Claims management other

GN 4.6 Payments to Medicare Australia

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General

Insurers are encouraged to actively identify claims where medical services for a work-related injury may have been paid by Medicare. For example, when:

• an application for dispute resolution has been lodged with the Personal Injury Commission (excluding disputes that only relate to work capacity decisions)
• accepting liability for a condition that is contracted or caused by gradual process or that may be an aggravation of a disease
• there is a retrospective entitlement to compensation (ie when liability for medical expenses had been disputed but later accepted six months or more after the liability dispute), or
• a settlement of a claim for compensation is initiated that will exceed $5,000.

Claim for a lump sum greater than $5,000 initiated

If the worker indicates that no Medicare benefits have been paid in relation to their compensable work-related injury, or none have been paid since their last Medicare notice of past benefits was issued, it is prudent for the insurer to determine whether this is consistent with the history of the claim.

The insurer should ask the worker to complete a Section 23A statement (Form mo023). This is forwarded to Medicare Australia with a Notice of judgment or settlement (Form mo022) at the time the claim is determined. Full payment can then be made to the worker.

Medical services for a work-related injury paid by Medicare

If the insurer has determined that reasonably necessary medical treatment and services for a work-related injury have been paid by Medicare, and the lump sum (all costs) exceeds $5,000, then the following steps apply:

1. The insurer, with the worker, completes a Medicare history statement request (Form mo026). If the form is not completed with the worker, the information on the Medicare history statement can only be released to the insurer where a Medicare State Insurance Regulatory Authority 95 compensation recovery third party authority (Form mo021) has been signed by the worker.
2. The insurer forwards the form/s to: Department of Human Services Medicare Compensation Recovery GPO Box 4104 Sydney NSW 2001
3. Medicare will send the worker a Medicare history statement which the worker returns to Medicare having identified the services relating to the compensable injury. If no response is received from the worker, Medicare will deem that all the Medicare services relate to the injury.
4. The insurer will check the Medicare history statement and reimburse Medicare costs incurred for reasonably necessary medical treatment relating to the compensable injury.
5. Medicare then sends a Medicare notice of past benefits to the insurer for payment once settlement on the claim is reached. This is valid for six months. If it expires before settlement, another Medicare history statement should be requested from Medicare prior to finalisation of settlement.
6. The Medicare notice of past benefits becomes a Medicare notice of charge once settlement is reached.
7. The Notice of judgment or settlement is sent to Medicare within 28 calendar days of the judgment or settlement date.

Further information (including how to make payments to Medicare) can be found on the Medicare website.