Claims management other

Overview

Prompt payment of invoices and reimbursements for medical, hospital and rehabilitation services ensures workers can remain focused on their recovery.

This guidance provides information for insurers regarding the payment of invoices and reimbursements as part of claims management.

Payment of invoices

Insurers should be aware that medical, hospital and rehabilitation providers are required to comply with the Guidelines for the Provision of Relevant Services (Health and Related Services.

Billing requirements

When billing, medical, hospital and rehabilitation providers must not:

• request pre-payment of fees for reports and services from the insurer
• directly bill services to an injured worker who has already lodged a claim (excluding providers of independent medical examination services and/or providers of assessment of permanent impairment services)
• where the maximum amount of an employer’s liability has been fixed under a SIRA fees order made under sections 61 – 63A of the Workers Compensation Act 1987 (1987 Act) or section 339 of the Workplace Injury Management and Workers Compensation Act 1998:
  1. bill an amount that is above the maximum amount fixed in the relevant fees order
  2. charge the injured person any additional or gap fee
• charge a fee for cancellation or non-attendance by an injured worker for treatment services (excluding relevant service providers as defined in Clause 4A(1)(za) of the State Insurance and Care Governance Regulation 2021).

Insurers should notify SIRA if they become aware of any provider billing for the above items.

Invoicing requirements

The following invoicing requirements apply to medical, hospital and rehabilitation providers (excluding pharmaceutical services). Invoices must be submitted within 30 calendar days of the service provided, and include:

1. the injured worker’s first and last name, and claim number
2. payee name, address, telephone number and email address
3. payee Australian Business Number (ABN)
4. name of the relevant service provider who delivered the relevant service
5. in the case of medical practitioner services, the provider’s:
   • Australian Health Practitioner Regulation Agency (AHPRA) number, and
   • Medicare provider number (unless not registered with Medicare).
6. in the case of allied health services, the following provider numbers:
   • the provider’s SIRA approval number (where applicable), and
   • the provider’s AHPRA number/professional association accreditation/membership number
   • in the case of allied health services provided interstate by a service provider who doesn’t have a SIRA approval number, the service provider number INT0000 must be included on the invoice instead
   • in the case of allied health services provided to exempt workers, by a service provider who doesn’t have a SIRA approval number, the service provider number EXT0000 must be included on the invoice instead.
7. in the case of private hospital services, the service’s:
   • Medicare Benefits Schedule item (if applicable)
   • theatre banding (if applicable)
     • if the invoice is for a higher-banded procedure which requires a complexity certificate, the certificate of complexity must accompany the invoice.
   • theatre duration (if applicable).
8. in the case of invoices for surgery:
   • a detailed operation report including a description of the initial injury and an outline of the mechanism of injury, time surgery commenced and finished, intra-operative findings and the procedures performed, including structures that were repaired (stating the anatomic location) and technique of repair.
9. relevant SIRA payment classification code or Australian Medical Association (AMA) Fees List item number (where applicable)
10. service cost for each SIRA payment classification code or AMA Fees List item number and service duration (if applicable)
11. date of service
12. date of invoice (must be on the day of or after last date of service listed on the invoice).

An invoice for relevant services from a registered pharmacy must meet the requirements set out below. Invoices must include the following information:

• pharmacy name and street address
• dispensing pharmacist’s name
• pharmacy ABN
• invoice number and date
• total amount charged
• injured worker’s name, address and claim number (or date of birth and date of injury)
• date of service (date dispensed)
• PBS item code (for PBS dispensed medications)
• a copy of the original script for medications that are available on the PBS but are dispensed privately (non-PBS), and a copy of the repeat prescription where applicable
• full description of the medication (including script number, brand name, form)
• quantity of medication dispensed
• strength of the medication dispensed
• prescriber name/address/prescriber number
• amount charged per item.

If an insurer receives an invoice that does not meet the requirements, they should promptly address any issues directly with the provider for correction.

Questions regarding invoices can often be resolved quickly with a telephone call to the provider. If telephone contact is unsuccessful, then an email or letter should be sent to request clarification of the issue.

Insurers should always attempt to resolve an issue rather than not pay an invoice. Non-payment of an invoice can be detrimental to the relationship between the insurer and service provider and may negatively impact the worker’s recovery.

Payment of reimbursements

Questions regarding reimbursements can also be addressed (and potentially resolved) with a telephone call to the worker.

Insurers should always attempt to resolve an issue rather than not pay a reimbursement to a worker. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification.

Insurers should proactively prompt workers to submit claims when they know reimbursement claims should be forthcoming, for example, where a worker regularly claims reimbursements for travel to attend treatment.

Proactively reminding a worker to submit reimbursements and establishing a regular timeframe for the lodgement of these claims can benefit both the worker and the insurer.

See also Standard of practice S.10 Payment of invoices and reimbursements.