Providing rehabilitation services in the NSW CTP schemes - FAQs

What are the principles of treatment?

Clinical Framework

All rehabilitation providers 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 MAIA, 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 six months from the date of accident
• Limited domestic assistance (graded to match the injured person’s recovery)
• Possibility of treatment beyond 26 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; this can include training and other vocational support
  • ­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 six months 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 six months 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.

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?

Some injured people may require additional services from a rehabilitation provider to coordinate services such as:

• assessing or reviewing the injured person’s rehabilitation needs
• recommending or planning for appropriate services for the injured person
• assisting the injured person to identify and achieve their goals
• empowering the injured person to manage their injury and recovery
• linking the injured person to the services they need
• facilitating communication between all parties involved in the injured person’s rehabilitation
• supporting the injured person to stay at work or return to work while they recover
• helping the injured person to maintain or recommence usual home and community activities
• monitoring the appropriateness and progress of services being provided.

Your role does not include:

• advocating for the injured person in relation to the management of their claim, litigation or other compensation processes
• providing or recommending services that are not related to the injuries sustained in the motor accident.

The expectation for rehabilitation provider services for each person should be discussed with the CTP insurer and the injured person at the time of referral. All allied health practitioners involved in the recovery plan should be notified.

How will injured people be referred to me?

Referral for rehabilitation provider services will usually (but not always) be initiated by the CTP insurer making contact with you.

The insurer may make a referral for rehabilitation provider services for:

• an assessment only, specifying the issues to be addressed (for example review of capacity, review of treatment, vocational, workplace or education assessment or care needs assessment) and a summary of recommendations
• an assessment and rehabilitation plan when it is apparent services will be required.

Once you have received a referral, you may want to contact the insurer with any questions about the referral. The insurer may have additional information available that is relevant to the referral.

You must always get approval from the insurer before providing services, including initial assessment, to ensure accounts will be paid.

When can I provide rehabilitation services?

You must always get approval from the insurer before providing services, including initial assessment, to ensure accounts will be paid.

For more information, see what forms should I use?

Who can 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.

How will the CTP insurer manage the request for treatment?

The insurer will use the information provided in the rehabilitation services 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. 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 rehabilitation services 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.

The insurer may require a case closure report from you when:

• the injured person’s goals have been achieved
• the injured person has made significant progress and is now able to independently manage their recovery
• the injury has stabilised and further treatment is not indicated
• the claim is approaching settlement
• services are not of benefit
• the injured person has not complied with their agreed rehabilitation plan.

You should check with the insurer if they require a case closure report. The rehabilitation services request can be used for case closure if needed.

You are expected to update key parties (for example general practitioner, other allied health practitioners and case managers) 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

What forms should I use?

Rehabilitation services request form

There are a number of different forms you may need to use. Prior to completing these forms, ensure you are aware of the principles of treatment, what services you can provide,  and the relevant service codes.

Use the rehabilitation services request form:

• report on an assessment of capacity, treatment outcome, vocational, workplace, educational or care needs assessment, propose treatment and request payment for proposed services (for example case management, workplace rehabilitation)
• to review the current treatment plan or to document case closure if the insurer requires it.

The fee for the payment of the rehabilitation services request needs to be agreed with the insurer before completion.

A Microsoft Word version of the rehabilitation services request form is available if you are unable to access the link above. Contact CTP Assist on 1300 656 919 or email [email protected] to obtain a copy.

This form is only for NSW CTP personal injury claims.

Agreed goals for rehabilitation form

Use the agreed goals for rehabilitation form if you are a rehabilitation provider to communicate the injured person's goals to all parties to facilitate client centred rehabilitation.

It is a standardised letter to send to enable all parties to work together focusing on the injured person’s goal.

This form is only for NSW CTP personal injury claims.

Attendant care request form

You can download a copy of the attendant care request form here.

This form is only for NSW CTP personal injury claims.

Equipment Request form

You can download a copy of the equipment request form here.

This form is only for NSW CTP personal injury claims.

What type of equipment can I request?

The injured person may require aids or equipment to support treatment, assist recovery or to compensate for a limitation caused by the compensable injury or injuries.

How do I request equipment?

In general terms, there are three forms that can be used to request equipment.  Which form to use depends on the individual circumstances. Contact the insurer  for advice if the matter is urgent, or you are unsure which form to use.

Use the equipment request form when recommending items that are:

• complex to set up or use
• custom made
• high cost
• not typically required for managing the injury

How do I invoice the CTP insurer?

What fees can I charge?

There are no gazetted rates for the services of allied health practitioners. 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 and rehabilitation
providers:

• 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 should but are not required to 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 and rehabilitation providers must include the relevant service code(s), listed below, when requesting approval for services using an allied health recovery request or rehabilitation services request.

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?

Other than early intervention services,  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 a rehabilitation provider 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 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

• Visit the Rehabilitation Provider section of 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.