Published: 12 August 2019
Last edited: 12 August 2019

Approving surgery

Some workers will require surgical intervention as part of their recovery and return to work.

All surgery must be approved by the insurer beforehand, unless it is within 48 hours of the injury occurring or provided by an emergency department at a public hospital.

The surgeon intending to perform the surgery must make the request for approval and provide the following information to the insurer:

  • the reason surgery is required
  • the conservative (non-surgical) management undertaken to date
  • expected outcome of surgery
  • name, item codes and costs for surgery requested (including name and cost of any prosthesis required)
  • whether a surgical assistant is required.

All medical treatment requests are to be determined within 21 days.

If the insurer has questions regarding the proposed surgery these should be raised with the surgeon and/or the nominated treating doctor.

A referral for an independent medical examination cannot take place until attempts have been made to contact the surgeon, and the surgeon has been provided with a reasonable opportunity to answer the relevant questions but has not done so.

The insurer should also clarify the:

  • anticipated period of stay in hospital
  • time of total incapacity expected
  • treatment required after surgery
  • progress anticipated after surgery.

This information will help the insurer arrange any required assistance after surgery.

Urgent surgery

If a request for urgent surgery is made, all reasonable efforts must be taken by the insurer to make a decision in the reduced timeframe.

Getting a second opinion

Workers can ask the insurer for approval to receive a second opinion on recommended treatment. Once approved, the nominated treating doctor can arrange a referral to another specialist.

After surgery

The worker may have additional needs after surgery. The worker and/or nominated treating doctor should discuss these with the insurer prior to the surgery so appropriate arrangements can be made.

Fees and invoicing

Fees for medical specialists are set out in the Medical Practitioner Fees Order on the SIRA website. There are separate Fees Orders for surgeons and orthopaedic surgeons.

The Fees Orders specify how much can be charged and what codes specialists are to use. Fees Orders specify the maximum amount payable per service and any service restrictions, and reiterate that workers are not liable for these costs.

No fees are payable for cancellation or non-attendances. Pre-payment of fees for reports or services is not permitted.

Invoices should include:

  • the worker's first and last name, and claim number
  • the date of invoice (must be on the day of or after last date of service listed on the invoice)
  • the date of service
  • name and ABN of the medical practitioner or service provider who provided the service
  • payee details
  • SIRA workers compensation approval number or medical practitioner's Health Insurance Commission provider number (where applicable)
  • SIRA workers compensation payment classification code or AMA item number where applicable. Refer to the Fees Order on the SIRA website and the Workers compensation insurer data reporting requirements
  • service cost for each SIRA workers compensation payment classification code or AMA item number and service duration (if applicable).

To prevent delays in payment, these details need to be provided on all invoices.