Policy - Lodgement & registration of
New Claims
This topic covers how a claim can be lodged, how we identify and deal with specific
claims such as treatment injury claims, sensitive claims and accidental death
claims, and how we register claims for cover.
Policy
Computer-generated ACC45
Claim forms
Consequential injuries
Treatment injury claims
Sensitive claims
Dental injury forms
Accidental death claims
Conversion probability threshold
Process
Lodging a manual claim
Lodging electronic claim
Missing mandatory data
Streaming a claim from registration
Streaming TI claim
Responding to provider requests
Reference
Electronic claim checklist
Manual claim checklist
Health Practitioner Index
Streaming criteria
Applying streaming criteria
Claim types
Sensitive Claim Engagement Form
Policy
Lodgement and registration policies are:
Computer-generated ACC45
Claim forms
Consequential injuries
Treatment injury claims
Sensitive claims
Dental injury forms
Accidental death claims
Conversion probability threshold
Computer-generated ACC45
Introduction
The ACC45 Injury Claim form is available only as a commercially published document because each
claim form has to be individually numbered.
Some providers complete the form with the client by hand and send it to ACC.
Providers with computerised systems can submit computer-generated ACC45 forms that can be
viewed in Eos as a PDF document.
The information required on the form is exactly the same as the paper version but may be laid out
slightly differently. Providers may also include some internal reference information on the form.
Rules
Form version and claim number sequence
Providers must use an ACC-approved version of the form. Each provider is issued a sequence of
claim numbers to use on these forms, to avoid duplication with other electronic versions or with claims
submitted on paper.
As the provider uses up their allocated claim numbers, they ask ACC to issue a new sequence of
numbers.
Approving a new form version
ACC must approve a computer-generated version of the ACC45 before allowing a medical practice to
use it.
Refer any provider or software developer enquiries about computer-generated versions of the ACC45
to:
National Manager Claims Processing & Specialist Services
Corporate Office
List of approved versions
There are currently seven approved versions of the ACC45, four developed by software companies
and three by providers. These are listed below.
ACC approved versions developed by software companies
and prints out
Company
identified by…
on…
‘HTL’ at the top centre of the page, beside the name of the
Health Technology Ltd
two A4 pages
form
Advanced Clinical
‘HG’ on the left-hand side of form, below the ACC45 logo two A5 pages
Records
Virtuoso Productions
‘VPL’ on the left-hand side of the form, below the ACC45 two A5 pages
Limited
logo
IntraHealth (MMAS
‘Macintosh Medical Administration System’ on the top left two A4 pages
system)
of the form
ACC approved versions developed by providers
These versions are identified by the provider’s name at the top of the form:
Mid Central Health
Canterbury Health
Pegasus Medical Group.
Allocating a claim number sequence
The treatment provider must apply to ACC for a claim numbering sequence to be allocated for the
approved version of the ACC45 they intend to use.
Enquiries from providers regarding the claim numbering sequence should be referred to:
Northern Processing Centre
PO Box 90-341
Auckland Mail Centre
The Northern Processing Centre is also responsible for allocating the number sequence for electronic
versions of the Accident Insurance Treatment Certificate (AITC).
Receiving a claim on a computer-generated ACC45
When you receive a claim on a computer-generated ACC45, you must check the version of the form
used by the provider to see if it is an approved version or a non-approved version.
If the form is…
then…
an approved version
follow the normal procedure for processing claim forms
return it to the provider immediately with a covering letter that:
explains al computer-generated forms must be approved by ACC before
not an approved
use
version
provides contact details to arrange this, if they wish
asks them to resubmit the claim on a standard paper form.
Claim forms
Introduction
Claims can be submitted on any of the ACC-approved ACC45 injury claim form versions or the
Accident Insurance Treatment Certificate (AITC).
For more information about the special requirements for work injuries that occurred between 1 July
1999 and 30 June 2000, se
e Which Act to use.
Rules
Submitting claim forms
For all non-work injuries, or work injuries received after 1 July 2000 use:
the ACC45 ACC injury claim form (ACC45).
For work injuries received between 1 July 1999 and 30 June 2000 use:
an ACC45 or AITC.
Lodging a claim
When a claim is lodged, it is important to note that:
acceptance for lodgement does not mean a claim has been accepted for cover
the date of lodgement determines when the ‘clock starts ticking’ for the purposes of determining
the correct insurer, cover and payment of statutory entitlements
mandatory information is required for each claim.
For information about lodgement processes, see:
Lodging a manual claim
Lodging an electronic claim
Managing missing mandatory data.
Consequential injury claims
Introduction
A consequential injury is an injury that occurs as a result of a previous injury, eg gradual process,
disease or infection due to a covered injury or due to treatment for a covered injury.
Legislation
AC Act 2001, Sections 20(2)(d) & (h) relate to cover for personal injury that is a consequence of
treatment given for a previous personal injury, for which the person has cover.
AC Act 2001, sections 20(2)(g) relates to cover for personal injury that is a gradual process,
disease, or infection consequential on personal injury suffered by the person, for which the
person has cover:
AC Act 2001, Section 28(5) relates to cover for work-related injury that is a consequence of
treatment given for a previous work-related injury.
Rules
Consequential claim identification
A consequential injury caused by treatment is identified by any of the following:
text on the ACC45 ACC Injury claim form (ACC45) stating the client has an existing physical
injury claim, and while receiving treatment for this injury, incurred a further injury
the key words ‘treatment’, ‘medical’, ‘hospital’, ‘surgery’, ‘physiotherapy’, ‘chiropractor’ or ‘doctor’
appearing on the ACC45
a tick in the ‘Is this claim for treatment injury?’ box on the ACC45 or, for older ACC45s, the
‘Medical misadventure’ box
discussion with the client and/or provider.
The difference between consequential injury and treatment injury
The key point in the difference between a treatment injury and a consequential injury is understanding
what the treatment is provided for, that gives rise to the claimed new injury:
if the treatment is for an underlying condition and the person suffers new injury from the
treatment provided by a registered health professional , it is considered under the treatment
injury provisions (s32 of the AC Act 2001)
if the treatment is for a covered ACC injury and the person suffers new injury from the treatment,
it is considered under the consequential injury criteria (s20(2)(d) & (h)) – TI delegation to
determine cover
if the person has a covered ACC injury and that injury through gradual process, disease or
infection develops into another injury, this is a consequential injury that the branch has
delegation to determine cover [as there is no intervening treatment that gives rise to the
additional injury] (s20(2)(g)
Forwarding consequential injury claims
All consequential injuries caused by treatment, whether or not the original injury claim is lodged or
accepted, are sent to one of the following for processing:
the ACC Treatment Injury Centre, for non-accredited employer claims
the registered accredited employer, for accredited employer claims.
See
Receiving and streaming treatment injury claim.
Fund code
You must make sure the correc
t fund code is allocated to the claim.
Treatment injury claims
Introduction
A treatment injury is a personal injury arising from treatment that meets ACC’s
Cover criteria for
treatment injury.
Rules
Treatment injury claim identification
A treatment injury claim may be identified by any of the following:
text on the ACC45 ACC Injury claim form (ACC45) stating the client has an existing physical
injury claim, and while receiving treatment for this injury, incurred a further injury
the key words ‘treatment’, ‘medical’, ‘hospital’, ‘surgery’, ‘physiotherapy’, ‘chiropractor’ or ‘doctor’
appearing on the ACC45
a tick in the ‘Is this claim for treatment injury?’ box on the ACC45 or the ‘Medical misadventure’
box on older ACC45s
material accompanying the ACC45, eg th
e ACC2152 Treatment Injury Claim (123K) form and
any medical notes.
The difference between consequential injury and treatment injury
The key point in the difference between a treatment injury and a consequential injury is understanding
what the treatment is provided for, that gives rise to the claimed new injury:
if the treatment is for an underlying condition and the person suffers new injury from the
treatment provided by a registered health professional , it is considered under the treatment
injury provisions (s32 of the AC Act 2001)
if the treatment is for a covered ACC injury and the person suffers new injury from the treatment,
it is considered under the consequential injury criteria (s20(2)(d) & (h)) – TI delegation to
determine cover
if the person has a covered ACC injury and that injury through gradual process, disease or
infection develops into another injury, this is a consequential injury that the branch has
delegation to determine cover [as there is no intervening treatment that gives rise to the
additional injury] (s20(2)(g).
Lodgement date
A claim for treatment injury must be lodged within 12 months of the later of:
the date the registered health professional (RHP) first considered the personal injury to be a
treatment injury
the date the client suffered the injury as determined under the
AC Act 2001, Section 38.
Late lodgement
ACC must not decline a claim on the grounds that it was lodged late, unless the claim’s lateness
prejudices the ability of ACC to determine cover. See
Eligibility of late claims.
Transitional claims
If a client lodges a claim for the first time on or after 1 July 2005, apply the treatment injury rules. The
rules f
or medical misadventure apply to claims lodged before 1 July 2005.
Exception
We can consider a claim under the treatment injury provisions if it was lodged on or after 1 July 2005
and previously declined under the medical misadventure rules if no personal injury was established at
the time, but a personal injury arises after the claim was declined from that past incident. The
personal injury could arise before or after 1 July 2005.
Example:
After a period of hospitalisation before 1 July 2005, a client is diagnosed with Methicillin Resistant
Staphylococcus Aureus (MRSA) but they have no symptoms at the time. Some time after 1 July 2005
they develop a serious infection. A personal injury becomes present so their claim can be considered
under the treatment injury provisions.
Forwarding treatment injury claims
When you receive a treatment injury claim, you must capture the details as a new claim and forward
any hard copy materials to the Treatment Injury Centre. This includes any material accompanying the
ACC45, eg th
e ACC2152 Treatment Injury Claim (123K) form and any medical notes.
Specialist staff in the Treatment Injury Centre assess the claim and make the cover decision.
You must:
refer any enquiries about treatment injury claims to the Treatment Injury Centre
ensure any material that accompanied the ACC45, eg the ACC2152 and clinical notes, is clearly
marked with the claim number or ACC45 number.
See
Receiving and streaming treatment injury claim for further information.
Sensitive claims
Introduction
AC Act 2001, Section 21 deals with cover for mental injury from offences listed in
Schedule 3 of the
AC Act. These refer mainly to sexual abus
e. Section 21 claims are also known as sensitive claims.
Refer any enquiries about sensitive claims to:
Sensitive Claims Unit
PO Box 1426
Wellington
The SCU deals with potentially sensitive issues and it is essential that we use sensitivity and
discretion when dealing with these claims.
Rules
Identifying sensitive (section 21) claims
ACC has instructed treatment providers to send all sensitive (Section 21) claims directly to the SCU. If
you identify a sensitive claim, you must send it to the SCU immediately.
How to recognise a sensitive claim
An ACC45 injury claim form for a sensitive (Section 21) claim has all the following features:
it has been completed by a:
counsellor
nurse practitioner
general practitioner (GP)
doctor registered with Doctors for Sexual Abuse Care (DSAC)
the treatment provider either:
included
a READ code (274K) for a mental injury in the ‘Diagnosis’; box on the ACC45
used a term like ‘depression’ as a diagnosis
the ‘Part B: Injury Details’ section in the ACC45 form shows a Schedule 3 offence, including the
section number of the offence, or a description of it.
A DSAC-registered doctor may also include a separate report with the ACC45.
Special cases
If…
and…
then…
the ‘Injury Details’ section the READ code indicates a you must process the claim in the same way as
of the ACC45 describes a physical injury and no
any oth
er physical injury caused by an accident
Schedule 3 offence
mental injury
(PICBA) claim
you must consult an SCU case manager or
the claim involves both
team manager and transfer the claim directly to
needs case management
physical and mental injury
the SCU if they agree it should be managed by
the SCU
Forward sensitive (section 21) claims
You must ref
er to AC Act 2001, Section 21 to identify a mental injury claim.
You must only identify a claim as a sensitive claim once you receive al of the required information.
You must contact the client if you need further information.
If...
then…
consult an SCU case manager or the team manager to
the claim involves both physical and
decide who should manage the claim
mental injury and needs case
within 24 hours of receipt, send the claim via Boxlink or
management
email, with no further investigation or registration, to the
SCU
Claims for physical injury as a result of Section 21 are processed by the claims assessor.
Refer all enquiries about Section 21 claims to the Sensitive Claims Unit.
Forms required to register a dental
injury
Introduction
Providers can register dental injuries on either:
ACC42 Dental claim registration form
ACC45 ACC Injury claim form.
Although general practitioners (GPs) can register dental injuries, we always ask the dentist to
complete an
ACC2303 Request for more information on dental claim (191K) form or an ACC42 form.
This enables ACC to register tooth ‘sites’ and other injuries to the region. It also al ows us to gain
information regarding pre-existing conditions for entitlement decisions.
Notes:
Providers can obtain a copy of either the ACC42 or ACC37 Dental treatment and tax invoice
forms by calling the Provider Line on 0800 222 070.
Email either
[email address] or [email address] for copies of the ACC2303 form.
Rules
If you receive an…
then you must…
ACC45 without an ACC37
register the claim using the correct codes
ACC37 without an ACC45
not register the claim
ACC37 accompanied by a
treat the ACC45 as a duplicate
second ACC45
register the claim and update it with the corresponding information
ACC42 without an ACC37
from the ACC42
register the claim and update it with the corresponding
ACC42 with an ACC37
information from the ACC42
send the ACC37 for an entitlement decision
Forms we need to make an entitlement decision for a dental claim
Entitlement can be applied for on several different forms:
ACC37 Dental treatment and tax invoice
ACC1345 Request for prior approval of simple dental treatment (112K)
ACC899 Dental implant assessment and treatment plan
ACC4231 Request for prior approval of orthodontic dental treatment (273K)
Lodgement and registration processes
For more information, see:
Lodging a manual claim
Lodging an electronic claim
Managing missing mandatory data.
Accidental death claims
Introduction
The two key differences between accidental death and other injury claims are:
the sensitive nature of accidental death claims, ie ACC has contact with the deceased client’s
family
that any resulting entitlements, except the funeral grant, are to assist surviving family members
and are fixed for a period of time.
Rules
Eligibility
A death can be covered as an accidental death claim if it’s caused by one of the fol owing:
an accident
a consequence of treatment for personal injury
a work-related gradual process, disease or infection (WRGPDI)
a treatment injury.
Although
Disentitlement applies to wilfully self-inflicted deaths, a death resulting from suicide may stil
be covered, if it was the result of a covered mental injury.
Forwarding accidental death claims
Once a claim has been identified and lodged as an accidental death claim, it is forwarded to the
Accidental Death Unit (ADU) without registering or determining the managing insurer for the claim.
Claims for cover of an unborn child
A 2003 Court of Appeal decision
, Harrild v Director of Proceedings CA92/02, means ACC doesn’t
extend cover to an unborn child for accidental death suffered before birth.
Accidental death to a foetus is considered for cover as a physical injury to the mother.
If an infant is born alive but injured because of a pre-birth accident to the mother, ACC may consider
separate cover for the infant's injuries, from the date of the infant’s birth.
A claim for mental injury to the mother arising from her covered physical injury may also be
considered.
Conversion probability threshold
Introduction
Conversion Probability measures the likelihood a client will need weekly compensation within the first
28 days of lodging their claim. It's measured as a percentage. For example, if a claim has a
conversion probability of 35%, it means there’s a 35% chance that the client will need weekly
compensation within the first 28 days of lodging their claim.
When working out the conversion probability, we also consider a claim’s duration rating. Duration
rating predicts how long a client will need weekly compensation for. Duration rating is rated on a scale
from 1 to 10, where 1 represents the 10% of claims with the shortest time on weekly compensation
and 10 represents the 10% of claims with the longest time on weekly compensation.
Eos automatically streams earner claims based on an individual claim’s conversion probability and
duration rating.
Depending on whether claims meet or exceed the set conversion probability threshold, claims are
either:
streamed to Registration - Actioned Cases
assessed by the Service Needs Assessment (SNA) team before being allocated
allocated directly to a Short Term Claims Centre (STCC) or branch for case management.
Current policy sets the conversion probability threshold at 30% for all duration ratings.
Claims with a conversion probability that:
is less than the 30% threshold are streamed to Registration - Actioned Cases
meet or exceed the 30% threshold are streamed to either:
the SNA team for assessment
an STCC or branch for case management.
Conversion probability thresholds for each duration rating
ACC can choose to vary the conversion probability threshold for each duration rating. The following
table details the current thresholds for streaming earner claims immediately after registration. These
thresholds may change over time.
Duration rating
Threshold (no existing open claims) Threshold (existing open claims)
1 - shortest claims 30%
30%
2
30%
30%
3
30%
30%
4
30%
30%
5
30%
30%
6
30%
30%
7
30%
30%
8
30%
30%
9
30%
30%
10 - longest claims 30%
30%
