Process
Lodging a manual claim
Lodging electronic claim
Missing mandatory data
Streaming a claim from registration
Streaming TI claim
Responding to provider requests
Lodging a manual claim
The Hamilton and Dunedin Registration Centres use this process when they receive
a manual injury claim form to confirm the form’s data is complete and that it’s not
a duplicate claim.
Latest updates 27/11/2013: A number of small process corrections and separation of streaming
steps out into separate process.
Receive, check and sort claims
Responsibility
Lodgement team
When to use
Use this instruction when you receive one of the following manual claim forms at the Hamilton or
Dunedin registration centres:
ACC45 ACC Injury claim
ACC42 Dental claim registration
ACC21 Advice of accidental death claim
ACC2151 Treatment Injury claim.
Instruction
Step 1
Check the claim form for any missing
mandatory data that you need to register the manual claim,
including:
the client’s first and last names
the client’s home address
the client’s date of birth
the date of the accident
a description of the accident
details about whether a motor vehicle was involved
details about whether the accident happened at work
the client’s employment status, eg non-earner, employee, self-employed or other, including
shareholder employee, contracted employee or commission-only salesperson
employer details for all work accident claims
the injury, eg
READ code (274K) and a diagnosis of the injury
work capacity information, if it applies
the client’s or the provider’s signature.
Step 2
Note or highlight any missing mandatory data.
Step 3
Check the form for:
dental claims
work injuries
non-work injuries
accredited employer claims
staff claims
‘test’ claims, eg Mickey Mouse or Joe Blow.
Step 4
Sort non-work injury claims into the following groups:
full registration ‘accept’, eg to be registered with full data then streamed
full registration ‘held’, eg needing further investigation for:
non-work gradual process
late lodgement
overseas injury
mental injury
hernias
anything else out of the ordinary.
Step 5
Sort the following claims into groups to be held for further investigation:
non-work gradual process
late lodgement
overseas injury
mental injury
hernias
anything else out of the ordinary.
Step 6
Check the ACC42 dental claims to make sure:
there is an injury marked for each tooth listed
there is a pre-accident condition marked for each tooth
any teeth with prior damage have this specified in either the check boxes or the additional
comments
additional comments regarding restorations and caries specify the size
that ‘no prior damage’ and ‘prior damage’ are not both specified, eg no prior damage and
medium fil ing
any damage to a prosthesis is specified, eg which teeth or if a denture was fractured down the
middle
the oral hygiene, periodontal condition and caries activity ‘oral assessments’ are completed. If
they're the only missing dental information on the form, we can still register the claim
‘permanent teeth missing’ is highlighted if the claim is going to the missing mandatory team for
another reason
there are full dental tab details, unless it is a late lodged claim.
Step 7
Check for missing or conflicting data.
If there is…
then…
allocate the claim form to the appropriate Lodgement team, eg non-work,
no missing or
work related gradual process injury
conflicting data
go to
Check if ACC45 number in Eos and claim is a copy
missing or conflicting go to step 8
data
Step 8
Check if the form is signed by the provider and client.
If the form is… then…
If the form is… then…
signed
go to step 9
issue a letter against the client party record and return the form
not signed
this process ends
Step 9
Check the claim form for the following client information:
name
date of birth
gender.
What happens next?
If there is…
then…
enough information to
go to
Check if ACC45 number in Eos and claim is a copy
register the claim
place the manual claim form in the ‘missing mandatory box’ to be
investigated for missing or conflicting data
not enough information to
register the claim
go to
Managing missing mandatory data
this process ends
Back to process map ↑
Check if ACC45 number in Eos and claim is a copy
Responsibility
Lodgement team
When to use
Use this instruction to check if an ACC45 number is in use and if the new claim is a copy of an
existing claim in Eos.
Step 1
Search for the claim number in Eos.
Step 2
If the…
then…
If the…
then…
the claim lodged in Eos with the same ACC45 number
‘Claim Search’ results screen appears
displays
go to step 3
the ACC45 number is not in use
‘Person’ tab on the ‘Claim Search’
screen appears
go to
Check if client party exists in Eos and/or claim
is a duplicate
Step 3
Open the claim and check the client’s name and accident details to determine if it’s a copy.
If…
then…
stamp the claim with ‘copy’ or write ‘copy’ on it
all the claim details
write the date the original claim was registered and who registered it
match and no change is
add a contact with the details of the claim copy
needed
go to step 4
re-link the claim to the correct client
check the ‘incorrect’ client and amend any details changed in error, eg
the address
the claim has been
advise your Team Manager or Team Leader to remove the incorrect
linked or registered to
claim form document and check all linkages in the form of a task,
the wrong client
contact or document have been removed or moved to the correct party
add a contact advising why the claim form document has been
removed, ie 'incorrect client selection at registration'
go to step 4
make the changes or corrections
add a contact noting:
you received a copy of a claim from the provider
you need to change or
the changes that you made
add any claim details
if other ACC forms are attached to the copy, detach and forward to the
appropriate person or unit
go to
Preparing, scanning and filing documents for VCF to file the
ACC45 copy
this process ends
Step 4
If the…
then…
If the…
then…
go to
Closing physical files
claim is in Eos and it’s an
exact copy
this process ends
ACC45 number is in Eos and it’s not a issue a ‘dummy’ ACC45 number using your local team
copy
process
go to
Check if client party exists in Eos and/or claim is a
ACC45 number is not in use
duplicate
Back to process map ↑
Check if client party exists in Eos and/or claim is a duplicate
Responsibility
Lodgement team
When to use
Use this instruction to determine if the client party exists in Eos and if the claim is a duplicate.
Before you begin
You can't duplicate a claim if the existing claim has the cover status of ‘held’ or ‘declined’ because the
duplicate wil take on the cover status of the original claim, although it will show as a duplicate.
Instruction
Step 1
Search for the client in Eos using the Alt+1 method and include all the following fields. This search will
display any matches of the NHI number.
NHI number
first initial
last name
date of birth
gender.
If there...
then go to...
are no matches
step 2
is one match
step 3
If there...
then go to...
is more than one match
Register manual claim as complete or incomplete
Step 2
Remove the NHI number from the criteria and run the search again. Eos will display all similar results.
If there …
then …
create a new party record
are no similar results
go to step 4
is one similar result
go to step 3
is more than one similar result go to
Register manual claim as complete or incomplete
Step 3
Select and open the party record and review the information to ensure that the fol owing fields match
those in the ACC45 form
first name
full last name
date of birth
gender.
If the information is...
then go to...
an exact match
step 4
different in any way, eg
slight spel ing differences in names where all other
criteria are exact matches
near matched date of birth where all other criteria are
Register manual claim as complete
exact matches
or incomplete
hyphenated last name
twins with first name initials matched
different NHI numbers but al other details match
Step 4
Select the client record to view the client’s list of claims and check for possible duplicates of the claim
that you're registering:
Open each claim dated within seven days of the date of the accident
Compare each claim with the one to be registered.
Step 5
Check for ACC45 numbers that may have been keyed incorrectly, eg the ACC45 numbers are similar
but two numbers are transposed. If you find any, pull the claim from filing to check if the number was
keyed correctly.
If the ACC45 was then…
keyed…
correctly
go to step 6
add the correct ACC45 number as
a case alias
add a contact with details of any changes
incorrectly
send both the client and the provider an
EXR07 Change of ACC45 number
(36.5K)letter so they know we've assigned a new ACC45 number
go to step 6
Step 6
Check that all the claim details match, including:
the date of the accident
the accident details
the client’s employment status
the cause of the injury.
Remember that:
some people have more than one accident in a week or even in a day and the accidents may be
similar, eg elderly people often fall; rugby players often hurt their knees
the injuries do not have to be the same as long as it is the same accident. A client may go back
to their doctor for an additional injury they did not realise they had, or that was missed on the first
claim form.
Step 7
If there are…
then…
no duplicate claims
go to
Register manual claim as complete or incomplete
If there are…
then…
case alias to existing claim
duplicate dental claims forward the ACC42 and ACC37 forms, if included, to the Dental Unit
this process ends
duplicate claims
go to step 8
Step 8
Use the following table to check if the registered claim was accepted and the new claim can also be
accepted.
If the registered
and the new claim can then…
claim…
be…
was accepted
accepted
it's a duplicate
do not case alias
was accepted
held
continue registering the claim
lodge the claim with ‘held’ status
do not duplicate
continue registering the claim
is held or declined
accepted or held
lodge the claim with ‘held’ status
add ‘Possible duplicate’ in the ‘Additional Injury
Comments’ field
What happens next
If the duplicate should be… then…
lodged
go to
Register manual claim as complete or incomplete
link the duplicate claim to the existing claim
case aliased
go to
Preparing, scanning and filing documents for VCF
Back to process map ↑
Register manual claim as complete or incomplete
Responsibility
Lodgement team
When to use
Use this instruction when you’re ready to enter the manual claim details into Eos.
Before you begin
Employment details in the Employer Search Tool (Step 3) come from IPS2. Only the ACC Business
Service Centre (BSC) can update incorrect details in IPS2. If you update the Employer Search Tool,
you must ask the ACC BSC to correct the details in IPS2.
Instruction
Step 1
Register the claim. Make sure you select ‘full’ for all claim registrations from the ‘Registration type’
dropdown list.
Step 2
Print the
Checklists for registering a manual claim and use this to ensure you enter the claim details
correctly.
Check the details from ‘Part A: Personal Details’ of the ACC45 and
update the client’s party record as
needed.
Step 3
Check that the employment details from ‘Part B: Accident and Employment Details’ are correct and
enter them into Eos.
If…
then…
give the following details to the
ACC Business Service Centre,
either by email or via the ACAF template:
ACC number
the employer details are
incorrect
employer name
correct address details
go to step 4
check the Employer Search Tool, the
whitepages.co.nz and
you're unable to find the
coys.co.nz
employer
go to step 4
you're unable to match the
phone the client or employer to get more information
employer details
go to step 4
you're unable to find the
use the default proxy number ‘Regproxy’
employer number
go to step 4
If…
then…
the claim is WRSPDI
use the gradual process default proxy number GPProxy
Hearing Loss claim
go to step 4
Step 4
Enter the details from ‘Part – C: Injury Diagnosis and Assistance’.
If…
then…
the claim has a ‘Z’ code (T149 or R69 for ICD10)
the injury side is not stated, eg left or right for ‘paired’ body parts
register the claim as
such as legs, hands, arms etc
incomplete
go to step 5
there are any conflicting details on the ACC45
there is no provider number or you can't read the provider number
register the claim as
incomplete
the injury side the provider marked doesn’t match the side the
go to
Managing missing
client says they injured
mandatory data
this process ends
Step 5
Enter the details from ‘Part D: Ability to Work’.
Step 6
Enter the details from ‘Part E: Treatment Provider and Patient Declaration’:
Enter and search the provider number in Eos so MFP will pick it up
Check the ACC45 is dated
If you’re unable to locate the provider or there is no date on either side of the form, register the
claim as ‘incomplete’.
Step 7
Check the ACC45 for any
missing mandatory information on the claim form then use the following
table to determine whether to submit the claim with missing mandatory data or pause registering the
claim.
If there is…
then…
If there is…
then…
select ‘Yes’ in the ‘Submit Form with Missing Mandatory
Data?’ field
missing mandatory data and you’re
click ‘OK’ at the bottom of the ‘ACC Form registration’
unable to get it straight away
screen
go to step 8
select ‘Yes’ in the ‘Submit Form with Missing Mandatory
Data?’ field
type ‘Check correct party ID’ in the ‘Missing Mandatory
any information that does
not match
Data Notes’ field
that in the party record
click ‘OK’ at the bottom of the ‘ACC Form registration’
screen
go to step 8
click ‘Pause’ at the bottom of the ‘ACC Form
registration’ screen
missing mandatory data and you can
close the registration screen
get it straight away
update the claim from your personal work queue once
you have obtained the missing information
go to step 8
select ‘No’ in the ‘Submit Form with Missing Mandatory
Data?’ field
no missing mandatory data
click ‘OK’ at the bottom of the ‘ACC Form registration’
screen
go to step 8
Step 8
If you selected…
and…
then…
a message displays the missing data
there is missing
mandatory data
you won't be able to proceed until you enter all
‘No’ in the ‘Submit Form
the mandatory data
with Missing Mandatory
the claim is ‘complete’
data?’ field
there is
no missing
go to
Streaming a claim from registration
mandatory data
this process ends
Eos generates the ‘Missing mandatory data’ task
and forwards it automatically to the appropriate
'Yes’ in the ‘Submit Form
'Missing Mandatory Data Work Queue’
with Missing Mandatory
n/a
Data?’ field
go to
Managing missing mandatory data
this process ends
Lodging an electronic claim
The Hamilton and Dunedin Registration Centres use this process when they receive
an electronic ACC45 claim form, to confirm the form’s data is complete and that it’s
not a duplicate claim.
Determine if mandatory data is missing or conflicting
Responsibility
Lodgement team
When to use
Use this instruction in the Hamilton or Dunedin Registration Centre when you receive an electronic
ACC45 Injury claim form.
Instruction
Step 1
Check the PDF claim form for any
missing mandatory data that you need to register the electronic
claim. Look for:
the client’s date of birth
the date of accident and a description of the accident
the client’s name
work capacity information, if it applies
a missing
READ code, injury or injury diagnosis
the date of accident is the client’s date of birth, if it applies
’test’ claims, eg Mickey Mouse or Joe Blow.
Step 2
If there is…
then…
missing or conflicting data
go to step 3
no missing or conflicting data go to
Check if ACC45 number in Eos and claim is a copy
Step 3
Determine if there is enough party information
to register the claim as incomplete. Check the claim for
the following party information:
the client’s name
the client’s date of birth
the client’s gender.
Step 4
If there is…
then…
enough
go to
Check if ACC45 number in Eos and claim is a copy
information
continue registering the claim with information available
select ‘No’ to ‘Submit form with missing mandatory data?’
not enough
the registration process ends and Eos generates the ‘Missing mandatory data’
task and forwards it automatical y to the appropriate 'Missing Mandatory Data
information
Work Queue’
go to
Managing missing mandatory data
this process ends
Back to process map ↑
Check if ACC45 number in Eos and claim is a copy
Responsibility
Lodgement team
When to use
Use this instruction to check if the ACC45 number is in use and if the new claim is a copy of an
existing claim in Eos.
Instruction
Step 1
Search for the ACC45 number in Eos using the ‘Create Claim’ screen.
Step 2
If…
then…
there is already a claim lodged in Eos with the
go to step 3
same ACC45 number
go to
Check if client party exists in Eos and/or
the ACC45 number is not in use
claim is a duplicate
Step 3
Open the claim and check the client’s name, accident details and injury diagnosis to determine if it is
a copy.
If…
then…
all the claim details match cancel the task with the reason ‘original task inappropriate’
and you don’t need to
this process ends
change anything
re-link the claim to the correct client
check the ‘incorrect’ client’s details and amend any details changed
in error eg the address
the claim has been linked
advise your Team Manager or Team Leader to remove the incorrect
claim form document and check all linkages in the form of a task,
or registered to the wrong
contact or document have been removed or moved to the correct
client
party
add a contact advising why the claim form document has been
removed, ie 'incorrect client selection at registration'
go to step 4
make the changes or add the new details
add a contact noting you received a claim copy from the provider and
you need to change or add
any changes you made
any claim details
upload the ACC45 to master claim
go to step 4
Step 4
If the ACC45
then…
number is…
allocate a new claim number from the claim spreadsheet
in Eos and the claim enter the claim number, the date, the reason for the new number and your
is not a copy
initials in the spreadsheet
send a copy of th
e EXR07 Change of ACC45 number (36.5K) letter to the
client and the provider so they know we’ve changed the ACC45 number.
go to
Check if client party exists in Eos and/or claim is a duplicate
not in use
go to
Check if client party exists in Eos and/or claim is a duplicate
Back to process map ↑
Check if client party exists in Eos and/or claim is a duplicate
Responsibility
Lodgement team
When to use
Use this instruction to check if the client party exists in Eos and the claim is a duplicate.
Before you begin
You can't duplicate a claim if the existing claim has the cover status of ‘held’ or ‘declined’ because the
duplicate wil take on the cover status of the original claim, although it will show as a duplicate.
Instruction
Step 1
Search for the client in Eos using the Alt+1 method and include all the following fields. This search will
display any matches of the NHI number.
first initial
last name
date of birth
gender
NHI number.
If there...
then go to...
are no matches
step 2
is one match
step 3
is more than one match
Register electronic claim as complete or incomplete
Step 2
Remove the NHI number from the criteria and run the search again. Eos will display all similar results.
If there…
then…
create a new party record
are no similar results
go to step 4
is one similar result
go to step 3
is more than one similar result go to
Register electronic claim as complete or incomplete
Step 3
Select and open the party record and review the information to ensure that the fol owing fields match
those in the ACC45 form
first name
full last name
date of birth
gender.
If the information is...
then go to...
an exact match
step 4
different in any way, eg
slight spel ing differences in names where all other
criteria are exact matches
near matched date of birth where all other criteria are
Register electronic claim as complete
exact matches
or incomplete
hyphenated last name
twins with first name initials matched
different NHI numbers but al other details match
Step 4
Select the client record to view the client’s list of claims and check for possible duplicates of the
claim you are registering.
Open each claim dated within seven days of the accident date
Compare each claim with the one to be registered.
Step 5
Check for ACC45 numbers that may have been keyed incorrectly, eg the ACC45 numbers are
similar but two numbers are transposed. If you find any, pull the claim from filing to check if the
number was keyed incorrectly.
If the ACC45 number then…
was keyed…
correctly
go to step 6
add a contact with details of any changes
incorrectly
send both the client and the provider an
EXR07 Change of ACC45
number (36.5K) letter so they know we've assigned a new ACC45
number
If the ACC45 number then…
was keyed…
go to step 6
Step 6
Check that all the claim details match, including:
the date of accident
the accident details
the client’s employment status
the cause of the injury.
Remember that:
some people have more than one accident in a week or even in a day and the accidents may be
similar, eg elderly people often fall; rugby players often hurt their knees
the injuries do not have to be the same as long as it is the same accident. A client may go back
to their doctor for an additional injury they did not realise they had, or that was missed on the first
claim form.
Step 7
If there are…
then…
duplicate claims
go to step 8
no duplicate claims go to
Register electronic claim as complete or incomplete
Step 8
Use the following table to check if the registered claim was accepted and if the new claim can also be
accepted.
If the registered claim… and the new claim can be… then…
was accepted
accepted
it is a duplicate
is held or declined
accepted
do not duplicate
was accepted
held
continue registering the claim
lodge the claim with ‘held’ status
is held or declined
held
What happens next
If the duplicate should be… then…
If the duplicate should be… then…
lodged
go to
Register electronic claim as complete or incomplete
case aliased
link the duplicate claim to the existing claim
Back to process map ↑
Register electronic claim as complete or incomplete
Responsibility
Lodgement team
When to use
Use this instruction when you’re ready to enter the electronic claim details into Eos.
Before you begin
Employment details in the Employer Search Tool (Step 3) come from IPS2. Only the ACC Business
Service Centre (BSC) can update incorrect details in IPS2. If you update the Employer Search Tool,
you must ask the ACC BSC to correct the details in IPS2.
Instruction
Step 1
Print the
Checklists for registering an electronic claim and refer to this to ensure you enter the claim
details correctly.
Step 2
Check the details in ‘Part A: Personal Details’ of the ACC45 and update the
client’s party record, as
needed.
Step 3
Check that the employment details from ‘Part B: Accident and Employment Details’ are correct and
then enter them into Eos.
If…
then…
email th
e ACC Business Service Centre with the:
ACC number
the employer details are incorrect
employer name
correct address details
If…
then…
go to step 4
check the Employer Search Tool, the
whitepages.co.nz and
you're unable to find the employer
coys.co.nz
go to step 4
you're unable to match the
phone the client or employer to get more information
employer details
go to step 4
you're unable to find the employer
use the default proxy number ‘Regproxy’
number
go to step 4
the claim is WRSPDI Hearing Loss use the gradual process default proxy number GPProxy
claim
go to step 4
Step 4
Enter the details from ‘Part – C: Injury Diagnosis and Assistance’. Register the claim as incomplete if
any of the following apply:
the claim has a ‘Z’ READ code (T149 or R69 for ICD10)
the injury side is not stated, ie left or right, for ‘paired’ body parts, eg legs, hands, arms etc
there are any conflicting details on the ACC45
the injury side the provider marked doesn’t match the side the client says they injured.
Step 5
Enter the data from ‘Part D: Ability to Work’.
Step 6
Enter the details from ‘Part E: Treatment Provider and Patient Declaration’:
Search for the provider number in Eos so MFP will pick it up
If you’re unable to locate the provider, register the claim as ‘incomplete’.
Step 7
Check the ACC45 for any
missing mandatory information on the claim form then use the following
table to determine whether to submit the claim with missing mandatory data or pause registering the
claim.
If there is…
then…
select ‘Yes’ in the ‘Submit Form with Missing Mandatory
missing mandatory data and you’re
Data?’ field
unable to get it straight away
click ‘OK’ at the bottom of the ‘ACC Form registration’
If there is…
then…
screen
go to step 8
select ‘Yes’ in the ‘Submit Form with Missing Mandatory
Data?’ field
type ‘Check correct party ID’ in the ‘Missing Mandatory
any information that does not match
Data Notes’ field
that in the party record
click ‘OK’ at the bottom of the ‘ACC Form registration’
screen
go to step 8
select ‘No’ in the ‘Submit Form with Missing Mandatory
Data?’ field
no missing mandatory data
click ‘OK’ at the bottom of the ‘ACC Form registration’
screen
go to step 8
click ‘Pause’ at the bottom of the ‘ACC Form
registration’ screen
missing mandatory data and you can
close the registration screen
get it straight away
update the claim from your personal work queue once
you have obtained the missing information
go to step 8
Step 8
If you selected…
and…
then…
a message displays the missing data
there is missing
mandatory data
you won't be able to proceed until you enter all
No’ in the ‘Submit Form
the mandatory data
with Missing Mandatory
data?’ field
there is
no
the claim is registered as complete
missing
mandatory data
go to
Streaming a claim from registration
Eos generates the ‘Missing mandatory data’ task
‘Yes’ in the ‘Submit Form
and forwards it automatically to the appropriate
'Missing Mandatory Data Work Queue’
with Missing Mandatory
n/a
Data?’ field
go to
Managing missing mandatory data
this process ends
Managing missing mandatory data
Use this process to manage the missing data work queue and process claims with
missing mandatory data.
Retrieve task from work queue or manual claim form
Responsibility
Lodgement team
When to use
Use this instruction to identify claims with missing mandatory data or when there is a need to check
client information during claim registration.
Instruction
Step 1
Retrieve the new task from the Eos work queue and the manual claim form from the ‘missing
mandatory data’ box.
Step 2
Check the task description.
If…
then there is…
then go to...
Obtain missing
the task description is ‘Register
an eclaim that could not be registered
mandatory data and
Claim’
and is incomplete
complete fields
the task description is ‘Missing
either a manual or eclaim registered
step 3
Mandatory Data’
as ‘incomplete’
there is a manual claim form only a manual claim that was not able to be
Obtain missing
and the name or date of birth is
registered and has not had registration
mandatory data and
missing
started
complete fields
Step 3
Check the 'Missing Mandatory Data Notes’ field.
If...
then go to...
the note says ‘Check correct Party ID’
Check right 'Party' record
there are either other notes or no notes
Obtain missing mandatory data and complete fields
.
Back to process map ↑
Check right 'Party' record
Responsibility
Lodgement team
When to use
Use this instruction to ensure the ACC45 claim form has been linked to the correct Party Record.
Instruction
Step 1
Check the client’s 'Party' record in Eos and compare it with the following details on the ACC45 form:
first name
full last name
date of birth
gender.
Step 2
If the information on the ACC45…
then go to…
is similar to the information held in the ‘Party’
Obtain missing mandatory data and complete
record
fields
is
not similar to the information held in the ‘Party’
step 3
record
does not match
any of the information in the ‘Party’ step 6
record
Step 3
Phone the client to determine whether the client is the same one as shown in the selected ‘Party’
record. Request the following details to help with verification:
first name, middle name, last name
date of birth
gender
last injury
contact numbers
current and previous address
employer information
provider or medical centre.
Step 4
Update the Verification status for the information in Eos.
If...
then...
this is the first time the information has been
verify the information by clicking the Verified radio
verified
button
the information has been verified at some point
re-verify the information by clicking the 'thumbs-up'
before
icon
Step 5
If...
then...
select the correct ‘Party’ record
at least 5 of the items in the ‘Party’ record match
those provided by the client
go to
Obtain missing mandatory data
and complete fields
fewer than 5 items in the ‘Party’ record match those
create a new 'Party' record
provided by the client
go to step 7
you can’t contact the client
go to step 6
Step 6
Contact the provider to determine whether the client is the same one as shown in the selected 'Party'
record.
If...
then...
select the correct 'Party' record
the information from the provider confirms the client’s identity go to
Obtain missing mandatory
data and complete fields
either:
the information from the provider doesn’t match the
create a new 'Party' record
‘Party’ record
go to step 5
the provider can’t give you enough information to
ensure that the party record in Eos is the correct one
If...
then...
you can’t contact the provider
Step 7
Move the party to the new ‘Party’ record. Any tasks will move automatically.
Step 8
Advise your Team Manager and/or Team Leader to remove the ACC45 Injury claim form from the
incorrect ‘Party’ record. Make a contact to explain this.
What happens next
Go to
Obtain missing mandatory data and complete fields.
Back to process map ↑
Obtain missing mandatory data and complete fields
Responsibility
Lodgement team
When to use
Use this instruction to get any missing mandatory data that you need to complete the claim
registration from the client and/or provider and enter the missing data.
Instruction
Step 1
Check what mandatory information is missing, then do the missing mandator
y task.
Step 2
Retrieve the task and contact the client, employer, provider or other relevant person by phone to get
the missing information and resolve any areas of conflict or confusion.
Step 3
Add a contact to record the details of your phone cal .
Step 4
If you get the information you need go to step 6. If not, use the table below.
If you’re unable to get the information by phone then…
and…
return the form to either:
the client with the
CVR01 ACC45
Information request – claimant letter
there is client information missing from the claim
(35.5K)
form
the vendor with the
CVR02 ACC45
Information request – vendor (39.5K)
letter
go to step 5
send th
e CVR03 ACC45 Diagnosis request
– vendor (97K) letter to the provider
the provider supplied a read code of ‘Z…
Unspecified conditions’ and did not supply a
if it’s a manual claim, make sure ensure you
diagnosis in the ‘Additional Injury Comments’
return the form with the letter
go to step 5
return the form to the provider with either:
the CVR02 ACC45 Information request
there is provider information missing from a manual
– vendor INF03556 letter
claim form, eg signature, provider number etc
the ACC2303 Request for more
information on dental claim (191K) form
go to step 5
search for the client in Eos:
look for an existing claim in the last 3
months
consider that the client may have
the address on the manual claim form is invalid or
moved address from the last time a
you can’t read it
claim was filed
use other search tools if needed
contact the client or provider
go to step 5
email or post the form back to the provider
to sign or to get the client’s signature
the client and/or provider signature is missing on
a provider or representative may sign for an
the ACC45 claim form
incapacitated patient
go to step 5
Step 5
Add a contact under the claim record and note any action taken. The ‘Follow up Document/Report’
task auto-generates to check if the missing information has been received.
Step 6
If you…
then…
complete registering the claim using the supplied
receive the missing information
information
go to step 7
don't receive the missing
go to
Advise insufficient information to accept claim
information
Step 7
Record the missing information.
If the claim is… then…
stamp the physical ACC45 claim form with the completed registration date
note the following on the original form in red pen:
who supplied the information
the reason we asked for the information
manual
add a contact against the claim noting:
the correct information
who supplied the information
the date the information was supplied
add a contact against the claim noting:
the correct information
electronic
who supplied the information
the date the information was supplied
What happens next
Go t
o Streaming a claim from registration.
This process ends.
Back to process map ↑
Advise insufficient information to accept claim
Responsibility
Lodgement team
When to use
Use this instruction if you haven’t received al the information you need to accept a claim.
Before you begin
You must do this within 21 days of claim lodgement if you have not received all of the mandatory data
and the claim registration is incomplete.
Instruction
Step 1
Create
a CVR63 Claim decline - info not provided - claimant (37.5K) letter and save it to the client's
file.
Send a copy (cc) to the provider, advising them that we can’t register the claim because there is not
enough information. Include a sentence in the provider’s copy advising that the client didn’t return the
necessary information.
Step 2
Add a contact explaining that you couldn’t register the claim because there wasn’t enough
information.
Step 3
Decline cover before the 21 days expire.
Step 4
Move the claim to the 'Actioned Cases' department queue.
What happens next
This process ends. If the information is supplied at a later date, we'l re-examine the claim at that time.
Streaming a claim from registration
Latest updates 8/3/2015: Updated to reflect the new claim streaming process
and criteria.
The Hamilton and Dunedin Registration Centres use this process after they’ve
registered a manual claim form or an electronic claim and confirmed that it’s not a
duplicate, to stream the claim to the appropriate unit.
Determine cover status
Responsibility
Lodgement team
When to use
Use this instruction to review each system-generated cover recommendation that Eos makes based
on the details entered from the claim form.
Before you begin
You must assess each claim on a case-by-case basis.
Familiarise yourself with:
Streaming criteria
Applying streaming criteria
Claim types.
Instruction
Step 1
Check the details on the Eos registration ‘Summary Screen’ and consider the following questions:
Has there been an accident
Was it a personal injury
Was there an external force or resistance
Are the injury code and diagnosis acceptable
Does the cause of the personal injury meet th
e criteria for an accident as defined by the Accident
Compensation (AC) Act 2001, Section 25
Did the injury occur in New Zealand, as defined by the AC Act 2001, Section 16
Was the claim lodged within 12 months of the date of the accident
Is it a gradual process claim
Has the lodging provider diagnosed within their scope of practice?
Step 2
Update the details on the Eos ‘Summary Screen’ if needed.
You must only change details on the ‘Summary Screen’
You can’t return to the registration screen.
Select the reasons for your changes and add more information if needed.
Step 3
If you’re unsure whether we can accept the claim, place the claim on hold.
Step 4
Determine the claim status.
If the claim is…
then…
a staff claim
go to
Stream a staff claim
handled by an accredited employer go to
Attribute and forward claim to accredited employer
a dental claim
go to
Add dental details and transfer to the Dental Unit
a specialist claim
go to
Stream a specialist claim
change the cover status to 'held'
a declined non-specialist claim
go to
Stream a specialist claim
any other claim type
go to
Stream a non-specialist claim
Back to process map ↑
Stream a staff claim
Responsibility
Lodgement team
When to use
Use this instruction to stream a staff claim to the Staff Claims Unit when either:
the Eos party level Staff Indicator is true for the client
the client has named ACC as their employer on their claim form.
Before you begin
Familiarise yourself with:
Streaming criteria
Applying streaming criteria
Claim types.
Instruction
Step 1
then make sure the registration 'Summary Screen' in
If the client has...
Eos displays...
then make sure the registration 'Summary Screen' in
If the client has...
Eos displays...
‘Accredited Employer’ and Accredited Employer Claim
in the ‘Cover Status’ and ‘Cover Status Reason’ fields
named ACC as their employer
‘Staff Claims Unit’ in the ‘Transfer/Allocation’ field
either ‘Staff Claim – Work accident’ or ‘Staff Claim’ in
the ‘Transfer/Allocation Reason’ field
‘Staff Claims Unit’ in the ‘Transfer/Allocation’ field
a Staff Indicator in Eos
either ‘Staff Claim – Work accident’ for work accidents
or ‘Staff Claim’ in the ‘Transfer/Allocation Reason’ field
Step 2
Click ‘OK’ to stream the claim to the Staff Claims Unit.
What happens next
The Staff Claims Unit manages the claim.
This process ends.
Back to process map ↑
Attribute and forward claim to accredited employer
Responsibility
Lodgement team
When to use
Use this instruction to notify the client, provider and employer or third party administrator that we’ve
lodged a work injury claim where the employer is an accredited employer.
Before you begin
Familiarise yourself with:
Streaming criteria
Applying streaming criteria
Claim types.
Instruction
Step 1
Ensure the claim status is ‘Accredited Employer’ and the reason is ‘Accredited Employer’ in the
registration summary screen.
Step 2
Check if the claim needs special handling.
If the...
then...
go to
Stream a staff claim
accredited employer is ACC
this process ends
go to
Stream a specialist claim
claim is a sensitive claim
this process ends
go to either
claim is for a work accident that
Stream a specialist claim
is a 'Motor Vehicle Accident' with
Stream a non-specialist claim
an 'MV' fund code
this process ends
transfer the claim to the appropriate Hamilton or Dunedin
‘Actioned cases’ work queue to generate a task in the
accredited employer is not ACC
’Registration Centre – AE Notifications’ work queue
and no MV fund code applies
open the task from the ‘Registration Centre – AE Notifications’
work queue
Step 3
Generate the
‘Employer Claim Transfer Pack’.
Step 4
Select, print and send the following documents from the pack:
CVR25 Advise client claim to be managed by employer
CVR26 Advise provider claim to be managed by employer.
Step 5
Eos generates a template document for the email to the accredited employer.
Copy the body from the document into the blank email
Copy the email address and subject from the document into the blank email.
Step 6
If the claim is… then…
a manual claim
scan the ACC45 document
open the claim
an electronic claim select the ACC45 and any other employer documents and contacts
Step 7
Privacy check the email before sending it to the employer.
Step 8
Save the email and the letters in Eos with the title ’Accredited Employer Notification’.
What happens next?
The accredited employer manages the claim. If needed, go to
Archiving physical claim files to file the
ACC45 copy.
This process ends.
Back to process map ↑
Add dental details and transfer to the Dental Unit
Responsibility
Lodgement team
When to use
Use this instruction when you’ve registered a dental claim and you need to add details to the ‘Dental’
tab.
Instruction
Step 1
Review the dental information from ‘Part D: Injury diagnosis and pre-accident condition’ of the ACC42
Dental claim registration form.
If...
then...
any of the three ‘oral
go to the Eos Registration 'Summary Screen' and:
If...
then...
assessments’ are missing
change the Cover Status to 'Held'
change the Cover Status Reason to 'Claim Asssessment
Required'
click 'OK' to stream the claim to the Hamilton or Dunedin
SC - Dental department
go to the Eos Registration ‘Summary Screen’ and:
change the Cover Status to ‘Held’
’Prior damage - other causes’ is
change the Cover Status Reason to ‘Claim Assessment
selected
Required’
click ‘OK’ to stream the claim to the Hamilton or Dunedin
SC – Dental department
go to the ‘ACC Form Registration’ screen and:
select ‘Yes’ in the ‘Submit Form with Missing Mandatory
Data’ field
does not record any:
click ‘OK’ at the bottom of the screen
tooth numbers for injured
go to the Eos Registration ‘Summary Screen’ and:
teeth
change the Cover Status to ‘Held’
tooth injury classification
change the Cover Status Reason to ‘Missing Mandatory
prosthesis information
Data’
transfer the claim to the ‘Missing Mandatory Data’ queue
go to
Managing missing mandatory data
this process ends
Step 2
Open the claim in Eos and:
add dental details for the missing the oral assessment or prior damage
send the ACC42 form and any attached documents to the Dental Unit
this process ends.
Back to process map ↑
Stream a specialist claim
Responsibility
Lodgement team
When to use
Use this instruction to decide how to stream a specialist claims
Specialist claims include:
fatal, sensitive, treatment injury, hearing loss, dental and gradual process claims
claims for clients who are managed by the Remote Claims Unit (RCU)
declined and held claims
Employer Centric Services (ECS) claims.
Before you begin
Familiarise yourself with:
Streaming criteria
Applying streaming criteria
Claim types.
Step 1
Determine where to transfer the claim to.
If the claim is...
then...
unless it is also a ...
transfer the claim to either:
an accidental death or
‘Hamilton SC – Accidental Death Unit’ staff, accredited employer or
department queue
fatal claim
treatment injury claim
‘Dunedin SC – Accidental Death Unit’
department queue
for a client who has
either:
current claims
managed by the
transfer the claim to the 'Remote Claims
staff, accredited employer or
RCU
Unit' department queue
fatal claim
previous claims
managed by the
RCU and a current
active care indicator
transfer the claim to the ‘Sensitive Claims
a sensitive claim
staff, RCU or fatal claim
Unit’ department queue
if the claim is manual, refer to
Preparing, scanning and filing
staff, accredited employer,
a treatment injury claim
documents for VCF to upload either of
the following to the claim file:
RCU or sensitive claim
the ACC2152 Treatment injury
If the claim is...
then...
unless it is also a ...
claim form (121K)
any other documents attached to
the ACC45 form that relate to a
treatment injury claim
transfer the claim to the ‘Treatment
Injury Centre’ department queue
transfer the claim to either:
‘Hamilton SC – Hearing Loss’
staff, accredited employer,
a hearing loss claim
department queue
fatal, RCU, sensitive or
treatment injury claim
‘Dunedin SC – Hearing Loss’
department queue
transfer the claim to either:
‘Hamilton SC – Dental’
department queue
staff, accredited employer,
a 'held' dental claim
‘Dunedin SC – Dental’
fatal, RCU, sensitive or
department queue
treatment injury claim
send the relevant unit the ACC42
and/or ACC37 form and any attached
documents
transfer the claim to either:
‘Hamilton Registration – Actioned
Cases' department queue
staff, accredited employer,
an 'accepted' dental
‘Dunedin Registration – Actioned fatal, RCU, sensitive or
claim
Cases’ department queue
treatment injury claim
send the relevant unit the ACC42
and/or ACC37 form and any attached
documents
staff, accredited employer,
transfer the claim to the ‘Southern Short
a work-related gradual
fatal, RCU, sensitive or
Term Claims Centre (STCC) – Gradual
process
treatment injury or dental
Process’ department queue
claim
staff, accredited employer,
transfer the claim to the ‘Southern Short
fatal, RCU, sensitive or
an asbestosis claim
Term Claims Centre (STCC) – Gradual
treatment injury or dental
Process’ department queue
claim
transfer the claim to the ‘Employer Centric held, declined, staff,
an Employer Centric
Services – Administration’ department
accredited employer, fatal,
Service (ECS) claim
queue
RCU, sensitive, treatment
injury, dental or gradual
If the claim is...
then...
unless it is also a ...
process claim
staff, accredited employer,
fatal, RCU, sensitive,
transfer the claim to the 'Cover Assessment'
a 'held' claim
treatment injury, dental, work-
department queue
related gradual proces,
asbestosis or ECS claim
go to Stream a non-specialist claim
any other claim
this process ends
Step 2
Use the Claim Type criteria and the description of the accident to work out the correct claim type for
the claim.
Step 3
Check that Transfer/Allocation unit in the Eos 'Summary Screen' is appropriate for the claim type.
If the Transfer/Allocation unit then...
....
confirm the:
is appropriate for the claim type unit that the claim has been allocated to in the
‘Transfer/Allocation’ field
reason for the alloation in the ‘Transfer/Allocation Reason’ field
update the:
is not appropriate for the claim
unit that the claim has been allocated to in the
type
‘Transfer/Allocation’ field
reason for the alloation in the ‘Transfer/Allocation Reason’ field
Step 4
If needed, go t
o Archiving physical claim files to file the ACC45 form.
What happens next
If you streamed the claim to…
then...
the assessor wil :
Hamilton or Dunedin cover assessment
make cover decision at cover assessment
stream the claim based on their cover
If you streamed the claim to…
then...
decision
the Southern STCC Gradual Process Unit or a
the unit wil follow their relevant process
specialist unit
This process ends.
Back to process map ↑
Stream a non-specialist claim
Responsibility
Lodgement team, Cover Assessment team, Client Address Verification team, Inquiry Service Centres.
When to use
Use this instruction to decide how to stream a non-specialist claim.
Non-specialist claims exclude:
staff claims
accredited employer claims
fatal, sensitive, treatment injury, hearing loss, dental and gradual process claims
claims for clients who are managed by the Remote Claims Unit (RCU)
declined and held claims
Employer Centric Services (ECS) claims.
Before you begin
Familiarise yourself with:
Streaming criteria
Applying streaming criteria
Claim types
Conversion probability threshold.
Instruction
Step 1
Make sure the claim is a non-specialist claim and its Cover Status is 'Accept'.
If...
then...
both the:
claim is a non-specialist claim go to step 2
Cover Status is 'Accept'
go to
Stream a specialist claim
the claim is a specialist claim
this process ends
go to
Stream a specialist claim
the Cover Status is not 'Accept'
this process ends
Step 2
Check:
whether or not the client has any open existing claims that are managed by a branch, STCC or
ECS unit
whether or not the client's claim form has been checked with 'contact provider' or 'assistance
required'
the client's earner status in Eos.
If the client is an... then his or her earner status will be...
either:
'Non-earner'
non-earner
'Unemployed'
go to step 3
either:
'Other'
'Other' and 'Employed'
'Potential'
earner
'Potential' and 'Employed'
'Potential' and 'Other'
'Potential', 'Other' and 'Employed'
go to step 5
Step 3
Decide where the non-earner claim should be transferred to based on the followin
g Streaming criteria.
If the client has... and there is...
then the claim should be transferred to...
If the client has... and there is...
then the claim should be transferred to...
either:
an open existing
a provider
the department queue of the branch, STCC or ECS unit
request
claim
managing the existing claim
no provider
request
no open existing a provider request the STCC closest to where the client lives
claims
either the:
no open existing
‘Hamilton Registration – Actioned Cases’ department
no provider request
queue
claims
‘Dunedin Registration – Actioned Cases’ department
queue
Step 4
If you are...
then...
click ‘OK’ on the registration ‘Summary Screen’ to generate
streaming the claim from the
the CVR40 Cover acceptance – claimant (44K) letter, which
is sent from our third-party mailhouse direct to the client
'Registration summary' screen
go to step 8
not streaming the claim from the
manual y
transfer the claim based on the
Streaming criteria in
'Registration summary' screen ie
step 3
post-registration
go to step 8
Step 5
Decide where the earner claim should be transferred based on the following
Streaming criteria.
If client has.. and the client...
then the claim..
a provider
has an open existing
should be transferred to the department queue of the branch,
request
claim
STCC or ECS unit managing the existing claim
a provider
has
no open existing
should be transferred to the ‘Service Needs assessment’
request
claims
department queue
no provider
has or doesn't have an
will need
a Conversion probability threshold test before you
request
open existing claim
can decide where to transfer it
Step 6
If there
and you are...
then...
is...
click ‘OK’ on the registration ‘Summary Screen’ to
streaming the claim from
generate the
CVR40 Cover acceptance – claimant (44K)
a provider the 'Registration summary'
letter, which is sent from our third-party mailhouse direct
request
to the client
screen
go to step 8
not streaming the claim
manual y
transfer the claim based on the
Streaming
a provider from the 'Registration
criteria in step 5
request
summary' screen ie post-
go to step 8
registration
confirm the 'Transfer/Allocation' department to either the:
'Hamilton Registration - Auto streaming' department
queue
no
streaming the claim from
'Dunedin Registration - Auto streaming' department
queue
provider
the 'Registration summary'
request
screen
click ‘OK’ on the registration ‘Summary Screen’ to
generate the
CVR40 Cover acceptance – claimant (44K)
letter, which is sent from our third-party mailhouse direct
to the client
go to step 8
check:
the Insights tab on claim record in Eos for the client's
not streaming the claim
no
conversion probability and duration rating scores, which
from the 'Registration
are displayed in the 'conversion probability (%)' and 'WC
provider
Days (0-182)' dials
summary' screen ie post-
request
registration
whether or not the claim meets or exceeds the
Conversion probability threshold
go to step 7
Step 7
Manually
transfer the claim based on the following
Streaming criteria.
If the claim...
and the client..
manually transfer the claim to...
meets or exceeds the
has
no open existing the ‘Service Needs assessment’ department
Conversion probability
claims
queue
threshold
meets or exceeds the
has an open existing the department queue of the branch, STCC
Conversion probability
claim
or ECS unit managing the existing claim
threshold
If the claim...
and the client..
manually transfer the claim to...
either the:
does
not meet th
e Conversion has or doesn't have an ‘Hamilton Registration – Actioned
Cases’ department queue
probability threshold
open existing claim
‘Dunedin Registration – Actioned Cases’
department queue
has
no conversion probability has or doesn't have an the 'Service Needs Assessment - Screening
score and/or duration rating
open existing claim
Triage' department
Step 8
Complete any other business process for the claim.
If needed, go t
o Archiving physical claim files to file the ACC45 form.
What happens next
If you transferred the claim to:
the SNA team, they will
prepare and allocate for a service needs assessment
the Hamilton or Dunedin Auto-Streaming department queue, the claim wil be automatically
streamed based on its conversion probability
any other business unit, they'll continue to manage the claim.
This process ends.
Receiving and streaming treatment
injury claim
This process is used to check that a treatment injury claim has been registered and
to obtain information so the claim can be streamed and allocated appropriately.
The process map replaces the swimlane previously used in Manage Claims. You can
see that swimlane by clicking here: Receive and stream treatment injury claim
(45K)
Check information received
Responsibility
Case Administrator
When to use
Use this instruction when information is received via mail, fax, and email or Eos task. This information
could take the form of an
ACC2152 (123K), clinical notes or reports.
Instruction
Step 1
If the claim is…
then…
registered and unal ocated go to
Manage registered ACC45
set follow up document report task
registered and al ocated
set target date for the same day
go to
Manage registered ACC45
not registered
go to Step 2
Step 2
Check whether an ACC45 has been provided by the submitting provider.
If ACC45
then…
has…
email the Hamilton or Dunedin Service Centre to have the claim registered
been
wait until claim has been registered and returned
provided
go to
Manage registered ACC45
send a
TI15 Request ACC45 from provider (36K) form to the provider and record
the information in the Admin holding tray spreadsheet
not been
if the claim is stil not registered after 14 days, contact the provider to remind them
provided
of the need to submit an ACC45, wait another 14 days and then send all
documents back to the provider
this process ends
What happens next
When the ACC45 is received, the claim wil be registered and al ocated to the Treatment Injury work
queue.
Go to
Manage registered ACC45.
Back to process map ↑
Manage registered ACC45
Responsibility
Case Administrator
When to use
Use this instruction when a new treatment injury claim is received in the Treatment Injury Centre work
queue.
It is important to review al new claims within 48 hours of receipt from registration.
Instruction
Step 1
Open the claim and check it is a treatment injury claim.
If the claim is… then…
check that the ‘Treatment Injury Indicator’ on the ‘General’ tab is set to
a treatment injury
Treatment Injury
claim
go to Step 2
check the ‘Treatment Injury Indicator’ is not selected on the ‘General’ tab
change the accident cause in the ‘Accident’ subtab of the ‘Injury’ tab to
not a treatment
ensure that it is not Medical Treatment
injury
transfer the claim back to the lodging registration centre with the description
‘PICBA not TI – requires decision’
this process ends
Step 2
Check if the claim is a duplicate.
If the claim then…
is…
link the duplicate claim to the master claim
transfer claim to team manager to allocate to a case administrator. The Case
Administrator will send out either:
a duplicate
CVR44 duplicate accept (41K)
CVR65 duplicate decline (38K)
TI84 Duplicate claim decision – held claim
this process ends
not a
go to Step 3
duplicate
Step 3
Decide the next action for the claim.
If the claim includes…
then…
a request for more than 14 days off work
transfer the claim and all tasks to the Team
Manager’s (TM) work queue for allocation
Reason: Task: Department work flow
Description: reason for the transfer, eg
a surgery request
surgery request received
go to
Stream and allocate claim
transfer the claim and all tasks to the TM’s work
queue for allocation
an ACC2152 Treatment injury claim (121K)
form and/or clinical notes received
Reason: Task: Department work flow
go to
Stream and allocate claim
create a ‘TIPS Fol ow up ACC2152 Clinical
Records Request’ task:
Description: Send ACC2152 request to
provider
Target date: two working days
insufficient documentation, eg no ACC2152
create a ‘Fol ow up Needs Assessment’ subtask
or not enough records to progress claim
Description: Assess the claim
Target date: one working day
transfer the claim to the ‘TIPS-Admin’ work queue
go to
Request information from provider
Back to process map ↑
Request information from provider
Responsibility
Case Administrator
When to use
Use this instruction to request an ACC2152 from a health provider.
Before you begin
Consul
t How to manage legislative timeframes.
Instruction
Step 1
Open the ‘TIPS Fol ow up ACC2152 Clinical Records Request’ task.
Step 2
Check the claim information to find out if the required information has been submitted.
If the
then…
information…
has been
go to
Stream and allocate claim
submitted
check the name of the provider where the request for the
ACC2152 Treatment
Injury Claim (123K) form is to be sent
create a purchase order from the General QE tab
generate
a TI12 Clinical information request (ACC2152) (123K) form to send
to the provider or facility with a target date of 10 working days
update the ‘TIPS Fol ow up ACC2152/Clinical Records Request’ task:
Description: ACC2152 due from provider name
Target date: 15 working days
is still required
send the request to the provider with the following attachments:
either:
copy of the ACC45
signed authority to col ect relevant records on file
plus:
blank ACC2152
a freepost envelope for non-DHB
Step 3
When task target date has been reached, check to see if the ACC2152 has been received.
If the ĀCC2152 has…
then…
received
go to
Stream and allocate claim
not been received and the forward the task to Case Owner
claim is allocated
not been received and the generate and send to provider
TI13 Clinical information reminder -
If the ĀCC2152 has…
then…
claim is unal ocated
provider (45K) letter with a target date of 10 working days
update the ‘TIPS Fol ow up ACC2152/Clinical Records Request’
task:
Description: ACC2152 reminder sent
Target date: 11 working days
send the request reminder to the provider with the following
attachment:
copy of the original request letter
Step 4
If the information is not received after the reminder
then…
period and claim is…
allocated
forward the task to Case Owner
go to
Decline claim due to lack of
unal ocated and nearing the legislative timeframe
information
Back to process map ↑
Decline claim due to lack of information
Responsibility
Case Administrator
When to use
Use this instruction to decline the claim when the requested
ACC2152 (123K) form and/or clinical
records have not been provided.
Instruction
Step 1
Contact the client and explain:
that the claim will be declined due to a lack of information, as the ACC2152 form and clinical
records have not been provided
the claim can be re-opened for reassessment when the required information is provided.
Step 2
Record the conversation in the ‘Contacts’ tab, as well as any action taken.
Step 3
Update the cover details and treatment injury tabs in Eos.
Step 4
Prepare and send the client th
e TI62 Claim decline – no response letter (105K).
Step 5
Move the claim to actioned cases.
What happens next
This process ends.
Back to process map ↑
Stream & allocate claim
Responsibility
Team manager
When to use
Use this instruction when a new claim appears in your My Claims queue, to stream and al ocate the
claim to a clinical advisor who will determine cover.
Instruction
Step 1
Open the ‘My Claims’ tab and select the claim to be al ocated.
Step 2
Examine the claim and the supporting documentation including:
ACC2152 Treatment Injury Claim (123K) form
clinical records
relevant medical notes.
Step 3
Consider the complexity of the claim and other risk factors.
Consul
t Cover criteria for treatment injury an
d Managing legislative timeframes
Step 4
then transfer the claim to a case
then the claim is
If...
administrator and add the following
streamed as…
information in the description…
Reason: Department allocation
there is enough information
Description: straightforward claim and name
available to make cover
straightforward
of clinical advisor
decision
go to
Making treatment injury cover
decision
Reason: Department allocation
there is not enough
Description: moderate/complex claim and
information to make cover moderate/complex
name of clinical advisor
decision
go to
Gathering information for a
treatment injury claim cover decision
Reason: incorrectly allocated
the claim is not a treatment
injury
Description: not TI and next action required,
eg Transfer to Branch
What happens next
This process ends.
Responding to provider requests
Client Service Delivery (CSD) staff who work with claims and Cover Assessment
Staff use this process to contact providers and/or clients when a provider ticks
‘Contact Provider’ or ‘Assistance required’ on an ACC45 or other claim form when
the provider has not been already been contacted as part of a three-point contact or
Service Needs Assessment.
Review request and contact provider
Responsibility
CSD staff who work with claims and Cover Assessment Staff
When to use
Use this instruction when a provider ticks ‘Contact Provider’ or ‘Assistance Required’ on an ACC45 or
other claim form and:
you’ve been allocated either:
an AUTO ‘Contact Provider’ or ‘Assistance Required’ task
a claim with an open AUTO ‘Contact Provider’ or ‘Assistance Required’ task
the provider and/or client have not already been contacted as part of:
Completing initial three-point contact and action plan for Claims Management Network staff
Completing a Service Needs Assessment for Service Needs Assessment staff.
Instruction
Step 1
Open the task from your work queue and review the ACC45 or other claim form details.
Step 2
Contact the provider within two working days of being allocated the task or claim.
If the provider ticked…
and…
then…
contact the provider and discuss their
reasons for asking us to contact them
Do a task in Eos to:
‘Contact provider’ only
complete and close the open
AUTO ‘Contact Provider’ task
add a contact to the claim file
go to
Transfer claim
Do a task in Eos to:
you’ve talked to the
complete and close the open
provider or client before and
AUTO ‘Assistance Required’
task
you understand what
assistance the client needs
add a contact to the claim file
go to
Transfer claim
contact the provider and discuss the
‘Assistance Required’ only
assistance the provider says the
client needs
you haven’t talked to the
Do a task in Eos to:
provider or client about
complete and close the open
what assistance the client
AUTO ‘Assistance Required’
needs
task
add a contact to the claim file
go to
Transfer claim
If the provider ticked…
and…
then…
contact the provider and discuss the
assistance the provider says the
client needs
Do a task in Eos to:
'Contact Provider’
‘Assistance required’
to complete and close the open
AUTO ‘Contact Provider’ or
‘Assistance required’ tasks
add a contact to the claim file
go to
Transfer claim
Back to process map ↑
Transfer claim
Responsibility
CSD staff who work with claims and Cover Assessment Staff
When to use
Use this instruction to transfer a claim with an open AUTO ‘Contact Provider’ or ‘Assistance Required’
task to the appropriate team.
Step 1
Transfer the claim to the appropriate team.
If the provider indicates and your business then…
that…
unit...
transfer the claim to your business unit, if it’s in
the ‘Hamilton or Dunedin Registration –
Actioned Case’ queue
check for open ‘Contact Provider’ and
the cover decision at
‘Assistance Required’ tasks that are not
makes cover
assigned to a case owner
registration needs to be
decisions
reviewed
manual y transfer any unassigned ‘Contact
Provider’ and ‘Assistance Required’ tasks to
your business unit
go to
Confirming existing cover decision
this process ends
transfer the claim to the Cover Assessment
the cover decision at
doesn’t make cover
team
registration needs to be
decisions
check for open ‘Contact Provider’ and
If the provider indicates and your business then…
that…
unit...
reviewed
‘Assistance Required’ tasks that are not
assigned to a case owner
manual y transfer any unassigned ‘Contact
Provider’ and ‘Assistance Required’ tasks to the
Cover Assessment team
this process ends
us
e Updating an action plan to include the extra
the client needs extra
is the right unit to
assistance in the plan for managing the client’s
claim
assistance from us
manage the claim
this process ends
us
e Streaming a claim from registration to
transfer the claim to the correct business unit to
manage the claim type
check for open ‘Contact Provider’ and
the client needs extra
isn’t the right unit to
‘Assistance Required’ tasks that are not
assigned to a case owner
assistance from us
manage the claim
manual y transfer any unassigned ‘Contact
Provider’ and ‘Assistance Required’ tasks to the
correct business unit
this process ends
no action is required
this process ends
What happens next
If the claim has been transferred to a specialist or non-specialist unit, then that unit wil manage
the claim.
If the cover decision needs to be reviewed, then either the business unit managing the claim or
the Cover Assessment team wil review it.
If no action is required, then the business unit who is managing the claim will continue to
manage it.
