Claims Operational Guidelines

Please be advised that the Claims Operational Guidelines is no longer being updated and will be removed from this website on Monday 11 August 2014.

The purpose of this document is to provide clear guidelines to WorkCover's agent with respect to:

  • information on legislation, regulations and decisions required to manage workers compensation claims within the South Australian operating environment. 
  • existing WorkCover policy 

Claims agents should note that these guidelines replace the Injury and Case Management Manual (ICMM).

Claims Operational Guidelines

For ease of use the guidelines have been divided into individual chapters.

Chapter 1: About the guidelines

Contents:

Purpose; Operational authorities; Early return to work; Guiding principles for service; Disclaimer; Conditions of use.

Chapter 1: About the guidelines

Chapter 2: The WorkCover Scheme

Contents: 

The rehabilitation, return to work and compensation system; Benefits to injured workers; Objectives of the WorkCover Scheme; WorkCover mission and values; The role of Scheme participants; Employer responsibilities under the Scheme, Employer rights under the scheme; Worker responsibilities under the scheme; Worker rights; Treating medical practitioner responsibilities; Claims agent responsibilities; WorkCover’s access and equity claims management resource; Managing claims of workers from culturally and linguistically diverse backgrounds; Guidelines for managing the claims of Aboriginal and Torres Strait Islander people; Guidelines for managing claims for people with a disability; Guidelines for addressing whole-of-life needs. 

Chapter 2: The WorkCover Scheme

Chapter 3: Entitlement to compensation

Contents: 

Entitlement to compensation; Exceptions to coverage; Definition of worker; Injury; Employment inside and outside South Australia (territorial application of the Act); Compensability of injuries; Multiple injuries and claims.

Chapter 3: Entitlement to compensation

Chapter 4: Make a claim for compensation AND payments under provisional liability pending determination of a claim for compensation

Contents:

Make a claim for compensation AND payments under provisional liability pending determination of a claim for compensation; An overview of the process; Reporting a work-related injury; Give notice of an injury – section 51; Make a claim for compensation – section 52; Provisional weekly payments; Waiver of employer excess for the first two weeks of incapacity; Employers exempted by regulation from requirement to register and pay the first two weeks of income maintenance on a claim for compensation; Claims must identify the correct employer location registration; Claims where there is no active location registration.

Chapter 4: Make a claim for compensation AND provisional liability

Chapter 5: Determine the claim

Contents: 

Determine the claim; Summary of claim determination process; Claim determination principles; Time limits to determine the claim; Authority to conduct an investigation; Determine the claim; Redetermine a claim.

Chapter 5: Determine the claim

Chapter 6: Case management - Injury and claims management

Contents:

Case management; Injury and claims management; Claim lodgement; Claim registration; Three-point contact; Case management planning; Case conferences; Working/communicating with health care providers; Rehabilitation and return to work service providers; Sound decision-making/dispute minimisation; Communication; Instructing surveillance. 

Chapter 6: Case management - Injury and claims management 

Chapter 6A: Independent medical examinations and Medical Panels SA

Contents:

Independent medical examinations; Medical Panels SA.

Chapter 6A: Independent medical examinations and Medical Panels SA

Chapter 7: Return to work management

Contents:

Chapter 7: Return to work management, Purpose, Expected outcomes, Rationale and context, Roles and responsibilities for effective RTW management, Specific outputs that must be demonstrated, Activity guidelines, Services that can be provided by a workplace rehabilitation provider, WRP referral process, Resources, Evaluation.

Chapter 7: Return to work management

Chapter 7A: Rehabilitation and return to work coordinators and RISE

Contents:

Rehabilitation and return to work coordinators, Re-employment Incentive Scheme for Employers (RISE), RISE, Sections 58B and 58C – return to work, Section 58C – proposed termination, Factors to consider where redundancy occurs (or an employer proposes it is not reasonably practicable to provide suitable employment), Claims agent reporting requirements to WorkCoverSA, Complaint process / Review process, Serious and wilful misconduct, Interaction of various provisions of the Act and industrial relations legislation, Section 58B flowchart.

Chapter 7A: Rehabilitation and return to work coordinators and RISE

Chapter 8: Average weekly earnings

Contents: 

Average weekly earnings (AWE); Average weekly earnings (AWE) defined; Inclusions and exclusions when calculating average weekly earnings; Calculate the average weekly earnings; Other considerations that may impact on the calculation of average weekly earnings; Example of an average weekly earnings checklist.

Chapter 8: Average weekly earnings

Chapter 9: Payment - entitlements

Contents:

Payments – entitlements; Weekly payment entitlements; Weekly payments over designated periods; Entitlement periods; Work capacity assessments – section 35B; Application for continuation of payments after expiry of the third entitlement period – section 35C; Leave entitlements and effect of an allowance or benefit on weekly payments; Taxation on direct weekly payments (including top-up payments); Deduction authorities applied to income maintenance in Curam; Lump sum compensation for non-economic loss (section 43, 43A and 43B); Redemptions; Effect of redemption on subsequent claims; Loss of earning capacity assessment (LOEC); Deductions to Centrelink, Department of Education, Employment and Workplace Relations and Medicare Australia for section 42 and/or 43 lump sum payments; Payment of settlement monies and Tribunal costs; Compensation for property damage; Statutory first charges and garnishee orders.

Chapter 9: Payment - entitlements

Chapter 10: Review of weekly payments

Contents:

Review of weekly payments; Discontinuance of weekly payments; Effect of notice of dispute on discontinuance of weekly payments; Reduction of weekly payments; Effect of a notice of dispute on reduction of weekly payments; Suspension of weekly payments; Annual reviews; Economic adjustments under section 39; Review of weekly payments under section 38; Adjustments of average weekly payments – section 37.

Chapter 10: Review of weekly payments

Chapter 11: Payments - medical and other expenses

Contents:

Types of costs a worker is entitled to; Reasonable costs; reasonably incurred; Fees; Disallowance or reduction of charges; Types of medical services; Medical expert rehabilitation services; Hospitalisation and associated medical; surgical and nursing services; Travel; Accommodation allowances; Approved rehabilitation; home help services or attendance by a registered or enrolled nurse; Therapeutic appliances; Costs of medicines and other materials such as bandages; heat packs or the like; Any other costs authorised by WorkCover; Payment for services; Payment for appointment cancellation or non-attendance; Account and invoicing standards; Guidelines on supported and unsupported services.

Chapter 11: Payments - medical and other expenses

Chapter 12: Death claims

Contents:

Death claims; Entitlements; Funeral expenses; Counselling services; Lump sum payments; Definitions relevant to lump sum payments; Determining dependency; Amount of lump sum entitlements; Interest payable on lump sum payments; Change of circumstances; Case law; Guidelines for negotiated settlements; Transitional provisions - lump sum; Weekly payments; Weekly payment entitlement; Review of weekly payments; Taxation on weekly payments for minors; Commutation.

Chapter 12: Death claims

Chapter 13: Managing critical incidents

Contents:

Why people self-harm; warning signs; general approach and philosophy; support; threatening behaviour; contacts.

Chapter 13: Managing critical incidents

Chapter 14: Claims administration

Contents:

Claims administration; Estimating a claim; Records management by claims agents; File administration; Claims agent engagement of providers; Payment of compensation including accounts; File cost; Access to, use of and release of information (confidentiality); Confidentiality provisions of the Act; Employers’ obligation to maintain workers’ confidentiality; Requests for confidential information; Disclosure to other workers compensation authorities; Exceptions to the duty of confidentiality; Confidentiality and rehabilitation; Release of information to other parties; Disclosure authorised by the Minister for Workers Rehabilitation; Release of information to Commonwealth government authorities; Freedom of information; Request for previous lump sum payments; Physical transfer of files between claims agent and WorkCover; Access to information;  Complaint resolution; Constituent contact to Office of the Minister; Member of Parliament contact to the claims agent; Ministerials; WorkCover Ombudsman.

Chapter 14: Claims administration

Chapter 15: Fraud

Contents:

Definition of fraud; Worker fraud; Employer fraud; Provider fraud; Investigations unit; Detecting and reporting suspected fraud; Non-compliance; Indicators of possible fraud; Claim investigation authorities. 

Chapter 15: Fraud

Chapter 16: Dispute resolution

Contents: 

Dispute resolution; Flow chart outlining the basic stages of the dispute resolution process; Proceedings before the Tribunal; Principles of the Tribunal; Evidence; Powers of the Tribunal; Contempts; Territorial issues – choice of law; Tribunal may refer a medical question or require a worker to be examined by a medical panel; Responsibilities of the claims agent to notify WorkCover of an appeal; Notice of dispute; Reviewable decisions; Lodging a notice of dispute; Initial reconsideration; Who can reconsider the decision; Completing the reconsideration; Timeframes; Conciliation; Disclosure of information; Dispute management conference; Conciliation conference; Conciliation proceedings; Unresolved matters; Judicial determination; Constitution of the Tribunal; Pre-hearing conference; Unresolved matters; Judicial determination; Constitution of the Tribunal; Pre-hearing conference; Hearing the dispute; Full Bench referrals; Appeals to the Full Bench; Case stated to Supreme Court and final appeals to the Supreme Court; Costs; Costs in section 43 matters; Liability of representatives; Representation costs; Procedures for payment of settlement monies and Tribunal costs; Payment of settlement monies to solicitor’s trust account; Tribunal – payment of costs and disbursements; Special jurisdiction to expedite decisions; The claims agent’s role in dispute management; Impact on case management; Reconsideration; Workers under 18 years of age; Dispute management conferences and conciliation conferences; Assessment of dispute matters for referral to external specialist; Referrals to external providers; Pending disputes pre-dating an employers’ self-insured registration status; Judicial determination; Orders and decisions; Backpays/Interest and Consent Orders; Significant cases;

Chapter 16: Dispute resolution

Chapter 17: Claim recoveries

Contents: 

Claim recoveries; The importance of claim recoveries; Types of recoveries; Early identification of recoveries; Time limits to commence recovery action and early notification of recoveries; Third party recoveries; Liability / Negligence; Negligence of Both Employer and Third party Wrongdoer; Recoveries from workers; Overpayments of weekly payments recovered from workers; Overpayments of direct weekly payments recovered from workers and taxation implications; Recoveries from employers; Recoveries from providers; Recovering debts; Waiving and writing off recoverable amounts.

Chapter 17: Claim recoveries

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