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Assess Claim for Cover :: Late Lodged v16.0
6.0
Complete outstanding information requirement(s)
Linked Process
Accept Claim
5.0
Assess claim
Linked Process
Contact Client or Provider for Information at Lodgement
4.0
Confirm eligibility status
3.0
Confirm claim is not a duplicate
Team
riggers & Inputs
T
1.0
Determine if another open claim exists in a Recovery 
2.0
Determine actions required to support cover decision
-
Assessor
Assessor
Administrator
Assistant
Assistant
Assessor
Assessor
Assessor
Assessor
Cover 
Lodgement 
Cover 
Recovery 
Recovery Coordinator
Recovery Partner
Cover 
Senior Cover 
Cover 
Recovery 
Recovery Coordinator
Recovery Coordinator 
Supported
Senior Cover 
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Late Lodged
Uncontrolled Copy Only : Version 16.0 : Last Edited Tuesday, February 8, 2022 1:56 PM : Printed Tuesday, 7 June 2022 1:44 PM
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Assess Claim for Cover :: Late Lodged v16.0
Summary
Objective
To review late lodged claim information and determine what the cover decision should be, where the Cover Decision Service has not 
been able to accept the claim.
This process does not apply to the Remote Claims Unit, Te Ara Tika or any specialist teams (Hearing Loss, Dental etc.).
Background
The Cover Decision Service has identified that the claim was lodged more than 12 months after the date of accident. Eos sends a 
Confirm Cover Decision task for someone to make a manual cover decision. This task will include Late Lodged and Cover Decision 
Required information requirements. It may also include one or more of the following cover decision information requirements:
• Cover Assessment Required
• Check Eligibility - Overseas
• Check Eligibility - Dates
• Case Alias Check Required
The task may also include information requirements for information only, such as Address is Invalid, Client Address Matches Previous 
Home Address.
Late lodged claims are considered complex. This means we must make a cover decision (or a decision to extend the timeframe) 
within two months of the claim being lodged.
Owner
Out of scope
Expert
Out of scope
Procedure
1.0 Determine if another open claim exists in a Recovery Team
Cover Assessor, Lodgement Administrator
a In Eos, check for any open claims.
NOTE How do you check there is an active managed claim?
The yellow indicator on the General Screen shows the client has an active managed claim.
NOTE What if there is an active managed claim?
Go to Match Claim to Recovery Team.
End of Process
PROCESS Match Claim to Recovery Team
2.0 Determine actions required to support cover decision
Cover Assessor, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Open the Confirm Cover Decision task.
Do a task with information requirements
b Review the outstanding information requirement(s) to identify what aspects of the claim need to be resolved. If you need to 
contact the client or provider at any stage in this process, then ensure you resolve as many outstanding requirements in a 
single contact as possible.
NOTE Has the client been sent an automatic electronic notification advising them that we've received their claim?
In general, when a claim is held and sent for a manual cover decision to be made, the client is automatically sent an 
electronic notification advising them that we've received their claim and are considering it. You can check the contact 
tab to see whether this notification has been sent.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Late Lodged
Uncontrolled Copy Only : Version 16.0 : Last Edited Tuesday, February 8, 2022 1:56 PM : Printed Tuesday, 7 June 2022 1:44 PM
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NOTE What are the scenarios when this automatic electronic notification isn't sent?
Automatic claim notification isn't sent:
• If the client is managed by the Remote Claims Unit or Wellington Central Branch
• If the claim type is Sensitive or Fatal
• If the client is deceased
• If the client is under 16 years old
• If the client has a Safe Contact on their party record
• If the Stop Notification attribute on the client party record is set to Yes
• If the claim is for a serious injury (determined by the injury diagnosis code)
• If there is an outstanding Case Alias Check Required information requirement
• If the client has an invalid mobile number
number
If the client's mobile number is invalid, a Notification task will be created but cancelled automatically. For all other sce-
narios above no Notification task will be created.
NOTE What if I'm related to or know the client or any of the other parties associated with the claim?
Then you must not make a cover decision for the claim. Transfer the task back to the department it came from and in-
clude the reason for the transfer.
c Check if the claim has the default provider ID: J99966.
NOTE What if the claim has the default provider ID?
• Check if there's a contact on the claim that states the diagnosis is outside provider competency.
• If there is, then resolve the provider competency issue before you continue with this process. Go to the
Resolve Provider Competency process below to do this (start at step 3.0 of this process).
#Workaround: Resolve Provider Competency WORKAROUND process is required because Eos raises the Provider 
Competency Issue information requirement before the cover decision service has run. As registration is incomplete at 
this stage, a Lodgement Administrator cannot add a purchase order to the claim, which is needed to complete the 
process. They must add a default provider to the claim to get it through the cover decision service where registration 
becomes complete. We'll need to create a standard Resolve Provider Competency Issue process if changes are made 
in Eos to only raise this IR after the cover decision service has run (or if admin staff are given permission to enter the 
default provider ID and suppress this IR before the cover decision service has run).
PROCESS Resolve Provider Competency Issue
3.0 Confirm claim is not a duplicate
Cover Assessor, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Check the accident date is on or after 1 January 1982.
NOTE What if the accident date is prior to 1 January 1982?
Eos can't complete the automatic duplicate claim checks for claims with an accident date prior to 1982, as the records 
in Eos don't go back that far. A duplicate claim check must be completed before continuing with this process when the 
accident date is prior to 1982.
Search the static data store of pre-1982 claims via the InFact reporting portal (using the 4.02 Pre 1982 Report) to see 
if there are any existing claims for the injury/accident.
• If there are no existing claims for a similar injury and date, then go to step 2.0 to continue this process.
• If there's an existing claim that's similar to this new claim but the injuries aren't an exact match, then assess this 
claim and make a cover decision for it before deciding whether it's a duplicate or not. Go to step 2.0 to continue this 
process.
• If there's an existing claim that's an exact match of this new claim, then email the report to the Registration Inbox 
with a request for them to register the pre-1982 claim and link this new claim as a duplicate. This process ends.
NOTE Duplicate claim process
If you identify claim is a duplicate claim follow 'Duplicate Claim Process"
PROCESS Identify and Link Duplicate Claims :: Standard
4.0 Confirm eligibility status
Cover Assessor, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Check if one or both of the following information requirements are outstanding:
• Check eligibility - dates
• Check eligibility - overseas
NOTE What if one or both of these information requirements are outstanding?
They must be completed before you continue with this process. Go to the Verify Claim Information process below to 
do this.
PROCESS Verify Claim Information
NOTE What if I've completed the information requirement(s) and determined that the client is not eligible for cover?
If the client is not eligible for cover then you must decline the claim. Go to step 5.0 to complete the information require-
ment(s) and then decline the claim.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Late Lodged
Uncontrolled Copy Only : Version 16.0 : Last Edited Tuesday, February 8, 2022 1:56 PM : Printed Tuesday, 7 June 2022 1:44 PM
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5.0 Assess claim
Cover Assessor, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Review all available information on the claim and decide what additional information you need to make a cover decision. Use 
the policies below to help determine this. At a minimum you'll need to contact the client to ask for more information on the 
claim.
Which Act to use Policy
Cover criteria for personal injury Policy
Cover for visitors to New Zealand Policy
Cover for injuries suffered outside New Zealand Policy
Criteria for injury occurring outside New Zealand Policy
Eligibility of late claims Policy
Mental Injuries Policy
b Once you've determined what additional information is needed, contact the client to ask for more information on the injury. The 
purpose is to find evidence from the time of the original accident to support that there was an injury. Ask the client if they had 
treatment at the time of the injury and which provider they saw, and whether they saw anyone else in regards to the injury such 
as specialists, police, etc. Go to the Contact Client or Provider for Information process below to do this.
NOTE What if the client can't provide the requested information?
The claim should be assessed based on the information already provided. If the injury is for a foreign body (e.g. glass 
in foot) or a fracture then explain to the client that these injuries could likely be easily identified in an x-ray and they 
may wish to provide this to help with the cover decision.
c If you need additional information after speaking with the client, then:
• If you need to request medical or clinical records for a non-DHB provider, go to the Request Medical or Clinical Records 
(Policy) and Clinical Notes and Medical Records web links below.
• If you need to request medical or clinical records from a DHB, go to the Request Medical or Clinical Records (Policy), 
Requesting Clinical Records from District Health Boards and Contacts for DHB web links below.
Request medical or clinical records Policy
Requesting clinical records from District Health Boards
Contacts for requesting District Health Board clinical records
Clinical Notes and Medical Records
NOTE What if the provider or third party can't provide the requested information?
The claim should be declined due to a lack of information. Go to step 5.0 to complete the information requirement(s) 
and then decline the claim.
NOTE What if the information I've requested can't be provided before the cover decision due date?
Identify whether you can extend the cover decision timeframe. Go to the Timeframes to determine cover policy and 
Extend cover decision timeframes process below to do this.
PROCESS Extend Cover Decision Timeframe
Timeframes to determine cover (Policy)
Timeframes to determine cover Policy
d Review all information received and determine if there's enough evidence to support that an injury occurred, and that the injury 
meets criteria for cover.
NOTE What if you are unsure if you can make a decision based on the information available?
Talk to you Team Leader first, then refer to the Recovery Support Decision Tree to help with whether to seek internal 
guidance.
PROCESS Seek Internal Guidance
Recovery Support Decision Tree
NOTE How to request information from NZ immigration (Customs/PAX)
When requesting information around a client's international movements from NZ immigration - Please include a copy 
of the ACC45 with the request and wording request:
"I am currently considering a request for ACC cover and I need to confirm (x travel dates) for the following person: 
(client’s details).
I’ve attached a copy of the ACC45 form for this claim, in which the client authorises ACC to collect information to 
determine what support ACC can provide.
This request is in line with Principle 2(2)(c) and disclosure is in line with Principle 11(1)(c) of the Privacy Act 2020."
PROCESS
Contact Client or Provider for Information at Lodgement
Cover Assessor, Senior Cover Assessor
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Late Lodged
Uncontrolled Copy Only : Version 16.0 : Last Edited Tuesday, February 8, 2022 1:56 PM : Printed Tuesday, 7 June 2022 1:44 PM
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6.0 Complete outstanding information requirement(s)
Cover Assessor, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Update the Late Lodged and Cover Decision Required information requirements to Complete. Also update the Cover Assess-
ment Required information requirement to Complete if this is present on the task.
Complete information requirement
b Check if there are any outstanding information requirements for missing information.
NOTE What if there's one or more outstanding address-related information requirements (Address is Invalid, Client 
Address Matches Previous Home Address, Client Already Has an Address Starting Today, Client Already has 
a Post Address Starting Today)?
These should be completed before continuing with this process. Go to the Update Clilent Address process below to do 
this.
PROCESS Update Client Address
NOTE What if there's an outstanding Phone Number Verification information requirement?
This should be completed before continuing with this process. Go to the Update Client Phone Number process below 
to do this.
PROCESS Update Client Phone Number
NOTE What if there's an outstanding Vendor Status Removed or Facility Status Removed information requirement?
This should be completed before continuing with this process. Go to the Resolve Provider, Vendor or Facility Status 
Issue process below to do thi.
PROCESS Resolve Provider, Vendor or Facility Status Issue
c Check if there's an outstanding Case Alias Check Required information requirement.
NOTE What if there's an outstanding Case Alias Check Required information requirement?
This must be completed before continuing with this process. Go to the Identify and Link Duplicate Claims process 
below to do this.
Note: A claim can only be investigated as a potential duplicate once the cover decision has been determined, as the 
cover decision must match the original claim for it to be considered a duplicate.
PROCESS Identify and Link Duplicate Claims :: Case Alias IR
NOTE What if I identified a potential duplicate claim when searching the Pre-1982 Report in step 2.0?
Now that you've determined what the cover decision should be for this claim, you can decide whether it is a duplicate 
of the claim lodged prior to 1 January 1982. Go to the Identify and Link Duplicate Claims process below to do this.
PROCESS Identify and Link Duplicate Claims :: Standard
PROCESS
Accept Claim
Cover Assessor, Recovery Assistant, Recovery Coordinator, Recovery Coordinator - Supported, Senior 
Cover Assessor
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Late Lodged
Uncontrolled Copy Only : Version 16.0 : Last Edited Tuesday, February 8, 2022 1:56 PM : Printed Tuesday, 7 June 2022 1:44 PM
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