What will WorkSafe pay
The WorkSafe will pay the reasonable cost of external case management which is required as a result of a work-related injury or illness.
What is external case management?
External case management is a collaborative process which may include an assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and the utilisation of available resources to promote quality cost-effective outcomes. WorkSafe recognises that some eligible injured workers (for eligibility criteria see Section 7.13 in Online Claims Manual) at certain times require assistance beyond the case management role of an agent or the role of treating health care providers. Case management services are a time-limited service that complements the agent's role.
Who can provide external case management services?
External case management services can be provided by case management agencies/providers approved by WorkSafe.
Can an external case manager approve services for or on behalf of the injured worker?
External case managers cannot approve any services for or on behalf of an injured worker. All services recommended by an external case manager require prior approval by the WorkSafe Agent (Agent) or WorkSafe. The Agent will determine the reasonableness of any requested medical and like services.
What can the agent pay for in relation to external case management?
The Agent may pay for external case management where:
- the injured worker is eligible for the Community Integration Program (for eligibility criteria see Section 7.13 in Online Claims Manual)
- the service is authorised by WorkSafe to meet identified needs of an injured worker.
Are there any exceptions?
A request for external case management for eligible injured workers that do not meet the VWA's eligibility criteria or injured workers not participating in the Community Integration Program may be considered by WorkSafe on a case by case basis
When will WorkSafe not pay for external case management services?
WorkSafe will not pay for external case management services where:
- services that are required for an injury, condition or circumstance existing before the work related injury was suffered
- services that are not required as a direct result of the work related injury
- the agent considers that the cost of the service is not reasonable, necessary or essential
- the case management objectives identified in the Individual Plan have previously been addressed
- an injured worker withdraws/refuses to engage in the service, or
- there are no more active outcomes to be delivered by the external case manager. External case manager responsibilities do not include 'monitoring'. This is the role of the Agent.
Is prior approval required for payment of external case management?
Prior written approval for external case management services is required.
Request for the provision external case management services must come from a medical practitioner.