making a claim, as long as the insurer has provided approval. The injured person needs to notify the insurer of the accident and obtain approval, and will provide you with a claim number or a reference number. Access to services is at the insurer’s discretion.

If you are providing one of these initial treatments and do not think the person will require more ongoing treatment, you may not need to complete an AHHR form (see Requesting approval for treatment). However, it is recommended that you engage with the insurer regarding the early treatment.

How will the CTP insurer manage the request for treatment?

The insurer will use the information provided in the allied health recovery request to decide whether proposed services are reasonable and necessary.

They may contact you to discuss the plan or request additional information or clarification. This might include filling out other forms (listed in this guide)

They must provide a written response within 10 working days of the request being received. If they are declining or partially declining any treatment they will provide the reason/s.

If you don't receive a response within 10 working days, you need to contact the CTP insurer to ensure you have approval.

How is it determined that treatments should stop?

All treatment and rehabilitation is aimed at empowering the injured person to self-manage their symptoms and recovery. So it may be appropriate for services to stop before they have fully achieved their goal(s). This will need to be determined on a case-by-case basis.

You will generally not be required to provide a case closure summary to the insurer at the completion of treatment.

You are however expected to update key parties (for example general practitioner, other allied health practitioners, case managers and rehabilitation providers) on the injured person’s progress throughout the time you are providing services.

How do I contact the CTP insurer?

When you contact the CTP insurer, you may speak to the following team members:

• claims officers (who manage the claim) and/or
• rehabilitation advisors/injury management advisors (who generally have allied health backgrounds to provide recommendations around injury management).

CTP insurer contact details

Can I also provide rehabilitation services in the CTP scheme?

Rehabilitation services should be provided by someone other than a primary treating allied health practitioner. However, in some cases it may be appropriate for the allied health practitioner to perform certain rehabilitation provider tasks. For example, in rural and remote regions the rehabilitation provider may also be the treating occupational therapist.

Rehabilitation services should not be provided by an employee of the CTP insurer, solicitor, attendant care provider, family member or guardian.

If you are providing rehabilitation services, the CTP insurer may ask you to use the rehabilitation services request form to provide additional information. More information about this form is available on our Providing rehabilitation services in the NSW CTP schemes (frequently asked questions) page.

What forms should I use?

Most CTP insurers require that allied health practitioners complete an allied health recovery request (AHRR) and submit it to the insurer in order to request treatment for any motor accidents after 1 December 2017. Make sure you provide reasons to support your treatment intervention to allow the insurer to make an informed decision.

Click here for information to help you fill out this form.

If you are treating an injured person whose motor accident was prior to 1 December 2017, use the Accident Notification form (ANF) and Personal Injury Claim form (PICF), claims and dispute process and how you provide services will continue.

If you are providing rehabilitation services, the CTP insurer may ask you to use the rehabilitation services request form to provide additional information. More information about this form is available on our Providing rehabilitation services in the NSW CTP schemes (frequently asked questions) page.

How do I invoice the CTP insurer?

What fees can I charge?

SIRA has not set maximum fees for the services of allied health practitioners in the CTP scheme. You need to agree all rates with the CTP insurer before treatment is commenced. The exception is a $35.60 (plus GST) fee for the initial allied health recovery request. Subsequent allied health recovery requests do not attract a fee and should be completed as part of the standard consultation cost.

What information should I provide?

To facilitate prompt payment, we suggest allied health practitioners:

• send accounts directly to the CTP insurer. It is difficult to ensure timely submission of accounts by other parties (for example, an injured person or their solicitor).
• issue the account in the form of a tax invoice and include:
  • the claimant’s first and last name
  • the claim number allocated by the insurer
  • payee details
  • the Medicare provider number, if relevant
  • the Australian Business Number (ABN) of the provider
  • the name of the medical practitioner or service provider
  • the date of the service (the date of invoice must be on the day of or after last date of service listed on the invoice)
  • the payment classification code from the Authority, where applicable
  • the service cost for each payment classification code from the Authority, where applicable
  • the service duration, where applicable.
• direct all enquiries about payment to the claims officer you have been dealing with.

CTP insurers may fund early interventions. Once a claim has been accepted, CTP insurers are only obliged to pay for services that are reasonable and necessary.

If the insurer denies liability, the injured person is personally responsible for payment of accounts. They may be able to claim part or all of their expenses from Medicare, private health insurance, or from a personal accident insurance policy.

Service codes

All allied health practitioners must include the relevant service code(s), listed below, when requesting approval for services.

What if the injured person does not progress as expected?

Unfortunately, not all cases progress as initially expected.

If functional improvement is slow or absent, the cause(s) should be identified and where appropriate, recovery expectations may need to be adjusted.

In some circumstances, it may be appropriate to recommend referral to another health care practitioner.

By discussing that option with the insurer, the injured person and their allied health practitioner can help to change the intervention and seek better recovery outcomes.

What if the CTP insurer declines the proposed services?

What if the insurer denies liability?

You should not be providing treatment without approval to treat from the insurer.

What if the insurer declines a particular direction for treatment?

The insurer uses the information they have, included information that you have provided, to make decisions about the direction of treatment.

Sometimes the insurer may not agree with the proposed direction for treatment as it does not meet the reasonable and necessary criteria. The insurer must provide reasons for declining services.

These issues can often be resolved through discussion and/or by both parties providing further information, so if you have reviewed the insurer’s response and disagree:

• you may wish to discuss it with the insurer claims officer or rehabilitation advisor
• if the situation remains unresolved, you may wish to escalate your concern with the insurer.

Injured persons who disagree with an insurer’s decision on treatment may take steps to dispute the decision, with the first step being to contact the insurer to request an internal review.

How is privacy managed in the scheme?

When a CTP personal injury claim is submitted to the CTP insurer, the injured person or their guardian signs a declaration in the application for personal injury benefits form authorising the CTP insurer to obtain information about the motor accident injury from treating medical practitioners and allied health practitioners.

The declaration should give allied health practitioners confidence that the insurer is only requesting access to information to which they are entitled, to make decisions about the injured person’s claim.

The declaration:

• authorises the insurer to contact and obtain information and documents relevant to the claim from persons specified in this authorisation below and provide information and documents so obtained to persons specified in this authorisation below.
• authorises the release, use, disclose and exchange personal and health information on the form and information obtained in the course of the processing and managing the claim, between:
  • any doctor, ambulance service, hospital or other health related service provider
  • any police department
  • any property damage insurer
  • any employer or accountant of the injured person
  • any personal injury insurer or workers compensation insurer
  • Centrelink
  • Medicare Australia
  • Lifetime Care and Support Authority of NSW
  • State Insurance Regulatory Authority (SIRA).

In all circumstances, you are required to comply with the applicable laws in protecting injured person’s personal and health information.

What happens if I don’t comply with the legislation or guidelines?

SIRA may issue a direction to an allied health practitioner under section 26D of the State Insurance and Care Governance Act 2015 if they have:

• not complied with a provision of the motor accidents legislation
• not complied with the relevant provisions of the Guidelines for the Provision of Relevant Services (Health and Related Services) or the Motor Accidents Guidelines
• been referred to, or is under investigation by, a relevant clinical, professional or accreditation body.

A section 26D direction could include requiring the provider to take certain action or could suspend or exclude the provider from working in the CTP and WC schemes.

Failure to comply with a direction may result in penalties.

More information

• Complete our free online training module. Hosted by the Personal Injury Education Foundation, it will only take you about an hour.
• Practitioner-specific information can be found on the A-Z of Service Providers page.
• For enquiries, contact CTP Assist on 1300 656 919 or email [email protected].

Acknowledgements

These FAQs are based on and replace the Motor accidents guide for allied health practitioners, which was developed in conjunction with:

• compulsory third party (CTP) insurers
• the Australian Society of Rehabilitation Counsellors
• the Australian Rehabilitation Providers Association
• the Australian Physiotherapy Association
• the Chiropractors’ Association of Australia NSW
• Osteopathy Australia
• the Australian Psychology Association, and
• the Exercise and Sport Science Association.