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50.8 Ongoing General Review (26 pay period reviews)

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A treating Specialist report is required to confirm/reconfirm the Incapacity.

Exceptions to this rule are:

  • There is no treating specialist, there is no active treatment plan, where for whatever reason the treating specialist is not suitable or able to provide medical evidence or the circumstances of the claim are particularly complex or contentious. In these circumstances, a report by an independent specialist is appropriate.
  • Where we already have contemporary credible specialist medical opinion covering the ongoing Incapacity (based on previously advised specialist review).
  • Where there is an ongoing current rehabilitation plan (RTW plan).  Where the client is participating in a Rehabilitation plan the responsibility for obtaining any further medical certification lies with the Rehabilitation Coordinator.
  • Where the client has been assessed to be Chronically Incapacitated Category A or B or SRDP or Special Rate under the VEA.

An Ongoing Payee Incapacity Checklist is to be completed at this stage and a copy put on the file.  This checklist asks a variety of questions aimed at ensuring the client continues to be entitled to Incapacity, is being paid at the correct rate, has been considered/referred or assessed for rehabilitation in the past 12 months, has an end date in PMKeyS and that we have up to date information from the client.

A D1352 - Annual review of circumstances form should be sent to the client every 12 months to ensure we continue to maintain the most up to date and accurate client details and information and to ascertain if any of the client's circumstances have changes during the past 12 months