These Guidelines were used by all NSW CTP insurers for claims active before 1 January 2017. On 1 January 2017, they were replaced by the new (current) Motor accident guidelines: claims handling and medical (treatment, rehabilitation and care).
The Motor Accidents Compensation Act 1999 (MACA) and the Motor Accidents Act 1988 place responsibilities concerning treatment, rehabilitation and attendant care on the Motor Accidents Authority of NSW (MAA), the CTP insurers and claimants.
An important object of the MACA (section 5 (1a)) is to encourage early and appropriate treatment and rehabilitation to achieve optimum recovery from injuries sustained in motor accidents and to provide appropriately for the future needs of those with ongoing disabilities. Rehabilitation includes medical, social, educational and vocational measures to restore or attempt to restore an injured person to the maximum level of function of which the person is capable.
The main goal of the Treatment, Rehabilitation and Attendant Care (TRAC) Guidelines is to promote best practice and facilitate consistency in the rehabilitation of motor accident injuries within and between CTP insurers. The Guidelines ensure CTP insurers address the needs of claimants by facilitating their access to appropriate treatment, rehabilitation and attendant care throughout the life of a claim. The Guidelines provide standards and criteria against which insurers can measure their performance to demonstrate they are meeting their responsibilities.
Best practice involves continuous improvement. Continuous improvement is a cycle of change that builds upon previous achievements. Introducing beneficial changes to systems and supporting improved practices requires an organisational commitment to continuous improvement. Demonstrable evidence of improvement is a necessary component of the TRAC audit program.
This is the fifth revision of the Guidelines since inception in 1998.
These Guidelines, except 3.10, apply from the date they are gazetted to claims injuries arising from accidents under both the Motor Accidents Act 1988 and the Motor Accidents Compensation Act 1999.
Guideline 3.10 applies from 1 January 2007 to claims injuries arising from accidents under both the Motor Accidents Act 1988 and the Motor Accidents Compensation Act 1999.
These Guidelines are issued pursuant to Section 44 of the Motor Accidents Compensation Act 1999 and apply by Chapter 3 of that Act in respect of an injury caused by a motor accident. Further, these guidelines, so far as rehabilitation is concerned, apply in relation to insurers’ obligations under Section 84 of the Motor Accidents Compensation Act 1999. Sections 44 and 84 of the Motor Accidents Compensation Act 1999 apply in relation to treatment of injuries whether the injuries were sustained in accidents occurring before 5 October 1999, or on or after 5 October 1999.
The implementation of the Treatment, Rehabilitation and Attendant Care Guidelines for insurers requires demonstrated consideration and acceptance of the following general principles:
- Addressing the rehabilitation needs of claimants by facilitating their access to rehabilitation and attendant care is an integral part of the Motor Accidents Scheme.
- Effective treatment, rehabilitation and attendant care are a collaborative arrangement requiring communication and cooperation between the claimant, the provider and the insurer.
- The aim of rehabilitation is to maximise early recovery from injuries and promote independence and function.
- It is vital that treatment and rehabilitation are commenced as early as possible and are regularly monitored until conclusion. While not all CTP claimants will need rehabilitation services, it should be facilitated when required for all age groups, including children and older people.
- The review of rehabilitation is planned in accordance with anticipated management milestones of individual CTP claimants. For example, moving to high school or leaving school.
- Wherever possible, claimants should exercise choice about the selection of their treatment, rehabilitation and/or attendant care provider. However, the insurer is only obliged to pay for treatment, rehabilitation and attendant care costs that are reasonable and necessary, properly verified and relate to injuries resulting from the motor vehicle accident.
- The selection of a service provider should be determined by the claimant’s needs, not the relationship between the insurer and the service provider. Any commercial relationship between the insurer and the service provider is not a factor to be considered when selecting a service provider.
- Claimants should be encouraged to be involved in the development and ongoing review and modification of their rehabilitation plans.
- The insurer is not responsible for developing treatment, rehabilitation or attendant care plans. This is the responsibility of relevant service providers.
- There should be consistency in the decision making process about treatment, rehabilitation and attendant care issues between claims and rehabilitation staff.
- Successful implementation of the Guidelines relies on management support and teamwork between rehabilitation and claims staff employed by CTP insurers, and general acceptance of the notion of continuous improvement.
- All rehabilitation and claims staff actively seek to minimise the risk of disputes associated with managing the rehabilitation needs of claimants. They should be proactive in seeking resolution of disputes by facilitating referral to insurer’s internal complaints and disputes resolution processes, and when necessary, the appropriate external disputes resolution services.
Attendant care (or care and support services) assists people with disabilities to perform tasks they would normally be doing for themselves. Attendant care services aim to provide assistance to people with everyday tasks and include, for example, personal assistance, nursing, home maintenance and domestic services. They enable individuals to live independently and to exercise basic rights about choice of lifestyle.
Attendant care plan
An attendant care (or care and support services) plan should normally outline the claimant’s present condition, functional capacity, role of attendant carer (or support worker), goals and specified activities of the program and hours of care required. Attendant care plans are developed collaboratively between the attendant care agency, the provider involved, the claimant and their family, as well as the insurer.
For simple domestic assistance, the attendant care plan may take the form of a brief proposal. As a minimum this type of plan should include timeframes, costs and type of services.
The role of a claims officer employed by a CTP insurer, as related to these Guidelines, may include:
- responding to requests and paying accounts in a timely fashion
- ensuring the appropriate involvement of the rehabilitation adviser in facilitating assessment of the rehabilitation and attendant care needs of claimants
- where appropriate, establishing whether the proposed interventions and programs are ‘reasonable and necessary’ in consultation with the rehabilitation adviser
The statements in these Guidelines are not designed to limit the scope of the role of claims officers.
Refers to working days.
These Guidelines apply to all insurers who insure the person against the person’s liability for damages in respect of a claim, whether or not under a third party policy (section 42 of the Motor Accidents Compensation Act 1999). The insurer refers to all insurers who are licensed by the MAA and provide Compulsory Third Party (CTP) insurance in NSW, including insurers acting as agent for the Nominal Defendant.
The Guidelines reflect the definition of rehabilitation used in both the Motor Accidents Act 1988 (Section 35) and Motor Accidents Compensation Act 1999 (Section 3).
rehabilitation of an injured person, means the process of restoring or attempting to restore the person, through the combined and coordinated use of medical, social, educational and vocational measures, to the maximum level of functioning of which the person is capable or which the person wishes to achieve and includes placement in employment and all forms of social rehabilitation such as family counselling, leisure counselling and training for independent living.
The Guidelines support the philosophy that rehabilitation is the process of restoring an injured person as close as possible to their pre-injury level of functioning and to a quality of life comparable with their pre-injury level. Where function cannot be restored, the aim of rehabilitation becomes the acquisition of new functional or vocational skills.
The role of the insurer's rehabilitation adviser may include:
- facilitating the assessment of the treatment, rehabilitation and attendant care needs of claimants
- facilitating access of claimants to services if considered necessary
- establishing whether the proposed interventions and programs are reasonable and necessary
- providing a point of contact for the claimant, treating practitioners and rehabilitation providers
- undertaking a coordinating role between all involved stakeholders
- advising claims officers and managers on rehabilitation issues, and
- assisting the insurer to develop a consistent approach to decision making regarding ‘reasonable and necessary’.
Insurers either employ permanent or contract health professional staff in the role of rehabilitation advisers. Rehabilitation advisers do not provide direct services to claimants.
The statements in these Guidelines are not designed to limit the scope of the role of the rehabilitation adviser. The insurers use the term ‘rehabilitation adviser’ variously. The roles and titles may vary from insurer to insurer.
A rehabilitation plan is a formal document which identifies the assessed needs of the claimant, the goals or outcomes to be achieved, the proposed interventions or strategies to achieve these goals, time frames for achievement, periodic evaluation and reporting, and associated costings.
A rehabilitation provider delivers direct services to the claimant. A rehabilitation provider may be a multidisciplinary organisation or an individual health practitioner in either the public or the private sectors.
A service provider delivers direct services to the claimant. A service provider may be a multidisciplinary organisation or an individual. The services provided may include treatment, rehabilitation or attendant care.
An insurer has a responsibility to deal with requests for treatment. These requests should be dealt with in a timely fashion with reference to ‘reasonable and necessary’. CTP insurers are responsible for having a system in place for responding to such requests.
Format of the Guidelines
The MAA TRAC Guidelines for insurers divide the management of motor accident injuries into four phases. Claimants may move in and out of the different phases during their recovery and resettlement. The elements of treatment, rehabilitation and attendant care are addressed in each phase.
Each phase has an underpinning principle, followed by a standard. Objective criteria under each principle assist in the application of the standard and in the measurement of achievement.
Early identification of treatment, rehabilitation and attendant care needs.
Assignment of insurer's claims and rehabilitation staff.
Coordination of assessment and planning of treatment, rehabilitation and attendant care needs.
Monitoring and evaluation of treatment, rehabilitation and attendant care programs.
Each phase has a principle that outlines the basic tenet from which the standards and criteria derive. The principles are not measurable but act to encapsulate the beliefs of the particular phase.
Under each principle is a standard that is the overall standard for the phase. The criteria derive from the standard.
The criteria are statements that act to clarify the standard and provide practical advice on implementation. In the process of self-assessment and external audit of these Guidelines, the criteria provide the basis for assessing levels of achievement or compliance.
Phase 1 – Identification of treatment, rehabilitation and attendant care needs
Early identification of the need for services optimises clinical outcomes for claimants and provides the best opportunity for cost effective treatment, rehabilitation and attendant care.
The insurer has an effective system for the early identification of the needs of claimants and for the accurate coding of their injuries.
Policies and practices ensure:
Claimants who may need treatment, rehabilitation or attendant care are identified by a consistently applied screening system encompassing:
Screening is completed within 10 days of receipt of the claim.
Information is sent to those claimants who have been identified as requiring rehabilitation services on the role of insurer’s rehabilitation advisers; how to contact them; and the claimant’s rights and responsibilities (MAA brochure ‘Rehabilitation and the Motor Accidents Scheme’ or insurer’s own brochure with relevant information). The information is sent within 10 days of the identification.
Written communication with claimants is:
There is a claim file management system which ensures that insurers have a current, complete, accurate, retrievable and secure treatment, rehabilitation and attendant care file relating to each claimant.
Any contact, including verbal, about treatment, rehabilitation or attendant care between claimant, claimant’s solicitor or service providers is documented and dated in the claim file. A copy of any written correspondence must be kept on the claim file.
Claimant’s injuries are coded using the Abbreviated Injury Scale (AIS) 1985 Revision, and in accordance with the Injury Coding Guidelines published by the MAA.
All AIS Injury Coders are appropriately trained by MAA approved trainers.
Full claims (including claims converted from ANFs):
Accident Notification Forms (ANFs):
Phase 2 – Assignment of the insurer’s claims and rehabilitation staff
The assignment of claims and rehabilitation staff by the insurer promotes the provision and coordination of treatment, rehabilitation and attendant care services. Claimants requiring services need to know who to contact at the insurer and how to contact them.
The insurer assigns rehabilitation staff to claimants who may require rehabilitation and/or attendant care in order to oversee their assessment, rehabilitation and resettlement and to facilitate effective communication between all parties.
Policies and practices ensure:
A system is in place to:
The insurer continues to meet its treatment, rehabilitation and attendant care responsibilities during periods of staff absence.
All rehabilitation advisers have health professional qualifications, background and rehabilitation experience relevant to the role.
Potential conflicts of interest are identified and addressed.
NB: Possible situations include:
Relevant ongoing professional development, support, and performance review are provided for employed Rehabilitation Advisers, and a system of performance review is in place for contracted rehabilitation advisers.
Relevant ongoing training is provided for claims officers regarding the application of these treatment, rehabilitation and attendant care guidelines.
Phase 3 – Co-ordination of assessment and planning of treatment, rehabilitation and attendant care needs
Effective assessment and planning is essential and aims to ensure all parties involved are aware of the overall plan, their role, and the roles and responsibilities of others involved in the process.
The insurer refers claimants to appropriate providers, when necessary, for assessment of their rehabilitation and attendant care needs and responds to requests for treatment, rehabilitation and attendant care in a timely fashion.
Policies and practices ensure:
Claimants who have been identified as requiring treatment, rehabilitation or attendant care assessments or services must be referred to an appropriate provider within 10 working days of the identification.
A system is in place for responding to plans and requests for the treatment, rehabilitation and attendant care needs of claimants. Plans and requests are reviewed by rehabilitation advisers and/or designated claims officers to ensure all the needs resulting from the motor vehicle accident have been addressed.
Decisions on whether the request or proposed plan is reasonable and necessary are informed by:
Consistency in the determination of what constitutes ‘reasonable and necessary’ services by:
When there is a need to coordinate services or when there are differences of opinion about claimants’ programs, the insurer considers the use of case conferences involving rehabilitation advisers and/or providers, treating practitioners, attendant care agencies and claimants.
Service providers are advised of approved plans or requests for treatment, rehabilitation and attendant care:
When the insurer declines or partially declines to pay for the claimant’s treatment, rehabilitation or attendant care it will:
This requirement does not apply if the insurer has already provided the above information after previously declining to pay for the same plan or request.
NB. The following dispute resolution processes apply:
For accidents occurring before 5 October 1999, the options for resolving the dispute are to refer the matter to:
For accidents occurring on or after 5 October 1999, the options for resolving the dispute are to refer the matter to:
When the insurer decides to terminate previously approved treatment, rehabilitation or attendant care (for reasons other than settlement) they must advise the service provider and claimant in writing at least 5 days before the effective date of the decision for treatment and rehabilitation and at least 10 days before the effective date of the decision for attendant care programs and also:
Home modification requests are acknowledged in writing within 10 days. The insurer must advise the claimant and service provider in writing indicating in principle approval or rejection within three months.
When the request is denied the insurer will:
(Applicable from 1 January 2007)
Neuropsychological assessments are conducted in accordance with the appropriate “Neuropsychological assessment guidelines” issued by the MAA in 2006.
For assessments organised by the insurer
Where a claimant is a current patient of any of the NSW Brain Injury Rehabilitation Programs (BIRP), the BIRP will nominate the psychologist to conduct any assessment according to the guidelines.
Phase 4 – Monitoring and evaluation of treatment, rehabilitation and attendant care programs
Ongoing monitoring and evaluation ensures that treatment, rehabilitation and attendant care programs continue to address the needs of claimants to maximise their independence.
The insurer has an effective system for monitoring the progress of claimants and for reviewing their continuing treatment, rehabilitation, attendant care and achievement of agreed outcomes.
Policies and practices ensure:
The insurer has a system in place for ongoing monitoring of claimant files and reassessment of claimant needs.
N.B. Time frames for submission of progress reports may vary according to the nature of service and the nature and complexity of the claim.
The insurer has an appropriate system in place to review all claims involving a spinal cord injury or brain injury at least every six months and to review claimant files and reassess claimant needs where:
The reopening of cases should be in accordance with established criteria so that there is the opportunity to review and/or reopen any case after completion of rehabilitation programs and prior to settlement where there has been a change in circumstances.