It is important for ACC to be satisfied that treatment it is funding is for the covered injury, and not for an underlying or non accident related condition. For this reason, ACC’s prior approval is required before elective surgery is undertaken.
If the provider recommends a surgical procedure they need to electronically submit an ARTP to the Elective Surgery Unit via:
- HealthLink address to ‘acceartp’, or
- Email to ‘ARTPS4ESU@acc.co.nz’.
Assessment Report and Treatment Plan (ARTP)
The ARTP serves as a request for approval of treatment. The report should provide ACC with the crucial information needed to make decisions on funding for requested treatment procedures.
Note:
From 1 February 2012, the Surgical ARTP (PDF 126K) is the only version acceptable. If the ARTP does not meet the standards, it will be returned to the provider with a request for further information.
Clinical priority
The clinical priority (that is, the urgency of the client’s need for the treatment) should be clearly stated on the provider’s request.
The case manager can assign more urgency to the client’s treatment if the client meets any of these criteria:
- They could lose their current job because they cannot continue in paid employment while waiting for treatment (and the treatment is likely to reverse the relevant loss of function).
- They are currently receiving weekly compensation.
- They are currently receiving a high level of social rehabilitation assistance.
- The treatment is likely to help restore the client’s independence in daily living activities (such as educational participation for a school student).
Contracted or regulation
A contracted provider is one who requests elective services treatment for a client, and has an Elective Services Agreement (contract), with ACC to provide the type of treatment procedure in the request. This is the standard method of applying for funding for surgery. Contract holders are allocated an annual budget to fund approved surgical services. The nationally agreed price paid for surgery covers the surgical treatment and the six weeks post procedure care after discharge from hospital. This includes the follow-up assessments, short term hire of equipment, and the majority of pharmaceuticals required.
To find out more about the contract, see Elective Surgery – Contract.
Who can hold a contract
The Elective Services Agreement is usually held by hospitals and relates to the surgical treatment of the injury.
The contract requires individual service providers (ie medical specialists) who will work under the contract, to be named on the service agreement. A specialist can be named on more than one Elective Services Agreement.
To find out how to apply for a contract, see Apply for a contract.
Regulation (non-contracted) surgery
ACC is liable to pay or contribute to the cost under Regulation 18: Elective surgery costs of the Injury Prevention, Rehabilitation and Compensation (Liability to Pay or Contribute to Cost of Treatment) Regulations 2003 (‘non-contracted surgery’).
Maximum contributions:
- District Health Boards (DHB) are paid at 100% of the contracted rate.
- Private hospitals are paid at 60% of the contracted rate.
- For regulation surgery undertaken in a private facility, the client is liable for the remaining costs between ACC’s maximum contribution and the total amount charged by a non-contracted provider.
- Implants are paid at 100%.
All payments under regulation surgery cover the surgical treatment and the six weeks post procedure care after discharge from hospital.
Clients must make the decision regarding the choice of having surgery under regulation rather than under contract, due to the potential cost to them. The medical specialist should therefore ensure that the client has all information available to them to make this decision. This includes the amount ACC will contribute to the surgery costs.
ACC has a requirement to inform the client that surgery can be performed by a contracted provider at no cost to the client. This information is provided directly to the client in a decision letter. The client must sign the letter and return it to ACC to demonstrate understanding and consideration of all of the options available.
ACC requires the completed documentation before any payments can be made for the provision of surgery.
The surgeon who requests approval for regulation surgery is responsible for ensuring that payment is made to the hospital, anaesthetist, and others from the maximum contribution amount. The surgeon can request that a hospital take on the lead provider role. If this is the case, the hospital is responsible for distributing payments to all parties concerned.
ACC is not liable to pay any fees above this amount.
Surgical procedures
Core list procedures
Core list procedures are less complex than red list procedures and are high volume. Examples can include procedures associated with personal injury or as a consequence of pre-existing factors.
Non-core procedures
Non-core treatment procedures are not included in the treatment procedure list and are usually either:
- a less common treatment procedure, or
- a combination of a core treatment procedure listed in the contract and a procedure that is not listed.
Red list procedures
- Red list procedures are relatively complex, high cost and low volume
- Providers who carry out red list procedures have a red list variation in their contract
- Only a specialist who is named in the contract to perform red list procedures can perform them.
Process for assessing surgical requests
ACC staff, including medical professionals, will consider whether the proposed treatment will be funded by ACC. As part of this process, ACC will usually obtain all relevant medical records.
Time taken to make a decision about funding surgery
The time taken for ACC to make a decision about whether we can fund surgery is affected by several factors. These include:
- the quality of information received by ACC
- the time taken by health professionals to respond to our requests for information
- the complexity of the proposed surgery and the complexity of the client’s medical history
- whether we need to obtain a second opinion about the surgery from another specialist.
In most cases, collecting information should take 2 to 4 weeks. We should then be able to make a decision within 2 weeks. If we need to obtain a second opinion, this will take an additional 2 to 4 weeks.
Invoicing and payments
The Elective Service Centre (Dunedin) processes all surgical invoices.
Invoices must be submitted electronically. To find out more about working electronically with ACC see Working electronically with ACC.
The provider can submit their invoice for payment from the date of discharge. All invoices must be submitted electronically within 12 months of the treatment provided. The provider must also supply a copy of the Operation Note for the procedure.
If the cost of an implant(s) is greater than $8,000 then a copy of the supplier’s invoice must also be provided to ACC.
Retrospective payment
If, on commencing an approved surgical procedure, it is found that an alternative unanticipated procedure is necessary and more appropriate, the procedure may be carried out. A detailed invoice requesting retrospective funding must be submitted to ACC.
In addition to the invoice, the following information is required:
- the operation notes
- other relevant supporting documentation.
ACC may not pay for any surgery undertaken without prior approval unless it meets the criteria for retrospective reimbursement.
Operational guidelines
The operational guidelines are designed to help suppliers holding the ACC Elective Services Agreement to interpret the contract, and access it when appropriate. The guidelines are a living document and updated versions will be made available on the ACC provider website as queries arise.
Decision-making review
ACC completed an internal review of its elective surgery decision-making processes (the Review).
ACC has accepted the findings of the Review and considered, together with key stakeholders, a wide range of suggestions for improvement. More detail on each area for improvement is provided in the relevant section of the report. To read the full review, see ACC Review of Elective Surgery Decision-Making (PDF 369K).
To read the executive summary of the review, see ACC Review of Elective Surgery Decision-Making: Executive summary.
External ACC guide
The New Zealand Private Surgical Hospitals Association Inc (NZPSHA) commissioned Buddle Findlay, Lawyers, to provide practical guidance on the application of the Accident Compensation Act 2001 (‘The Act’).
To read the full guide, see Personal Injuries and the ACC – A guide to cover, entitlements, and the claims process (PDF 236K).
Other information
Related legislation
Accident Compensation Act 2001
- Schedule 1, Clauses 1 to 6 (external website).
Injury Prevention, Rehabilitation, and Compensation (Liability to Pay or Contribute to Cost of Treatment) Regulations 2003
- Regulation 18: Elective surgery costs (external website)
ACC contact details
If you want to discuss contract options with ACC, please contact our Health Procurement Team:
- Phone: 0800 400 503
- Email: health.procurement@acc.co.nz.
If you have more general questions, comments or suggestions to make on the process or options that might be considered, please channel them through your professional representatives so they can develop a unified view on behalf of the sector.
All other queries should be directed to the ACC Provider Helpline:
- Phone: 0800 222 070
- Email: provider.help@acc.co.nz.
Elective Services Sector Updates
- Elective Services Sector Update – March 2012 (PDF 95K)
- Elective Services Sector Update – December 2011 (PDF 78K).
Last updated: 5 March 2012