Medical Services Agreement
Commercially Confidential
SCHEDULE 4 SECTION 4.1 PART 1
COMMON BUSINESS REQUIREMENTS
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SCHEDULE 4 SECTION 4.1 PART 1
COMMON BUSINESS REQUIREMENTS
1
GENERAL
1.1
The CONTRACTOR acknowledges that the standards set out in this Schedule 4 shall apply to
all of the Referral requests made to the CONTRACTOR by the AUTHORITY.
1.2
General Service Communication Standards
1.2.1
The CONTRACTOR shall display in all examination waiting room areas, information
that shall include but not be limited to:
a)
Claimant services standards as detailed at paragraphs 5.1 to 5.10;
b)
Claimant complaint procedures as approved by the AUTHORITY; and
c)
the name of the site manager.
1.2.2
Upon request, the CONTRACTOR shall provide to the AUTHORITY and any
Claimant or their nominated representative, accurate information in plain language
about how the Services are administered and provide details of the Claimant’s local
contact point.
1.2.3 The
CONTRACTOR
shall
ensure that all staff provide a courteous and helpful
service at all times.
1.2.4
The CONTRACTOR shall ensure that its staff, including Medical Personnel, who
have face to face contact with Claimants wear name badges at all times.
2
PUBLICATIONS IN WAITING ROOMS
2.1
The CONTRACTOR shall display various AUTHORITY publications as provided by the
AUTHORITY in all Claimant waiting room areas when reasonably requested to do so by the
AUTHORITY.
2.2 The literature that the CONTRACTOR shall display, will include, but not be limited to:-
AAA5PPDCS
Attendance
Allowance
(AA)
AA5PPDCSW
Attendance Allowance (AA) Welsh version
CAA5PPDCS
Carer’s
Allowance
(CA)
CAA5DCW
Carer’s Allowance (CA) Welsh version
DLAA5PPDCS
Disability Living Allowance (DLA)
DLAA5PPDCSW
Disability Living Allowance (DLA) Welsh version
DLACA5PPDCS
DLA for children
DLACA5PPDCSW
DLA for children Welsh version
BRA5DWP
Benefit Rates
BRA5DWPW Benefit Rates Welsh Version
DWP1001
Employment and Support Allowance
DWP1004
Industrial Injuries Disablement Benefit
DWP1008
WorkPath
DWP1011
New Deal for disabled people
DWP1021
The disability symbol and Disability Discrimination Act
DWP1026
Help if you are sick or disabled
GL24DWP
If you think our decision is wrong
GL24DWPW
If you think our decision is wrong Welsh Version
HC1 & HC5
Health Benefits
Inspire
Jobcentreplus Customer Magazine
VACDPA5PPDCS
Vaccine Damage Payments
VACDPA5PPDCSW
Vaccine Damage Payments Welsh Version
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2.3 The posters that the CONTRACTOR shall display will include, but not be limited to:
ESA - Employment and Support Allowance
ESA - Employment and Support Allowance – Welsh (where appropriate)
ESA - Support with moving into work
ESA - Support with moving into work – Welsh (where appropriate)
ESA - What to expect from your medical assessment
ESA - What to expect from your medical assessment - Welsh (where appropriate)
Waiting times
Waiting times – Welsh (where appropriate)
What to expect from your medical assessment
What to expect from your medical assessment – Welsh (where appropriate)
2.4 The Posters listed above are provided by the CONTRACTOR”
2.5 The CONTRACTOR shall obtain prior written approval from the AUTHORITY to display non-
AUTHORITY literature in accommodation which is used specifically for the provision of Services.
2.6 If the site is ‘Casual Hire’, for example where the CONTRACTOR ‘hires’ an examination room
within a GP’s surgery or a hospital, they may not necessarily be given room within the waiting
area to display posters and leaflets. In these instances the CONTRACTOR shall have an
information pack/folder available for the claimant to look at. This pack should contain all the
information, which the CONTRACTOR is required to display within other MEC’s.
2.7 Provision Of Items
2.7.1 The CONTRACTOR shall use reasonable endeavours for ensuring that sufficient quantities of
the leaflets detailed in paragraph 2.2 of this section are available.
2.7.2 The AUTHORITY shall notify the CONTRACTOR of any known amendment or updates to the
leaflets listed at paragraph 2.2. The CONTRACTOR shall liaise with the AUTHORITY’s
Leaflet Supplier to obtain additional stocks of these leaflets when required or as and when
notified of an update or amendment.
3
PROVISION OF ENQUIRY SERVICES
3.1
General
3.1.1
The CONTRACTOR shall provide medical and administrative enquiry services to
process enquiries from AUTHORITY staff, GPs and Claimants or their
representatives.
3.2
Level of Service
3.2.1
The CONTRACTOR shall ensure that all enquiry services are available, as a
minimum, on Working Days, between 08.30 and 17.00 hours. Outside of these
hours the CONTRACTOR shall, as a minimum, provide an answerphone service
with all messages acknowledged or responded to as detailed in paragraphs 3.3 to
3.5.
3.2.2
The CONTRACTOR shall ensure enquiries are accepted in any reasonable format,
(e.g. by telephone, in writing, by facsimile or e-mail) and responded to in the format
requested by the AUTHORITY. The CONTRACTOR shall provide all reasonably
requested documentation in relation to any such enquiries as and when requested
by the AUTHORITY.
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3.2.3
The CONTRACTOR shall use reasonable endeavours to ensure that all enquiries
or progress requests made by the AUTHORITY are responded to in the format
requested by the AUTHORITY.
3.3
AUTHORITY Enquiries
3.3.1
The CONTRACTOR shall use reasonable endeavours to respond to all enquiries
within two (2) Working Days of receipt of an enquiry, or exceptionally, where the
enquiry is of a complex nature, within five (5) Working Days of receipt of the
enquiry.
3.4
Advice to GPs
3.4.1
The CONTRACTOR shall use reasonable endeavours to provide immediate advice
on Working Days (subject to paragraph 3.2.1 of this Schedule 4.1) to GPs on
certification issues, completion of medical reports (including DS 1500) and other
medical matters relating to Incapacity Benefit and shall provide dedicated telephone
line(s) for this purpose.
3.4.2
The CONTRACTOR shall
offer general advice only to GPs through the dedicated
telephone line(s) and shall not discuss individual cases which are being assessed
for the benefit.
3.4.3
The CONTRACTOR shall provide contact details for the dedicated phone line(s) to
the AUTHORITY and shall
ensure that the AUTHORITY is notified of any changes
to those details within ten (10) Working Days of the change.
3.5
Claimant Enquiries
3.5.1
The CONTRACTOR shall use reasonable endeavours to provide an immediate
enquiry service on Working Days (subject to paragraph 3.2.1 of this Schedule 4.1)
for Claimants for enquiries connected with appointments for examinations.
4
ENQUIRIES AND COMPLAINTS
4.1
General
4.1.1
The CONTRACTOR shall respond to enquiries and complaints from either
Claimants or their representatives including Members of Parliament (MPs).
4.1.2
The CONTRACTOR shall provide appropriate information to assist the
AUTHORITY in responses to:
a) Treat
Official
correspondence
b) Ministerial
correspondence
c) Parliamentary
Questions
d) Ministerial
Briefings
e)
Parliamentary Commissioner for Administration cases
f) Press
enquiries
4.1.3
The CONTRACTOR shall ensure that all enquiries and complaints are fully
investigated to address all issues raised.
4.1.4
The CONTRACTOR shall, in addressing all the issues raised,
ensure that the
response includes:
a)
a factual account of the evidence and
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b)
a balanced assessment of the evidence provided
4.1.5
Where the outcome of the investigation identifies that remedial action is appropriate,
the CONTRACTOR shall include reference to the proposed remedial action that will
be undertaken in the response.
4.1.6
Where the investigation has identified that a medical report has been identified as
meriting a C Grade the CONTRACTOR shall notify the appropriate business unit of
the attributes which are deficient. In these types of cases the CONTRACTOR shall
inform the Claimant or their representative, within the response, that inaccuracies
have been identified within the report and that this has been brought to the attention
of the appropriate Business Unit. The CONTRACTOR shall
not intimate to the
Claimant or their representative that the findings may affect the AUTHORITY’s
decision on the Claimant’s entitlement to benefit.
4.1.7
The CONTRACTOR shall
ensure that its complaints procedure includes reference
to and details of, a process that will give the Claimant or their representative the
right to seek an independent review, by an independent tier, of their complaint
should normal procedures not result in a satisfactory resolution.
4.1.8
The CONTRACTOR shall
co-operate with the AUTHORITY to handle complaints
which relate to both services provided by the AUTHORITY and those provided by
the CONTRACTOR (known as “dual complaints”). Where appropriate the
AUTHORITY will direct the CONTRACTOR to coordinate the joint response to the
Claimant or their representative. The CONTRACTOR shall
coordinate the joint
response when so directed by the AUTHORITY.
4.1.9
The CONTRACTOR shall, when requested by the AUTHORITY, refer to the
AUTHORITY details of all complaints where the Claimant or their representative
expresses dissatisfaction with the response received from the CONTRACTOR.
4.1.10
The AUTHORITY reserves the right to instruct the CONTRACTOR to respond to
any complaints on the AUTHORITY’s behalf in relation to the Services, when
reasonably requested to do so.
4.1.11
The CONTRACTOR shall not enter into any correspondence or provide views or
opinions on policy issues to any person other than the AUTHORITY.
4.1.12
The CONTRACTOR shall
ensure that systems are in place to provide full details to
the AUTHORITY in relation to enquiries and complaints received, subject to the
provisions of the Data Protection Act 1998 (DPA).
4.2
Enquiries and Complaints received direct from the Claimant or their representative
4.2.1
The CONTRACTOR shall acknowledge all complaints received directly from
Claimants or their representatives within two (2) Working Days.
4.2.2
The CONTRACTOR shall provide a full response to each Claimant or their
representative within the required turnaround times as set out in Schedule 5 of this
Agreement. Where the CONTRACTOR is unable to provide a full response within
the required turnaround time, the CONTRACTOR shall
provide an update on what
stage the response has reached and the date the full response is expected shall be
provided to the Claimant or their representative.
4.2.3
The CONTRACTOR shall reply directly to the Claimant or their representative
where the complaint is confined to elements of the Services directly within the
CONTRACTOR’s control.
4.3
Serious Complaints
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4.3.1
The CONTRACTOR shall
ensure that its complaints procedure includes details of
procedures for dealing with serious allegations of professional misconduct made in
complaints received.
4.3.2
For the avoidance of doubt the main types of complaint that are included in this
category shall
include but will be not be limited to:
a)
assault as a consequence of examination
b)
injury as a consequence of examination
c) inappropriate
intimate
examinations
d) missed
diagnosis
of a serious nature
e) racial
abuse
f) sexual
abuse
g)
serious breaches of professional conduct
h)
theft or fraud
i) criminal
activities
4.3.3
The CONTRACTOR shall
inform the AUTHORITY upon receipt of all complaints
which fall into this category.
4.3.4
The CONTRACTOR shall
provide a progress report on all serious complaints
received to the AUTHORITY monthly or as otherwise required
.
4.4
Information for Parliamentary Questions, Treat Official /Ministerial Correspondence,
Ministerial briefings, Parliamentary Commissioner for Administration cases
4.4.1
The AUTHORITY will forward these types of correspondence to the
CONTRACTOR where the enquiry or complaint relates to those parts of the
Services wholly or partly within the CONTRACTOR’s control.
4.4.2
The CONTRACTOR shall provide the AUTHORITY with all the information as
required by the AUTHORITY.
4.4.3
Deadlines on these types of enquiries are extremely time critical. The AUTHORITY
will give individual response deadlines to which the CONTRACTOR shall adhere.
The CONTRACTOR shall use reasonable endeavours to provide a full response to
the AUTHORITY within the required turnaround times as set out in Schedule 5 of
this Agreement. Where exceptionally and with the agreement of the AUTHORITY,
the CONTRACTOR is unable to provide a full response within the required
turnaround time, the CONTRACTOR shall provide an update to the AUTHORITY
which sets out what stage the response has reached and the date the full response
is expected.
4.4.4
For avoidance of doubt, it is recognised that within the overall target for Treat
Official Correspondence as specified in Schedule 5 of this Agreement, the
individual response deadlines for Ministerial Correspondence, Ministerial Briefings,
Parliamentary Questions and Parliamentary Commissioner for Administration
(PCA) cases shall be met in all cases and will count towards the overall target.
4.5
Press Enquiries
4.5.1
The CONTRACTOR shall not respond directly to press enquiries concerning the
delivery of Services. The CONTRACTOR shall direct the enquirer immediately to
the AUTHORITY.
4.5.2
The CONTRACTOR shall use reasonable endeavours to provide the AUTHORITY
with any information relating to press enquiries as requested by the AUTHORITY.
4.6
Independent Tier
4.6.1 The CONTRACTOR shall implement a revised independent tier for complaints as
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agreed with the AUTHORITY.
5 MEDICAL
EXAMINATIONS
5.1
The CONTRACTOR shall give reasonable notice to Claimants or their representatives of the
time and place at which any medical examination will take place. Reasonable notice for these
purposes begins with the day on which the notice is given and ends of the day before the
examination is to take place. The CONTRACTOR shall give the following periods of notice,
which, where necessary, comply with any periods and requirements as stipulated in
legislation unless otherwise agreed with the Claimant.
a)
War Pensions examinations ten (10) Days (EMPs only)
b)
Vaccine Damage Payments Scheme examinations fourteen (14) Days
c)
Disability Living Allowance Fast Track examinations three (3) days
d)
any other medical examination (including Audiology) seven (7) Days, with the
exception of Occupational Health Assessments five (5) Days.
5.2 For the avoidance of doubt, when notice is given by post, the requirement is deemed to be met on
the day after the letter is posted (ie the day after it is collected), and ends after 7 clear calendar
days where; • where the letter has been properly addressed,
• the letter has been pre-paid and posted and,
• first class post is used.
5.3 For the avoidance of doubt,
a) A letter giving the time and place of a medical examination is collected for delivery on
Wednesday 6th. The first day of notice is Thursday 7th, Wednesday 13th is the 7th day of
notice and the earliest appointment date must be Thursday 14th.
b) A letter giving the time and place of a medical examination is prepared on Friday 1st and
collected for delivery on Monday 4th. The first day of notice is Tuesday 5th, Monday 11th is
the 7th day of notice and the earliest appointment date must be Tuesday 12th.
5.4
The CONTRACTOR acknowledges that if it arranges to undertake two (2) different
examination types consecutively, then the notice period shall always be that notice period
which is the greater of the two (2) notice periods.
5.5
The CONTRACTOR shall ensure that any Claimant is not required to travel for more than
ninety (90) minutes by public transport (single journey) for an examination, unless previously
agreed with the Claimant, with the exception of Regional Consultant examinations for the
Service Personnel & Veterans Agency in which case the CONTRACTOR shall use all
reasonable endeavours to ensure that any Claimant is not required to travel for more than
ninety (90) minutes by public transport (single journey) for an examination, unless previously
agreed with the Claimant.
5.6
The CONTRACTOR shall make reasonable endeavours to examine all Claimants who attend
for examination on the day of their scheduled appointment.
5.7
The CONTRACTOR shall use reasonable endeavours to ensure that examinations
commence within ten (10) minutes, of their scheduled time, when Claimants arrive in time for
their appointment.
5.8
The CONTRACTOR acknowledges that the examination is deemed to start when the
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Claimant is called through for the examination.
5.9 The
CONTRACTOR
shall
use reasonable endeavours to ensure that late arrivals (more than
ten minutes after the appointment time) are examined on the day of their original appointment
or offered a mutually acceptable alternative appointment.
5.10
The CONTRACTOR shall use reasonable endeavours to ensure that, where a Domiciliary
Visit is being undertaken, examinations shall commence within their scheduled time frame.
The CONTRACTOR shall, when arranging Domiciliary Visits specify a time slot in which the
Registered Medical Practitioner will arrive at the Claimant’s address or designated place of
examination which shall not exceed one (1) hour.
5.11
Special Needs
5.11.1
The CONTRACTOR shall
comply with any reasonable requests to accommodate
Claimants who have Special Needs.
5.11.2
Special Needs shall be deemed to include but not be limited to the requirement of
the Claimant for the examination to be undertaken by a Health Care Professional of
the same sex and the Claimant’s need for an interpreter during examination.
5.11.3
When a Special Need is identified on the day of the examination appointment and
the Special Need cannot be reasonably be accommodated the CONTRACTOR
shall use reasonable endeavours to ensure that an alternative appointment is
arranged within twenty four (24) hours of the Special Need being identified and
shall
ensure that the Claimant’s Special Needs will be accommodated at the new
appointment. The CONTRACTOR shall use reasonable endeavours to inform the
Claimant of the new arrangements within twenty four (24) hours of the new
appointment being made.
5.12
Did Not Attend And Abortive Visits
5.12.1
In the event of an Abortive Visit or a Did Not Attend, the CONTRACTOR shall
automatically, without reference back to the AUTHORITY, offer the Claimant a
further appointment. If the Claimant Does Not Attend or fails to avail themselves for
examination at home at the second attempt, the CONTRACTOR shall use
reasonable endeavours to return all papers to the AUTHORITY within twenty four
(24) hours of that failed appointment or Abortive Visit.
5.12.2 The CONTRACTOR shall use reasonable endeavours to ascertain the reasons why
the Claimant Did Not Attend or did not avail themselves of the examination(s) at
home and shall record the reasons on the appropriate form(s) which shall be included
in the documentation to be returned to the AUTHORITY.
5.12.3 For the avoidance of doubt the CONTRACTOR must adhere to the specific
requirements relating to Claimants who Did Not Attend in relation to Incapacity
Benefit and Severe Disablement Allowance examinations as set our in the
appropriate Section(s) of the Schedule 4.
5.13
Claimant Unable to Attend for Examination
5.13.1
In the event of a Claimant being Unable to Attend an appointment, the
CONTRACTOR shall automatically, without reference back to the AUTHORITY,
offer the Claimant a further appointment. Where the Claimant advises that they are
Unable To Attend a second appointment, the CONTRACTOR shall
use reasonable
endeavours to despatch all documentation to the AUTHORITY, including the
documented reasons for non-attendance, within twenty four (24) hours of the
Claimant’s second cancelled appointment.
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5.13.2 In the event of a Claimant in the first instance not attending an examination, and on
the second occasion being Unable To Attend for examination or vice versa, the
CONTRACTOR shall offer one more appointment to the Claimant.
5.13.3
Upon receipt of a Referral, from the AUTHORITY, in respect of a Claimant who was
previously Unable to Attend, the CONTRACTOR shall use reasonable endeavours
to reschedule a further appointment, if appropriate, within fifteen (15) Working Days
of receipt of the said Referral.
5.14
Claimants turned away unseen
5.14 1
The CONTRACTOR shall use reasonable endeavours to examine all Claimants
who attend for examination.
5.14.2
The CONTRACTOR shall note that only those Claimants who arrive late for their
appointment (i.e more ten (10) minutes after their scheduled appointment time) or
who arrive in an unfit state to be examined are excluded from the Service Level
requirements in Schedule 5 of this Agreement.
5.15
Treatment of Domiciliary Visits
5.15.1
The CONTRACTOR shall undertake a DV on the following occasions:
a)
at the AUTHORITY’S request
b)
when the Claimant’s GP has indicated that the Claimant is unable to travel on
health grounds or
c)
at the Claimant’s request, if supported by a suitable medical condition as
determined by the CONTRACTOR.
5.15.2
The CONTRACTOR may undertake DVs for business reasons, at its discretion,
notwithstanding the provisions of paragraphs 5.14.1
6
WELSH LANGUAGE ACT
6.1
The CONTRACTOR shall comply with the provisions of the Welsh Language Act to provide a
bi-lingual service for those Claimants who are resident in Wales in respect of
correspondence, telephone communications, face to face communications, and published
and printed materials.
6.2
Where either the AUTHORITY or the Claimant has previously advised the CONTRACTOR
that Welsh is the Claimant’s preferred language, the CONTRACTOR shall use reasonable
endeavours to ensure that Welsh speaking Health Care Professionals are used to deliver
medical examinations.
6.3
The
CONTRACTOR shall provide a report showing details of their compliance with the Welsh
Language Act as required by the AUTHORITY and in the format specified by the
AUTHORITY annually or as otherwise required by the AUTHORITY.
6.4
Correspondence
6.4.1
Where either the AUTHORITY or the Claimant has previously advised the
CONTRACTOR that Welsh is the Claimant’s preferred language, the
CONTRACTOR shall correspond in Welsh.
6.4.2
Where a letter is received from a Claimant in Welsh, the CONTRACTOR shall
respond in Welsh.
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6.4.3
Where the Claimant’s preferred language is not known, the CONTRACTOR shall
issue all correspondence bi-lingually.
6.5
Telephone Communications
6.5.1
The CONTRACTOR shall provide a bi-lingual greeting for all incoming telephone
calls in offices in Wales.
6.5.2
Where the Claimant requests that the call be conducted in Welsh and where the
person who answers the telephone in Wales is unable to advance further than the
greeting in Welsh, the CONTRACTOR shall arrange for the call to be referred to a
Welsh speaking member of staff. Where this is not immediately possible, the
CONTRACTOR shall arrange for the call to be returned by a Welsh speaker as
speedily as possible and no later than within one (1) Working Day of receipt of the
telephone call.
6.5.3
Where the Claimant has previously advised that Welsh is their preferred language,
the CONTRACTOR shall
ensure that all out going telephone calls are made by a
Welsh speaker. For all other out going calls the Claimant shall
be offered the
opportunity to conduct business in Welsh.
6.5.4
The CONTRACTOR shall ensure that where answer phones are used in offices in
Wales, all recorded messages are bi-lingual.
6.5.5
Where call centre telephony systems are used, irrespective of the location, the
CONTRACTOR shall provide Claimants who are resident in Wales with the
opportunity to conduct their business in either Welsh or English at the earliest
stage.
6.6
Face to Face Communications
6.6.1
The CONTRACTOR shall
ensure that they provide access to Welsh and English
language services in offices in Wales for all Claimants.
6.6.2
Where the Claimant has previously advised that Welsh is their preferred language,
the CONTRACTOR shall
ensure all face to face communications with all staff
including Medical Personnel are conducted in Welsh.
6.6.3
The requirements detailed above apply equally to Domiciliary Visits.
6.7
Medical Reports
6.7.1
For the avoidance of doubt, the CONTRACTOR acknowledges that medical reports
provided for the sole use of the AUTHORITY shall be provided in English in all
cases.
6.8
Published and Printed Materials
6.8.1
The CONTRACTOR shall
ensure that all published and printed material directed to
Claimants is available in Welsh. Wherever practical, all published and printed
material should be produced bi-lingually rather than as separate English and Welsh
documents. This includes all forms and associated explanatory material for use by
the public in Wales including:
a) posters
b) signs
c) directions
d) instructions
e) leaflets
f) staff
badges
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6.9
Claimant Surveys
6.9.1
The CONTRACTOR shall ensure that all Claimant surveys issued to residents in
Wales are produced bi-lingually rather than as separate English and Welsh
documents.
7
CLAIMANT SATISFACTION SURVEYS
7.1
The CONTRACTOR shall
undertake monthly surveys to gauge Claimants’ perception of the
service they receive.
7.2
The CONTRACTOR shall
ensure that at least 90% of Claimants who respond to the survey
are satisfied with the service provided and shall
continually strive to make improvements.
7.3
The CONTRACTOR shall ensure that the survey administration, sampling methodology,
questionnaires and data analysis conform to generally recognised market research industry
standards and shall ensure that the surveys are undertaken objectively and without bias.
7.4
The CONTRACTOR shall
ensure that the surveys are conducted across all benefit streams,
to a sample size agreed with the AUTHORITY which will be drawn from yearly national
volumes.
7.5
The CONTRACTOR shall
ensure
that Claimants are randomly selected in accordance with
agreed AUTHORITY guidelines.
7.6
The CONTRACTOR shall
ensure that the survey findings are analysed according to the
agreed AUTHORITY requirements with the facility for provision of data by a range of criteria,
e.g. age, gender, ethnic origin.
7.7
The CONTRACTOR shall
ensure that all survey evaluation reports are forwarded to the
AUTHORITY within agreed timescales.
8
CHANGES OF CIRCUMSTANCES
8.1
Upon receipt of notification of any relevant change to a Claimant’s circumstances the
CONTRACTOR shall use reasonable endeavours to inform the AUTHORITY immediately. If
directed to do so by the AUTHORITY, the CONTRACTOR shall despatch all documentation
requested by the AUTHORITY to the AUTHORITY on the day of the request or by no later
than the next Working Day.
8.2
The types of changes that might be relevant, include but shall not be limited to:
a)
admittance of the Claimant to hospital, or similar institution, as an in-patient
b)
detention of the Claimant in legal custody
c)
change of name and/or address of the Claimant
d)
death of the Claimant
e)
absence abroad of the Claimant
f)
return to work of the Claimant and the Claimant has terminated the benefit claim
g)
the Claimant’s claim for benefit has been withdrawn.
8.3
Upon notification of a change of circumstances of the Claimant by the AUTHORITY, the
CONTRACTOR shall use reasonable endeavours to take appropriate timely action to avoid
inconvenience to the Claimant and any embarrassment to, or criticism of, the AUTHORITY
which arises from the CONTRACTOR’S acts or omissions.
9 HOSPITAL
CASE
NOTES
9.1
Upon request by the AUTHORITY, or upon the necessity arising during the course of
processing a Referral, the CONTRACTOR shall provide a verbatim extract of all information
in Hospital Case Notes relevant to the condition(s) under consideration and to the
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requirements of the Referral type.
9.2
For the avoidance of doubt the CONTRACTOR shall adhere to the specific requirements
relating to Hospital Case Notes as specified in the appropriate sections of this Schedule 4..
9.3
The extract shall be made anonymous and not refer to or identify any individual other than the
Claimant and the individual preparing the extract
9.4
Original Hospital Case Notes shall
not be copied by the CONTRACTOR other than to
facilitate the expeditious production of the extract and return of the Hospital Case Notes to the
NHS Trust from which they were obtained. Any copies so made shall be destroyed as secure
waste within twenty four (24) hours of completing the extract. For the avoidance of doubt no
copies of Hospital Case Notes shall be retained for inclusion in the Referral documentation.
9.5
The CONTRACTOR shall endeavour to return Hospital Case Notes to the NHS Trust from
which they were obtained within ten (10) Working Days of their receipt from that NHS Trust.
10
RECEIPT OF DOCUMENTATION
10.1
The CONTRACTOR shall, within one (1) Working Day of receipt of any Referral, formally
record the date of the receipt the Referral and be able to provide proof on request by the
AUTHORITY, at any time, of the date of the receipt of the Referral.
10.2
For the avoidance of doubt, where a Referral is received after 16.00 hrs, the date of receipt
will be deemed to be the following Working Day.
11 RETURN
OF
DOCUMENTATION
11.1
The CONTRACTOR shall, within twenty four (24) hours of completion of their required action,
use reasonable endeavours to despatch to the AUTHORITY all required documentation,
including all Referral documentation, any Further Medical Evidence gathered and the
appropriate output form(s), unless specifically requested to dispose of any documentation by
the AUTHORITY.
11.2
The CONTRACTOR shall return all documentation to the AUTHORITY in the same format as
received, unless otherwise directed by the AUTHORITY.
11.3
The CONTRACTOR shall
ensure that when disposing of all documentation referred to in
paragraph 11.1 that this is destroyed in a confidential manner.
12
TRAINING FOR DECISION MAKERS
12.1
The CONTRACTOR shall confirm that it will work with the AUTHORITY to deliver a maximum
of 300 man days basic initial and ongoing training, face to face and on the AUTHORITY’s
premises, as required, in respect of the medical aspects of service delivery.
12.2
The CONTRACTOR shall deliver the training for, including but not limited to:
12.2.1
Decision Makers for Incapacity Benefit;
12.2.2
Decision Makers and Disability Living Allowance/Attendance Allowance;
12.2.3
Personal Advisers; and
12.2.4
Disability Employment Advisers.
12.3
The CONTRACTOR shall keep a record by benefit type of the number of man days delivered.
Any additional man days required for training will be discussed with the CONTRACTOR and
subject to change control.
12.4
The CONTRACTOR shall ensure that the cost of any additional days are pro-rata with the
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300 days previously agreed.
12.5
The CONTRACTOR shall work towards ensuring that all Health Care Professionals providing
training for Decision Makers have appropriate accreditation that meets the requirements of
the Authority within pre-agreed timescales.
13
CLAIMANT
EXPENSES
13.1
The CONTRACTOR shall consider the most cost effective approach to undertake the
examination of a Claimant in accordance with current legislation. The CONTRACTOR shall,
at all times operate within the parameters of this Section 4.1 of Schedule 4 when considering
the appropriate payment of any expenses, incurred by a Claimant and/or Companion, in
travelling to attend an examination.
13.2
The CONTRACTOR shall as a minimum adhere to the legal requirements imposed by the
Secretary of State with regard to the payment of Claimant expenses.
13.3
The CONTRACTOR shall also pay subsistence and financial loss allowance to Companions
of VDPS Claimants and War Pensioners who apply and who are eligible, and additional
expenses claimed in respect of VDPS Referrals.
13.4
Notwithstanding the requirement in paragraph the CONTRACTOR shall pay all reasonable
and actual expenses to Claimants and/or Companions who attend an examination and who
apply for reimbursement.
13.5
The CONTRACTOR shall from the Cutover Date:
13.5.1 ensure complete accuracy in all payment of expenses;
13.5.2 provide an effective system to pay and monitor all expenses payments with numerous
audit trails;
13.5.3 provide relevant and timeous Management Information (MI) in respect of Claimant
expenses;
13.5.4 make any payments properly due, upon receipt of a correctly completed and
documented application, within 14 Days of receiving the application; and
13.5.5 use the mileage rate as instructed by the AUTHORITY. From 28th April 2008 the rate
will be 25 pence a mile.
13.6 Claimant Expenses legislation
LEGISLATION
BENEFIT
IB/MA
SS Admin Act 1992 sec 180
SSP/SMP
SS Admin Act 1992 sec 180A
SDA
SS Admin Act 1992 sec 180
NTC
SS Admin Act 1992 sec 180
DLA/AA
SS Admin Act 1992 sec 180
IPC
SS Admin Act 1992 sec 180
IIDB
SS Admin Act 1992 sec 9 (2)
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OHA
SS Admin Act 1992 sec 180
VAC DAM
SS VDP Act 1979 Para 12 (3) a&b
VA
SPOrder 1983. Naval, Military and Air Forces
(Disablement and Death) SPO 1983 and the
Personal Injuries (Civilians) Scheme 1983
Analogous Industrial Injuries
Employment Training Act 1973 Sec 11 (2)
14
SUSPICIONS OR ALLEGATIONS OF FRAUD
14.1
The CONTRACTOR shall work collaboratively with the AUTHORITY to ensure that it reports,
in writing, to the AUTHORITY all suspicions of fraud and allegations of fraud received against
Claimants.
15 MISCELLANEOUS
15.1.1 Whilst the CONTRACTOR shall provide advice on Prognosis, in accordance with agreed
guidelines, the AUTHORITY will retain the right to determine the actual timing of any
subsequent Re-Referrals to the CONTRACTOR.
16 GRIEVANCES/INDUSTRIAL
TRIBUNALS
16.1 Monitoring Requirements
16.1.1 The CONTRACTOR shall provide the AUTHORITY with details of grievances and Industrial
Tribunals (ITs) relevant to Schedule 3.17 of this Agreement, within five (5) Working Days of
an official grievance/IT being notified to them. At each Annual Review, the AUTHORITY will
review this requirement when the requirement for the production of any future reports will be
decided.
17.0 Sensitive
Cases
17.1
Sensitive cases will be referred clerically and the CONTRACTOR shall ensure that Referrals
identified as sensitive cases are handled clerically and details not recorded electronically.
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SCHEDULE 4 SECTION 4.1 PART 2
MEDICAL REQUIREMENTS
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SCHEDULE 4 SECTION 4.1 PART 2
MEDICAL REQUIREMENTS
1.
GENERAL
1.1
Medical Recruitment Standards
1.1.1
The CONTRACTOR shall
ensure that it’s Registered Medical Practitioners, whether
employed or fee paid, are:
1.1.1.1
fully registered, without current restrictions, conditions or warnings, on
the Principal List of the General Medical Council (GMC); and in addition
1.1.1.2
from the date on which the GMC issues licences to practice, hold a
current licence to practice.
1.1.2
In addition they must have three (3) years post full registration experience as a
minimum. In individual cases, solely at the discretion of the AUTHORITY’s Chief
Medical Adviser, the requirement that:
1.1.2.1
no restrictions, conditions or warnings be attached to registration; and
1.1.2.2
Registered
Medical
Practitioners must have a minimum of three (3)
years post-registration experience, may be waived.
1.1.3
The CONTRACTOR shall ensure that its Registered Nurses, whether employed or
fee paid, are:
1.1.3.1
fully registered (Level 1) Registered General Nurses, without current
restrictions or cautions, with the Nursing and Midwifery Council (NMC).
1.1.3.2 In addition, they must have a minimum of (3) years post registration
experience.
1.1.4 In individual cases, solely at the discretion of the AUTHORITY’s Chief Medical
Adviser, the requirement that:
1.1.4.1
no restrictions or cautions be attached to registration; and
1.1.4.2
Registered Nurses must have a minimum of three (3) years post
registration experience, may be waived.
:
1.1.5 The CONTRACTOR shall ensure that its Registered Physiotherapists, whether
employed or fee paid, are:
1.1.5.1 fully registered Physiotherapists without current restrictions or cautions,
with the Health Professions Council (HPC).
1.1.5.2
In addition, they must have a minimum of (3) years post registration
experience.
1.1.6 In individual cases, solely at the discretion of the AUTHORITY’s Chief Medical
Adviser, the requirement that:
1.1.6.1
no restrictions or cautions be attached to registration; and
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1.1.6.2
Registered Physiotherapists must have a minimum of three (3) years
post registration experience, may be waived.
1.2
That experience should feature broad based medical practice in roles that have clear
relevance to a career in disability assessment medicine, unless specialist knowledge and
experience are required as detailed in this Schedule 4. The CONTRACTOR shall provide the
AUTHORITY with written confirmation of compliance with paragraph 1.1 by 31st March of
every year.
1.3
The CONTRACTOR shall ensure that Health Care Professionals providing the Respiratory
Disease Service shall be appropriately trained and assessed as being fit to provide the
Services to the standards laid out in Schedule 4 Section 4.1 of this Agreement.
1.4
When providing Specialist Medical Services the CONTRACTOR shall use only a Medical
specialist as defined in Schedule 1 who shall have training, qualifications and experience
pertinent to the condition under consideration.
1.5
The CONTRACTOR shall ensure that all audiometric technicians have contemporary and
relevant specialist qualifications.
1.6
The CONTRACTOR shall
ensure that all Health Care Professionals providing or supporting
the provision of Services have appropriate qualifications, experience, training and hold current
registration with the relevant licensing body.
1.7
The CONTRACTOR shall ensure that all Registered Medical Practitioners have a current
licence to practice issued by the General Medical Council.
1.8
Prior to use of Health Care Professionals, other than Registered Medical Practitioners, in any
benefit area in which they are not currently employed, the CONTRACTOR must obtain prior
approval from the AUTHORITY for the pilot and subsequent implementation.
2.
MEDICAL TRAINING FOR NEWLY RECRUITED AND HEALTH CARE PROFESSIONALS
2.1
The CONTRACTOR shall provide a training programme for each benefit area in accordance
with the requirements, detailed below, which will ensure that Health Care Professionals have
the required level of knowledge and skills to achieve Approval. The knowledge and skills
required in respect of the CONTRACTOR’s Health Care Professionals shall include but not be
limited to:
2.1.1
an understanding and an ability to perform the role of the disability medical analyst;
2.1.2
a knowledge of the legislative requirements for each of the benefits in which they
will be required to have an input;
2.1.3
an understanding of the legislative framework in which they are working. This may
include attendance as an observer at an Appeal Tribunal as part of ongoing training
for the relevant benefit area;
2.1.4
an up-to-date knowledge of relevant clinical subjects, which should specifically
include a knowledge of the disabling effects of musculoskeletal, mental, cardio-
respiratory and any other relevant disorders identified by the AUTHORITY;
2.1.5
an awareness of the AUTHORITY’s approach to Customer service and equal
opportunities;
2.1.6
disability awareness; and
2.1.7
an ability to deal with potentially violent situations.
2.2
Where no formal training programmes are detailed for specific benefit areas the
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CONTRACTOR shall liaise with the AUTHORITY to develop and implement an appropriate
training programme. The CONTRACTOR shall provide all necessary information, reasonably
requested by the AUTHORITY, prior to implementation of the programme.
2.3
The CONTRACTOR’s Health Care Professionals shall be given a course of theoretical and
practical training, which shall be developed and implemented by the CONTRACTOR in each
benefit area they are to work. The CONTRACTOR shall, following such training, conduct a
written and practical examination of each individual to ensure that, at the least, the minimum
levels of skills and knowledge have been achieved. The CONTRACTOR shall provide the
AUTHORITY with details of the satisfactory results of such testing within a reasonable period
of time; thereafter the AUTHORITY will Approve the individual Health Care Professional to the
appropriate role. .
2.4
The CONTRACTOR shall
, undertake during practical training, close supervision of new
Health Care Professionals as set out in the quality and training sections of the relevant
guidance listed in Schedule 28 of this Agreement.
2.5
The CONTRACTOR shall ensure that Health Care Professional giving advice and conducting
examinations shall be Approved by the AUTHORITY acting on behalf of the Secretary of
State. Approval will be dependent on individual Health Care Professional completing, to the
CONTRACTOR’s satisfaction, a course of training and appraisal in the relevant benefit area.
2.6
The CONTRACTOR shall ensure that the CMA is informed of Health Care Professionals who
fail to continue to meet the required quality standards in order that he may consider revoking
Approval. For the avoidance of doubt, the CMA has sole discretion whether to grant or
revoke Approval.
2.7
The CONTRACTOR shall ensure that all of its Health Care Professional providing Services to
the AUTHORITY are accredited in accordance with the requirement to retain registration with
the relevant licensing organisation.
2.8
The CONTRACTOR shall involve the AUTHORITY in the quality assurance process for the
development and refinement of all requirements, outcomes and standards of medical training
and Health Care Professional training courses relating to the delivery of the Services.
3.
MEDICAL TRAINING PROGRAMME FOR CME FOR HEALTH CARE PROFESSIONALS
3.1
The CONTRACTOR shall develop and deliver the medical training programme for CME (the
“Training Programme”) and its evaluation as part of the Services.
3.2
The Training Programme shall be developed, delivered and evaluated on an annual basis in
respect of each contract year from 1st September to 31st August (a “Year”).
3.3
The AUTHORITY shall, by 31st March in each year, provide the CONTRACTOR with an
outline stating topics that the AUTHORITY requires to be included in the Training Programme
for the forthcoming Year, and if the AUTHORITY considers it appropriate, an outline of the
manner in which such Training Programme shall be delivered (the “Outline”).
3.4
The CONTRACTOR shall provide all of its Health Care Professionals with a personal training
plan on an annual basis. The personal training plan shall contain details of the timescale for
which delivery of each individual module will need to be delivered to that individual.
3.5
New entrants shall be provided with a personal training plan within three months of their
formal approval/re-approval. New entrants will have the following training modules included
in that personal training plan for delivery within twelve (12) months.
3.5.1
clinical skills in the assessment of musculoskeletal problems;
3.5.2
multicultural
awareness;
and
3.5.3
mental health training.
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3.6
The CONTRACTOR shall undertake a Training Needs Analysis (TNA) that will identify areas
of training needs together with priorities for implementation. Information from the personal
training plans for the year to 30th June shall be incorporated into the TNA. The TNA shall be
provided to the AUTHORITY by 30th June of each year. The scope, objectives and
methodology of the TNA shall be subject to prior approval by the AUTHORITY. The outcome
of the TNA shall be subject to approval by the AUTHORITY (such approval not to be
unreasonably withheld or delayed) prior to incorporation into the training plan.
3.7
The CONTRACTOR shall
, within one month of agreeing the TNA outcome, provide the
AUTHORITY with a plan setting out in detail the manner in which the Training Programme
shall
be delivered (the “Training Plan”). The Training Plan shall include as a minimum the
following:
3.7.1
the name of the training module, and for each training module;
3.7.2
a timetable for delivery of each training activity;
3.7.3
the training personnel to be involved in the training activity;
3.7.4
the aims and objectives of the training;
3.7.5
the target population that includes the number of Registered Medical Practitioners
to be trained at each Medical Service Centre; and
3.7.6
the proposed method and estimate of duration of that training.
3.8
The Training Plan shall
be developed in co-operation with the AUTHORITY and shall
be
subject to approval by the AUTHORITY, such approval not to be unreasonably withheld or
delayed.
3.9
Any changes or amendments must
be submitted in writing for consideration to the
AUTHORITY’s Change Control manager who will have sole discretion as to whether the
amendment is significant enough to require formal Change Control procedures to be
instigated. Any agreement to dispense with formal Change Control action will not be valid
unless written agreement is provided by the AUTHORITY’s Change Control manager.
3.10
For the avoidance of doubt, the AUTHORITY’s approval of a Training Plan shall not relieve
the CONTRACTOR of its overriding obligation to meet the requirements and all other
applicable provisions of the Agreement unless otherwise specifically agreed in writing by the
AUTHORITY.
3.11
The CONTRACTOR shall provide the AUTHORITY with information in relation to training
activities organised by the CONTRACTOR in a form agreed with the AUTHORITY. The
CONTRACTOR shall
3.11.1 carry out surveys at the times specified, in order to evaluate the perception of training
and the effectiveness of training delivery. Such surveys shall be subject to the
AUTHORITY’s prior approval (such approval not to be unreasonably withheld or
delayed); and
3.11.2
summarised in an annual report to be provided to the AUTHORITY no later than
31st December. The report shall
contain detailed analysis of surveys completed by
a randomly selected sample of at least fifteen per cent (15%) of the target
population for each completed trainer led and distance learning module. The report
shall cover the twelve (12) month period ending 31st August in the same year
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3.12
The surveys shall be completed in two stages as follows:
3.12.1
immediately upon completion of the training activity:
3.12.1.1
a reactionnaire for trainer led modules to be issued to a randomly
selected sample of a minimum of fifteen per cent (15%) of the target
population;
3.12.1.2
a multiple choice questionnaire for trainer led modules to be issued on
occasion following agreement between the AUTHORITY and the
CONTRACTOR;
3.12.1.3
a multiple choice questionnaire for distance learning modules to be
issued to one hundred percent (100%) of the target population unless
considered inappropriate for any specific module by both the
AUTHORITY and the CONTRACTOR; and
3.12.2
six months after completion of the training activity for both trainer led and distance
learning modules, a follow up Questionnaire to be sent to a randomly selected
sample of a minimum of fifteen per cent (15%) of the target population. The
questionnaire will:
3.12.2.1
test
perception of the training; and
3.12.2.2
apply to at least fifty per cent (50%) of modules, that will include a
mixture of trainer led and distance learning modules that are
considered to be relevant, subject to the AUTHORITY’s prior approval
(such approval not to be unreasonably withheld or delayed).
3.13
If the AUTHORITY considers it appropriate, the CONTRACTOR shall interrogate
MSD for breached attributes relevant to a maximum of three (3) of the training
modules undertaken in order to ascertain that the principles of training have
translated into good practice.
3.13.1
the timescale and methodology of such audit to be subject to the AUTHORITY’s
prior approval (such approval not to be unreasonably withheld or delayed);
3.13.2
the audit to be carried out on an agreed sample size, at all Medical Services
Centres, subject to a minimum of ten (10) randomly selected cases selected per
Medical Services Centre for each identified module; and
3.13.3
results to be summarised in an annual report as specified in paragraph 3.11.5. The
content of the report shall be subject to approval by the AUTHORITY (such
approval not to be unreasonably withheld or delayed).
3.14
The CONTRACTOR shall provide the AUTHORITY with ad hoc reports on request.
3.15
The CONTRACTOR shall liaise with the AUTHORITY when defining the requirements for
CME for Health Care Professionals.
4.
MEDICAL PROCESS STANDARDS
4.1
General Standards
4.1.1
The CONTRACTOR shall use reasonable endeavours to ensure that a minimum of
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ninety nine per cent (99%) of Health Care Professional reports, in each business
area, are Fit for Purpose and do not result in Rework. Health Care Professional
reports shall be adjudged fit for the required purpose by the AUTHORITY’s
representative (for example a Decision Maker) making use of the report against the
standards defined in this Schedule.
4.1.2
The CONTRACTOR shall ensure that all medical reports and medical advice
provided by Health Care Professionals shall be Fit for Purpose, that is:
4.1.2.1
fair and impartial;
4.1.2.2
legible and concise;
4.1.2.3
in accordance with relevant legislation;
4.1.2.4
comprehensive, clearly explaining the medical issues raised;
4.1.2.5
in plain English and free of medical jargon;
4.1.2.6 presented
clearly;
4.1.2.7
complete, with answers to all questions relating to disability or
incapacity matters raised by the AUTHORITY, free of medical
abbreviations and in keeping with advice as directed, taking into
account written material; e.g. the Disability Handbook;
4.1.2.8
fully detailed where necessary and consistent, fully clarifying any
contradictions in medical evidence; and
4.1.2.9 capable
of
comprehensively answering questions posed by the
AUTHORITY without compromising any subsequent decision making.
4.1.3
Any cases supplied to the AUTHORITY’s representatives and deemed as being not
Fit for Purpose will be Reworked at the CONTRACTOR’s expense.
4.1.4
The AUTHORITY will have sole discretion on determining whether medical advice
or medical examination reports are Fit for Purpose.
4.1.5
The AUTHORITY will specify the reason for cases being returned as not Fit for
Purpose.
4.1.6
The CONTRACTOR shall accept Rework Referrals in accordance with the Fit for
Purpose criteria which will be specified by the AUTHORITY.
4.1.7
The CONTRACTOR shall use all reasonable endeavours to ensure that any issues,
with regard to Rework Referrals, are dealt with and resolved locally at an
operational level, in the most timeous and efficient manner.
4.1.8
The CONTRACTOR shall collect data and provide Management Information
relating to Rework on the reports detailed in Schedule 16 of this Agreement.
4.1.9
The CONTRACTOR shall ensure that all Referrals relating to the Terminally Ill, or
potentially Terminally Ill, are handled with priority and dealt with in a way that
minimises inconvenience and distress to the Claimant. For the avoidance of doubt,
if potentially Terminally Ill or Special Rules cases require examination, the
CONTRACTOR shall comply with the relevant statutory notice of appointment.
4.1.10
The CONTRACTOR shall ensure that the following persons are excluded from
examining a Claimant or providing advice:
4.1.10.1
anyone directly affected by the case in question;
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4.1.10.2
any Health Care Professional who has regularly attended the Claimant
or practises at a surgery where the claimant is or has been registered’.
;
4.1.10.3
any Health Care Professional attending, who has attended, or who is
anticipated to attend the Claimant at some time in the future for the
purposes of providing reports in respect of commercial matters;
4.1.10.4
any Health Care Professional providing, who has provided, or who is
anticipated to provide services at some time in the future to the
Claimant’s employer;
4.1.10.5
anyone previously involved in advising or examining on a claim that
has resulted in an appeal, in relation to this Claimant;
4.1.10.6
anyone identified as unsuitable by the AUTHORITY;
4.1.10.7
anyone who has attended an examination as a witness in relation to
this Claimant;
4.1.10.8
anyone who is an employer of the Claimant, or employed by the
Claimant, or is employed by the Claimant’s employer;
4.1.10.9
anyone not appropriately qualified or Approved; and
4.1.10.10
friends or relatives of the Claimant.
4.1.10.11 any Healthcare Care Professional who the Claimant has made a
complaint about.
4.2
Where the Claimant in question is an employee of the CONTRACTOR, the exclusion at
4.1.11.8 above shall not apply and the Referral shall be processed in accordance with the
relevant documentation in Schedule 28 of this Agreement. However, the CONTRACTOR shall
apply all the other criteria listed.
4.3
The CONTRACTOR shall not comment upon or offer advice to Claimants about any aspect of
the Claimant’s medical care, or the potential decision on the claim to benefit or pension.
4.4
Where an Appeal Tribunal has raised an issue with the quality of a medical report, the
CONTRACTOR shall provide to the AUTHORITY the total number of Referrals that have
been received from the Tribunals Service by the CONTRACTOR every six (6) months.
4.5
Basis of Medical Advice
4.5.1
The CONTRACTOR shall ensure that wherever possible all medical reports and
medical advice:
4.5.1.1
is evidence based, that is, there is a consensus of critically evaluated,
published medical evidence in support of the advice provided by the
CONTRACTOR;
4.5.1.2
where no such consensus exists, the CONTRACTOR shall explain the
reason for the advice in clear terms demonstrating why no other
reasonable interpretation of the medical situation could apply given the
onus of proof required for that particular Referral;
4.5.1.3
is fully justified, particularly when any advice is at variance with other
evidence including the Claimant’s statement or a medical report;
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4.5.1.4
addresses,
explains or refutes, any variation of the Claimant’s condition
from the expected manifestation and progress of the condition within
the same statistically predictable group (in general, that group of the
same age and sex);
4.5.1.5
is based only on documents that are consistent with one another as to
the evidence they contain; inconsistent evidence shall be indicated and
the inconsistency explained when providing advice to the AUTHORITY.
The CONTRACTOR’s advice supporting claimed disablement and
activities reported by the Claimant, shall
only be given if the activities
and disablement are consistent with each other and in keeping with the
diagnosis and the likely disabling effects;
4.5.1.6
takes full account of variations in the relevant medical condition(s) that
shall be described and the advice shall
reflect the degree of the
Claimant’s disability and it’s effects which are present most of the time;
4.5.1.7
takes full account of and records the effects of pain, fatigue and
medication on the Claimant’s functional capacity or care needs;
4.5.1.8
is appropriate to the questions raised by the AUTHORITY and shall
comprehensively answer the questions posed by the AUTHORITY;
4.5.1.9
is legible, presented to the AUTHORITY in the English language and
understandable to those without medical qualifications. The
CONTRACTOR shall ensure that medical jargon and abbreviations are
not used in advice to the AUTHORITY and that medical terminology is
explained unless the terms have passed into every day use;
4.5.1.10
accounts for all conditions claimed to be relevant by the Claimant;
4.5.1.11
documents conditions which may be less tangible, such as claimed
mental health problems. These shall be fully explored and their effects,
or lack of effect, on disablement of the Claimant, shall be documented
and carefully explained; and
4.5.1.12
takes full account of the guidance in respect of each benefit, where
appropriate, in respect of the use of aids, prostheses and medication.
4.6
The CONTRACTOR shall ensure that if an examination is required then it shall be performed
in such a way that it gathers all the evidence required to present the appropriate advice and
provide the factual information in the manner required by the AUTHORITY. Any additional
questions to be answered, or particular areas of difficulty that require explicit clarification, will
be communicated to the CONTRACTOR by the AUTHORITY.
4.7
Medical Process Outcome Standards
4.7.1
The CONTRACTOR shall use reasonable endeavours to ensure that the advice
given shall be consistent in that, where possible, the Medical Process outcome
advised falls within a range of results related to the mean of all the
CONTRACTOR’s Medical Process outcomes advised as a result of that process.
4.7.2
The CONTRACTOR acknowledges that the Medical Process outcomes information
provided shall be reviewed and refined from time to time when necessary to reflect
the AUTHORITY’s requirements and to reflect the CONTRACTOR’s processing
initiatives.
4.7.3
The ranges shall apply at individual unit and individual Health Care Professional
level. It should be noted that there may be great inter-unit variation due to
demographic and other factors. Therefore consistency of the results over a period
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of time at both individual unit and individual Health Care Professional level is of
greatest relevance.
4.7.4
In the event that any of these outcomes fall without the agreed range the
CONTRACTOR shall provide written explanation to the AUTHORITYThe
CONTRACTOR shall describe how the Outcome will be brought back within range
or initiate Change Control Procedures.
4.7.5
Any business process revision or any other change that will cause any of these
Medical Process outcomes to fall outside the agreed range shall be subject to
Change Control Procedures.
4.7.6
In the event that any such Change Control Procedure is approved by the
AUTHORITY, the AUTHORITY shall revise the range accordingly.
4.7
Unexpected Findings
4.8.1
If, during the examination of the Claimant, the CONTRACTOR’s findings indicate or
suggest the existence of a disease or medical disorder that may not be apparent to
the Claimant or the Claimant’s medical carer, the CONTRACTOR shall provide an
explanation to the Claimant and obtain the Claimant’s consent to pass on the
information unless there are circumstances in which failure to obtain consent can
be justified. The CONTRACTOR shall use reasonable endeavours to communicate
those findings to the Claimant’s Medical Practitioner or other appropriate medical
carer within twenty four (24) hours. If the CONTRACTOR’s findings are
communicated by telephone and are Clinically Urgent, reasonable endeavours
shall
be made to communicate the findings in writing, within twenty four (24) hours, by
the CONTRACTOR. The CONTRACTOR shall advise the Claimant to consult their
Medical Practitioner, in a manner that does not give rise to undue concern to the
Claimant. In the case of International Pension Centre (IPC) the CONTRACTOR
shall, if the Claimant does not have a UK based Medical Practitioner, advise the
Claimant that he should seek medical attention; the CONTRACTOR shall provide
the Claimant with a letter detailing the clinical findings.
4.8.2
If, during review of the file of the Claimant for the purpose of provision of advice to
the AUTHORITY, the CONTRACTOR’s findings indicate or suggest the existence
of a disease or medical disorder that may not be apparent to the Claimant or the
Claimant’s medical carer, then the CONTRACTOR shall provide an explanation to
the Claimant and obtain the Claimant’s consent to pass on the information unless
there are circumstances in which failure to obtain consent can be justified. The
CONTRACTOR shall use reasonable endeavours to communicate those findings to
the Claimant’s Medical Practitioner or other appropriate medical carer within twenty
four (24) hours following confirmation that the Claimant consents to release of the
information.
4.8
Customer Service
4.9.1
The CONTRACTOR shall use reasonable endeavours to ensure that any Specialist
examination required shall be performed in such a way that it gathers all the
evidence required to form accurate advice and to provide the factual information
required by the AUTHORITY. If there are additional questions to be answered or
particular areas of difficulty that require explicit clarification, these will be
communicated by the AUTHORITY to the CONTRACTOR with the Referral
documentation.
4.9.2
If the behaviour of the Claimant is abnormal, due to a medical condition, (for
example chronic alcoholism or mental health problems), the CONTRACTOR shall
use reasonable endeavours to ensure that the examination is completed to the
extent that allows advice to be given on the questions posed by the Decision Maker
without causing distress to the Claimant.
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4.9.3
If, during the course of providing the Services, it becomes apparent to the
CONTRACTOR that the Claimant may be in receipt of a benefit that is unsupported
by the contemporary evidence, the CONTRACTOR shall record this separately to
the Referral under consideration and advise the AUTHORITY by returning the
record with the Referral.
4.9
Medical Certificates and Medical Reports
4.11
In respect of medical certificates and medical reports the CONTRACTOR shall:
4.12.2
maintain existing local arrangements whereby Registered Medical Practitioners
provide training and guidance to Health Care Professionals at educational or
professional meetings;
4.12.3 liaise with the author of reports or certificates which are frequently completed to a
poor standard, with a view to improving the author's understanding of the
requirements to the AUTHORITY, and his own responsibilities under the terms and
conditions of service;
4.12.4
subsequently notify the AUTHORITY’s CMA of any such Registered Medical
Practitioners who continues to fail to comply with his terms and conditions of
service in this respect;
4.12.5
immediately notify the AUTHORITY’s CMA of any Registered Medical Practitioners
who provides a certificate or report that is, or may be, fraudulent; and
4.12.6
ensure that all advice is consistent with the requirements of the AUTHORITY.
4.12
In the event that the CONTRACTOR notifies the AUTHORITY’s CMA, the AUTHORITY’s
CMA shall be provided with a copy of the report(s) or certificate(s), if one exists, and copies of
all relevant evidence, correspondence and telephone conversation records.
4.13
The CONTRACTOR shall not take any action or correspond directly with local or National
Health Authorities in respect of medical certificates or reports.
4.14
The CONTRACTOR shall develop administrative systems and training that will meet the
contractual requirements.
4.15
Sensitive Information
4.16.1 The CONTRACTOR shall
ensure that all written medical reports and advice are
phrased with the expectation that they will be seen by the Claimant, therefore
sensitive information shall be handled as set out in the quality and training sections of
the relevant Documentation detailed in Schedule 28 of this Agreement. The
CONTRACTOR acknowledges that sensitive information includes, but is not limited
to:
4.16.1.1 harmful
Information;
4.16.1.2 embarrassing
information;
and
4.16.1.3 confidential
information.
4.16
The CONTRACTOR shall ensure that potentially Harmful Information apparent at Scrutiny or
examination is identified to the Decision Maker as set out in the quality and training sections
of the Documentation detailed in Schedule 28 of this Agreement, so that it can be withheld
from the Claimant if the Decision Maker so directs.
4.17
The CONTRACTOR shall provide to the AUTHORITY as requested written advice and
identification where necessary in respect of any Harmful Information contained within the
Referral documentation.
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4.18
Further Medical Evidence
4.19.1 When obtaining Further Medical Evidence, the CONTRACTOR shall make it clear to
the author of that evidence that all evidence may be given to the Claimant and that
the only information that can legally be withheld from the Claimant is that which may
be harmful to the Claimant’s health.
4.19.2 The CONTRACTOR shall use reasonable endeavours to provide advice based upon
the evidence provided by the AUTHORITY. Where this is not possible because the
existing evidence does not materially support the Claimant’s stated incapacity or
disablement the CONTRACTOR shall use reasonable endeavours to ensure that the
evidence it seeks to gather, which may include examining the Claimant, will materially
contribute to the advice given to the AUTHORITY.
4.19
Posthumous Claims
4.20.1 The CONTRACTOR acknowledges that a new claim can be made, or an existing one
may continue to be processed, following the death of a Claimant. In such cases a
representative acts for the estate of the deceased and shall give consent in the same
circumstances as a living Claimant, to progress the claim. The CONTRACTOR shall
use reasonable endeavours to progress the claim on the documentary evidence held
or obtained. The CONTRACTOR acknowledges that in these circumstances the
representative has the same legal rights as the deceased Claimant.
4.20
Health Care Professional Standards
4.21.1
At all examinations the CONTRACTOR shall adhere to the standards of conduct
required by the AUTHORITY that includes but is not limited to the following:
4.21.1.1
allow the Claimant sufficient time to give their relevant medical history,
disability or loss of faculty;
4.21.1.2
maintain a non-adversarial manner;
4.21.1.3
explain the purpose of the examination and what it entails;
4.21.1.4
perform the examination in a manner that avoids unnecessary
discomfort to the Claimant; and
4.21.1.5
answer any appropriate relevant medical questions posed by the
Claimant, without giving an opinion on the outcome of the claim or
medical condition.
4.21
Conduct of Specialists
4.22.1
The CONTRACTOR shall use reasonable endeavours to ensure that the conduct of
Specialists engaged by the CONTRACTOR, is to the same standard as the
CONTRACTOR’s Health Care Professionals.
4.22
Miscellaneous Medical Requirements
4.23.1
Where no medical training or procedural guidance exists for the provision of a
Service the CONTRACTOR shall ensure that relevant Documentation is created
which meets the requirements of the AUTHORITY.
4.23.2
The CONTRACTOR shall contribute towards training and any necessary training
material required for the AUTHORITY’S personnel when specified by the Authority.
5
MEDICAL QUALITY ASSURANCE
5.1
Systems for recording and reporting information relating to recruitment, training and
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monitoring
5.1.1
The CONTRACTOR shall maintain databases that collect and report information in
relation to recruitment, training, monitoring, Approval and revocation of Approval.
5.1.2
The information that is required to be captured includes but is not limited to the
following details:
5.1.2.1
Recruitment:
5.1.2.1.1
employment
history;
5.1.2.1.2
qualifications;
and
5.1.2.1.3
professional
Registration.
5.1.2.2
Training:
5.1.2.2.1
training undertaken to support Approval; and
5.1.2.2.2
Continuing
Professional and Medical Education.
5.2.2.3
Monitoring:
5.2.2.3.1
audit;
5.2.2.3.2
complaints;
5.2.2.3.3
rework;
and
5.2.2.3.4
feedback including appraisal.
5.2.2.4
Approval and revocation of Approval.
5.2.2.5
Revalidation.
5.1.3
In relation to training the information that is required includes, but is not limited to
the following:
5.1.3.1
dates and training module completed for:
5.1.3.1.1
disability
analysis;
5.1.3.1.2
disability
awareness;
5.1.3.1.3
professional
standards;
5.1.3.1.4
legislation and policy intent;
5.1.3.1.5
customer
requirements and service;
5.1.3.1.6
equal opportunities; and
5.1.3.1.7
potentially
aggressive
situations.
5.1.3.2
dates, assessment modules completed and outcomes for:
5.1.3.2.1
all
written
tests of training content; and
5.1.3.2.2
all practical tests of training content including benefit
type, number and extent of satisfactory performance and
number and extent of unsatisfactory performance.
5.2
The CONTRACTOR shall record and maintain, separately, for Health Care Professionals,
data for each benefit area in which those personnel work, that shall include, but not be limited
to:
5.2.1
the number passing the written assessment the first time;
5.2.2
the number passing the written assessment at resitting;
5.2.3
the number passing the practical assessment the first time;
5.2.4
the number passing the practical assessment at resitting; and
5.2.5
the number dropping out of training for any other reason.
5.3
The CONTRACTOR shall provide a Medical Quality Monitoring report as detailed in
Schedule 16 of this Contract. The Medical Quality Monitoring Report shall, as a minimum,
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report on and analyse the following:
5.3.1
IB process outcoomes;
5.3.2
ESA process outcomes;
5.3.3
Percentage
over threshold for ESA;
5.3.4
Rework;
5.3.5
Complaints
5.3.6
Delivery of training;
5.3.7
Quality Report – performance against quality targets (
5.3.8
Mitigation (level of detail dependent upon the performance against targets);
5.3.9
Actual versus Expected Audit Sample size
5.3.10
HCP Capability - annual
5.4
The CONTRACTOR shall
report additional information pertaining to recruitment, training,
monitoring, remedial action, Approval and revocation of Approval and revalidation in an
agreed format periodically, as required by the AUTHORITY.
5.5
The CONTRACTOR shall:
5.5.1
take account of complaints about the conduct, manner or behaviour of it’s Health
Care Professionals; and
5.5.2
ensure the ongoing good conduct, manner and behaviour of its Health Care
Professionals.
5.6
Health Care Professional Capability Measure
5.6.1
The skill and competence of all Health Care Professionals employed by the
CONTRACTOR shall be measured against the following five (5) criteria:
5.6.1.1 fully registered with the GMC (Registered Medical Practitioners only),
NMC (Nurses only) and validated by the CONTRACTOR;
5.6.1.2
validation portfolio up to date (Registered Medical Practitioners only);
5.6.1.3
technical training relating to specialism completed;
5.6.1.4
continuing Medical Education complete; and
5.7.1.5
approved for benefit work by Chief Medical Adviser.
5.6.2
The number of Health Care Professionals who fail to fulfil all the five (5) criteria
specified for the Health Care Professional capability measure shall not exceed zero
(0).
5.6.3
Any Health Care Professional shall, for the first twelve (12) months of his/her
employment by the CONTRACTOR, be measured against the Health Care
Professional Capability Measure but will not have that measure applied to him/her.
5.7
Multiple Complaints Against Health Care Professionals
5.7.1
The definition of multiple complaints is more than three complaints received within a
three-month period – More information is provided in KPI 15 as listed in Schedule 16.
5.8
Only the AUTHORITY may remove Approval from any of the CONTRACTOR’s Health Care
Professionals.
5.9 Revalidation
5.9.1
The CONTRACTOR shall provide all Registered Medical Practitioners working
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for and on behalf of the CONTRACTOR with any available evidence required for GMC
revalidation from the first date for presentation of annual revalidation evidence after
implementation of the GMC revalidation legislation
5.10
Diploma in Disability Assessment Medicine
5.10.1
The CONTRACTOR shall
provide, to the AUTHORITY by 31st March of each year,
a proposal that meets the requirements of the AUTHORITY, which includes details
of the number of Registered Medical Practitioners who will be sponsored by the
CONTRACTOR to sit the Diploma in Disability Assessment Medicine.
6.
POLICY ADVICE AND ADVISORY BODIES
6.1
The CONTRACTOR shall attend in order to give evidence to bodies as required, which shall
include but not be limited to the following: any government committee, statutory body or
judicial AUTHORITY as required by the AUTHORITY.
6.2
The CONTRACTOR shall use reasonable endeavours to attend other fora as invited guests
as required by the AUTHORITY which shall
include but shall not be limited to:
6.2.1 policy
research;
6.2.2
policy development and maintenance;
6.2.3
development of benefits for sick and disabled people;
6.2.4
evaluation of provision of medical services to the AUTHORITY; and
6.2.5
promoting Social Security medically related issues to GPs and other interested
groups by way of presentations to courses.
6.3
The CONTRACTOR shall comply with any invitation to attend or provide representation on
the council of the European Union of Medicine in Assurance and Social Security (EUMASS).
6.4
The CONTRACTOR shall provide the AUTHORITY with advice, guidance and support on any
issues relating to the provision of Services, when reasonably requested to do so.
6.5
The CONTRACTOR shall take positive action to share with the AUTHORITY any proposals or
views and initiatives which could bring about improvement in the Services.
6.6
The CONTRACTOR shall provide information to the AUTHORITY as reasonably required, to
assist in the monitoring and evaluation of the likely effect of any proposed policy development
on the Services.
7.
APPEALS
7.1
Should the AUTHORITY decide to implement mechanisms for improved feedback on the
outcome of Appeals at local levels, the CONTRACTOR shall fully
cooperate with the
AUTHORITY in that implementation, at all times complying with agreed timescales.
8.2
8.
PROVISION OF TRAINING TO REGISTERED MEDICAL PRACTITIONERS IN THE ISLE
OF MAN
9.1
The CONTRACTOR shall confirm that it is willing to provide training to Registered Medical
Practitioners in the Isle of Man Department of Health and Social Security.
10.
MEDICAL REPORTS – MISCELLANEOUS REQUIREMENTS
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10.1
Should the AUTHORITY require it, the CONTRACTOR shall work with the AUTHORITY to
provide, IB85 reports and other reports to the AUTHORITY, electronically, in addition to the
requirement to provide electronic IB85 reports to DCS as specified in Schedule 4 Section 4.12
10.2
Should the AUTHORITY agree to the replacement of LiMA as the software for the production
of electronically generated, evidence based reports, the CONTRACTOR shall be responsible
for all costs associated with installing and configuring new software, data migration and any
staff training.
10.3
The CONTRACTOR shall work collaboratively with the AUTHORITY to implement the
national rollout of electronically generated, evidence based medical reports for individual
benefits that includes but may not be limited to:
• AA/DLA
• IIDB;
and
• Service Personnel & Veterans Agency
10.4
Should the AUTHORITY require it, the CONTRACTOR shall work collaboratively with the
AUTHORITY to progress the production of reports via a single medical examination.
11.
ENHANCEMENT OF THE MEDICAL SCRUTINY PROCESS
11.1
The CONTRACTOR shall provide full cooperation to the AUTHORITY in the provision and
analysis of Personal Capability Assessment data and provide full cooperation in any revisions
to the Scrutiny process whether on a national or pilot basis that might arise from that analysis.
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SCHEDULE 4 SECTION 4.2
SERVICE DESCRIPTION
INCAPACITY BENEFIT/INCOME SUPPORT/HOUSING BENEFIT/COUNCIL TAX BENEFIT AND
OTHER RELATED ADVANTAGES
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SCHEDULE 4 SECTION 4.2
SERVICE DESCRIPTION
INCAPACITY BENEFIT/INCOME SUPPORT/HOUSING BENEFIT/COUNCIL TAX BENEFIT AND
OTHER RELATED ADVANTAGES
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of Schedule 4 and the Service Levels detailed in Schedule 5.
1.2
The CONTRACTOR shall ensure that:
1.2.1
Medical advice is provided by Approved Health Care Professionals.
1.2.2
Medical scrutiny is provided by Approved Health Care Professionals.
1.2.3
PCA examinations are undertaken by Approved Health Care Professionals.
1.3
Upon completion of all the necessary actions, the CONTRACTOR shall return to the
AUTHORITY all documentation received from the AUTHORITY or gathered on behalf of the
AUTHORITY.
2.0
Advice Referrals
2.1
The CONTRACTOR shall provide any medical advice or clarification of medical advice that
the AUTHORITY requests.
3.0 IB
Referrals
3.1
Issuing the questionnaire
3.1.1
On receipt of a Q referral, the CONTRACTOR shall issue the IB50 questionnaire to the
Claimant or their representative.
3.1.2
The CONTRACTOR shall automatically issue a reminder to the Claimant or their
representative if the IB50 questionnaire is not returned to the CONTRACTOR after twenty
eight (28) calendar days of having provided it to the Claimant or their representative.
3.1.3 If the Claimant or their representative does not return the completed IB50 questionnaire within
forty three (43) calendar days of its issue, the CONTRACTOR shall advise the AUTHORITY,
except where Mental Health conditions have been notified by the AUTHORITY.
3.1.4
Where Mental Health conditions have been notified by the AUTHORITY and the IB50
questionnaire is not returned, the CONTRACTOR shall undertake a “Scrutiny check” as
detailed in para 3.2.
3.2
Scrutiny
3.2.1
The CONTRACTOR shall undertake a Scrutiny check to establish whether:
3.2.1.1 The IB50 has been completed with all relevant information:
3.2.1.2 FME is required to provide advice to the Authority:
3.2.1.3 If PCA examination is required, whether it is more appropriate to be conducted by
a Registered Nurse or Medical Practitioner in accordance with the agreed criteria.
3.2.1.4 If PCA examination is required, whether it is appropriate for an examination in a
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Medical Examination Centre (MEC), or a Domiciliary Visit
3.2.2
Upon completion of the Scrutiny check, the CONTRACTOR shall:
3.2.2.1 Advise the AUTHORITY whether the Claimant is suffering from an exempt
incapacity: or
3.2.2.2
Advise the AUTHORITY whether the Claimant meets the threshold for incapacity:
or
3.2.2.3
Arrange a PCA with the Claimant.
4.
Personal Capability Assessment
4.1
General
4.1.1
Where the CONTRACTOR is unable to determine that the Claimant is suffering from an
exempt incapacity or meets the threshold for incapacity, the CONTRACTOR shall arrange
with the Claimant for a PCA to be carried out.
4.1.2
If during the course of the PCA, the Claimant has a condition that falls into an exempt
category, the CONTRACTOR shall curtail the PCA and advise the AUTHORITY.
4.1.3
The AUTHORITY reserves the right to instruct the CONTRACTOR to complete a Face to
Face Assessment.
4.2 In respect of Claimants who are Unable to Attend
4.2.1
The CONTRACTOR shall offer a further appointment to those Claimants who are Unable to
Attend the first arranged appointment without reference back to the AUTHORITY.
4.2.2
If the Claimant is Unable To Attend the second arranged appointment, the CONTRACTOR
shall use reasonable endeavours to despatch all documentation to the AUTHORITY within
twenty four (24) hours of the second arranged appointment date.
4.2.3
The CONTRACTOR shall record the reasons for non-attendance on MSRS.
4.3
In respect of Claimants who Do Not Attend
4.3.1 If the Claimant Does Not Attend an arranged appointment the CONTRACTOR shall use
reasonable endeavours to despatch all papers to the AUTHORITY within twenty four (24)
hours of the date of that arranged appointment.
4.3.2
The CONTRACTOR shall use reasonable endeavours to despatch to those Claimants who
Do Not Attend the examination the appropriate form which obtains the reasons for non
attendance within twenty four (24) hours of the Claimant not attending the arranged
appointment.
4.3.4
The CONTRACTOR shall record the reasons for non-attendance and details of all attempts to
contact the Claimant.
5.0
Own Occupation Test Referrals
5.1
The CONTRACTOR will receive the appropriate Referral documentation from the
AUTHORITY
5.2
The CONTRACTOR shall advise whether or not the Claimant’s capable of their own
occupation, and if not, when significant improvement could be expected.
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SCHEDULE 4 SECTION 4.3
SERVICE DESCRIPTION
SEVERE DISABLEMENT ALLOWANCE
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SCHEDULE 4 SECTION 4.3
SERVICE DESCRIPTION
SEVERE DISABLEMENT ALLOWANCE
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements as
detailed in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY.
1.3
Upon completion of all necessary actions, the CONTRACTOR shall return all Referral
documents received from the AUTHORITY or gathered on behalf of the AUTHORITY in the
format agreed with the AUTHORITY.
1.4
When required by the AUTHORITY, the CONTRACTOR shall, in addition to giving an opinion
on the disablement question for Severe Disablement Allowance, provide advice on the future
application of the Personal Capability Assessment, where in the CONTRACTOR’s opinion the
assessment of the level of disablement is less than eighty percent (80%).
1.4.1
For the avoidance of doubt, the legislation requires that an assessment of
disablement must be expressed as a percentage and that, for the purposes of the
assessment:
1.4.1.1
whole numbers which are not multiple of ten (10) but are multiples of
five (5) should be rounded up to the next higher multiple of ten (10) and
other intermediate whole numbers should be rounded to the nearest
multiple of ten (10), i.e. an assessment of sixty five percent (65%)
should be rounded up to seventy percent (70%) and sixty four percent
(64%) down to sixty percent (60%); and
1.4.1.2
where in the CONTRACTOR’s opinion the disablement is found to be
less than five percent (5%) in total, the CONTRACTOR shall not round
this figure down to zero but shall record its opinion of the assessment
of disablement as the actual percentage i.e. one to four.
1.4.2
Rounding is applied only to the opinion on the total assessment and not to the
assessment of each individual condition.
1.4.3
When the CONTRACTOR is informed of the death of a Claimant before it has
provided an opinion on the case, the CONTRACTOR shall immediately suspend
further action and shall return all documentation, including any Further Medical
Evidence obtained, to the AUTHORITY.
1.4.4
The CONTRACTOR may be able to provide an opinion on disablement without the
need for examination if in its opinion the Claimant is eighty percent (80%) disabled
based on the evidence on file or if it considers that it is likely that it would be able to
provide an opinion that the Claimant is eighty percent (80%) disabled if Further
Medical Evidence is obtained.
1.4.5
The CONTRACTOR shall record its opinion(s) on form(s) approved by the
AUTHORITY. The forms are designed to lead the CONTRACTOR to record a
statement of findings on all questions of fact material to its opinion regarding the
assessment of the disablement. The CONTRACTOR shall ensure that no other
form(s) are used without the prior approval and consent of the AUTHORITY.
.
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1.4.6
The AUTHORITY may require an opinion on disablement for a given period only. Where
this is the case the period shall be indicated to the CONTRACTOR by the AUTHORITY on
the appropriate form.
1.4.7
In respect of those Claimants who are Unable to Attend or Did Not Attend appointments,
the CONTRACTOR shall proceed in accordance with the provisions of Paragraphs 4.2 to
4.3 of Section 4.2 of this Schedule 4 except that the CONTRACTOR is not required to
dispatch to those Claimants who Do Not Attend the examination, the appropriate form
which obtains the reasons for non-attendance.
2 SPECIFICS
2.1
Referral for consideration of the 80% disablement test and where appropriate, in addition,
advice on the future application of the Personal Capability Assessment
2.1.1
Referral for the 80% Disablement Test only
2.1.1.1
Where the CONTRACTOR is unable to provide an opinion without examination the
CONTRACTOR shall make all necessary arrangements for a medical examination to be
undertaken. The CONTRACTOR shall provide an opinion on the disablement question and
complete the medical report form(s) taking into account all conditions found and giving the
date from which the opinion on the assessment begins and the date at which the opinion on
the assessment ends.
2.1.2
Referral for 80% Disablement Test and advice on the future application of the Personal
Capability Assessment.
2.1.2.1
The CONTRACTOR shall provide an opinion on the disablement question as in paragraph
2.1 of this section 4.3 of Schedule 4.
2.1.2.2
Where the AUTHORITY has indicated as part of the Referral documentation that it requires
advice regarding the future application of the Personal Capability Assessment in addition to
an opinion on the disablement, the CONTRACTOR shall complete a report on the
Claimant’s functional limitations based on the Claimants statement and clinical findings and
shall give an opinion of the functions in relation to the Personal Capability Assessment on
the appropriate form only when the level of disablement is assessed at less than 80%.
2.1.2.3
Where the CONTRACTOR is unable to provide an opinion of the functions in relation to the
Personal Capability Assessment without an examination, the CONTRACTOR shall return
the referral to the AUTHORITY. The AUTHORITY will make a new referral as per Section
4.2 of this Schedule 4, the SDA documentation will be sent as a supporting case file.
2.3 Advice where the claimant disputes the authority decision and provides Further Medical
Evidence
2.3.1
Upon receipt of the Referral documentation the CONTRACTOR shall provide an opinion as
to whether the further evidence supplied warrants a change to the previous opinion
provided by the CONTRACTOR in accordance with the requirements contained in this
section.
2.3.2
Where the further evidence supplied results in a revised opinion on the assessment of the
level of disablement the CONTRACTOR shall advise whether this revised opinion effects
the original opinion provided on the incapacity question.
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SCHEDULE 4 SECTION 4.4
SERVICE DESCRIPTIONS
HM REVENUE and CUSTOMS STATUTORY SICK PAY/STATUTORY MATERNITY PAY
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SCHEDULE 4 SECTION 4.4
SERVICE DESCRIPTIONS
HM REVENUE and CUSTOMS STATUTORY SICK PAY/STATUTORY MATERNITY PAY
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements set out in
Section 4.1 of this Schedule 4
1.2
The CONTRACTOR shall return all documentation to the AUTHORITY in the same format as
received, including any Further Medical Evidence which the CONTRACTOR has obtained in
order to advise the AUTHORITY, unless instructed to do otherwise by the AUTHORITY.
1.3
The CONTRACTOR shall use reasonable endeavours to provide advice from the evidence
presented by the AUTHORITY. Where it is not able to do so because the existing evidence
does not support the Claimant’s stated incapacity, the CONTRACTOR shall use reasonable
endeavours to ensure that any Further Medical Evidence it gathers shall materially contribute
to the advice given to the AUTHORITY. If the CONTRACTOR is unable to ensure that the
Further Medical Evidence will materially contribute to its advice, then the CONTRACTOR shall
arrange for an examination to be undertaken.
1.4
The CONTRACTOR shall ensure that authorisation for the examination is given by Medical
Personnel Approved by the Secretary of State.
1.5
The CONTRACTOR shall undertake Own Occupation Test medical examinations by the one
hundred and ninety sixth day (196th) of the Period of Interruption of Work, as indicated by the
AUTHORITY on the appropriate form, irrespective of the prescribed Service Level targets.
Referrals for the Own Occupation Test will be sent to the CONTRACTOR by the AUTHORITY
no later than ten (10) weeks before the one hundred and ninety sixth (196th) day of the Period
of Interruption of Work.
1.6
Where in the CONTRACTOR’s opinion the Claimant’s prognosis indicates that a further
Referral is to be made at a later date, the CONTRACTOR shall indicate if Further Medical
Evidence is required from the AUTHORITY.
2.
SPECIFICS
2.1
CN Referral to Determine If Incapacity is Pregnancy Related
2.1.1
The CONTRACTOR will receive the appropriate form from the Claimant’s Medical
Practitioner.
2.1.2
Upon receipt of this form, the CONTRACTOR shall determine if the
Claimant’s/employee’s incapacity is related to her pregnancy.
2.1.3
The CONTRACTOR shall reply in the format required by the AUTHORITY and shall
return the same to the AUTHORITY.
2.2
SO Disputed Pregnancy-Related Incapacities
2.2.1
The CONTRACTOR will receive the following from the AUTHORITY:
• the appropriate Referral documents
• the date of issue of the appropriate form requesting Further Medical Evidence
from the Claimant’s Medical Practitioner, if appropriate.
2.2.2
Upon receipt of the appropriate Referral documents from the AUTHORITY, the
CONTRACTOR will allow a reasonable time for the form to be returned from the
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Claimant’s Medical Practitioner and then proceed with the action as described in
Paragraph 2.2.3 below.
2.2.3
The CONTRACTOR shall give an opinion, as to whether the Claimant’s/employee’s
incapacity is wholly or partly pregnancy related. Where the CONTRACTOR is
unable to advise in accordance with the provisions of Paragraph 1.3 of this Section
4.4 of Schedule 4, it shall arrange for an examination to be carried out.
2.2.4
The CONTRACTOR shall complete all forms as required by the AUTHORITY and
shall return the same to the AUTHORITY.
2.3
SL Referrals for advice where an employer/employee has applied to the AUTHORITY for
a decision on payability of Statutory Sick Pay (including cases where the employer
refuses to pay Statutory Sick Pay).
2.3.1
The CONTRACTOR will receive the appropriate Referral documents from the
AUTHORITY.
2.3.2
The CONTRACTOR shall advise as to whether or not the Claimant is capable of
his/her own occupation and if not, when a significant improvement can be expected.
Where the CONTRACTOR is unable to advise in accordance with the provisions of
Paragraph 1.3 of this Section 4.4 of Schedule 4, it shall arrange for an Own
Occupation Test examination to be carried out.
2.3.3
The CONTRACTOR shall reply in the format as required by the AUTHORITY and
shall return the same to the AUTHORITY.
2.3.4
The CONTRACTOR shall provide advice for a retrospective period after incapacity
has ended as directed by the AUTHORITY.
2.4
SK Referrals when the AUTHORITY has received a request for advice from an Employer
regarding Repeated Short Period Claims
2.4.1
The CONTRACTOR will receive the following from the AUTHORITY:
• the appropriate Referral documents
• the date of issue of the appropriate form requesting Further Medical Evidence from
the Claimant’s Medical Practitioner, if appropriate.
2.4.2
Upon receipt of the Referral documents from the AUTHORITY, the CONTRACTOR
will allow a reasonable time for the form to be returned from the Claimant’s Medical
Practitioner and then proceed with the action as described in Paragraph 2.4.3 below.
2.4.3
The CONTRACTOR shall advise as to whether or not there are reasonable grounds
for the Claimant having frequent absences from work and as to whether the
evidence accounts for the current/recently-terminated absence from work. Where
the CONTRACTOR is unable to advise in accordance with the provisions of
Paragraph 1.3 of this Section 4.4 of Schedule 4, it shall arrange for an Own
Occupation Test examination to be carried out.
2.4.4
The CONTRACTOR shall reply in the format as required by the AUTHORITY and
shall return the same to the AUTHORITY.
2.4.5
The CONTRACTOR shall provide advice for a retrospective period after incapacity
has ended as directed by the AUTHORITY.
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SCHEDULE 4 SECTION 4.5
SERVICE DESCRIPTION
AGE DETERMINATION
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SCHEDULE 4 SECTION 4.5
SERVICE DESCRIPTION
AGE DETERMINATION
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
2
AGE DETERMINATION SPECIFIC REQUIREMENTS
2.1
The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY
that shall include but not be limited to:
a)
the file with any available supporting evidence;
b)
a minute directing the required action and indicating the Claimant’s recorded and
alleged date of birth; and
c)
the age applicable to the specific medical question.
2. 2
The CONTRACTOR shall ensure that the examination is carried out by an appropriate
Medical Specialist.
2.3
The CONTRACTOR shall provide an appropriately completed medical examination report
form, which provides responses to all questions raised by the AUTHORITY (particularly that
of whether on the balance of probability a person has reached the age now alleged).
2.4
The CONTRACTOR shall return to the AUTHORITY a fully completed medical report form
which gives a response and an opinion on the age of the Claimant. The medical examination
shall provide a reasonably reliable assessment of the Claimant’s age, stating the range within
which the age is estimated. The range shall not exceed five (5) years either way.
2.5
The CONTRACTOR shall highlight any Harmful Information contained within the
documentation being returned to the AUTHORITY. The CONTRACTOR shall complete a
separate form setting out this information, if requested to do so by the AUTHORITY.
2.6
The CONTRACTOR shall return all Referral documents received from the Authority or
gathered on behalf of the AUTHORITY in the same format as received, unless instructed to
do otherwise by the AUTHORITY.
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SCHEDULE 4 SECTION 4.6
SERVICE DESCRIPTION
JOBSEEKERS ALLOWANCE
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SCHEDULE 4 SECTION 4.6
SERVICE DESCRIPTION
JOBSEEKERS ALLOWANCE
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
2.
JOBSEEKERS ALLOWANCE SPECIFIC REQUIREMENTS
2.1
The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY.
2.2
The CONTRACTOR shall complete the appropriate report form which shall provide a
response to the questions raised by the AUTHORITY together with a medical opinion that
explains the effect that such a condition will have, or may have, on the sufferer.
2.3
The CONTRACTOR shall give clarification of the medical terminology contained within the
report to the full satisfaction of the AUTHORITY. The CONTRACTOR shall provide this
information in a format, which allows the AUTHORITY to understand and assimilate it. Any
clarification resulting from queries where the CONTRACTOR has not provided clarity will be
considered Rework.
2.4
The CONTRACTOR shall highlight any Harmful Information contained in the report. The
CONTRACTOR shall complete a separate form setting out this information if requested to do
so by the AUTHORITY.
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SCHEDULE 4 SECTION 4.7
SERVICE DESCRIPTIONS
OCCUPATIONAL HEALTH ASSESSMENTS
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SCHEDULE 4 SECTION 4.7
SERVICE DESCRIPTIONS
OCCUPATIONAL HEALTH ASSESSMENTS
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements set out
in Section 4.1 of this Schedule 4.
1.2
Upon completion of all necessary actions the CONTRACTOR shall
return to the AUTHORITY
all documentation received from the AUTHORITY or gathered on behalf of the AUTHORITY
in the same format as received, unless instructed to do otherwise by the AUTHORITY.
2.
OCCUPATIONAL HEALTH SPECIFIC REQUIREMENTS
2.1
The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY.
2.2
Upon receipt, the CONTRACTOR shall
arrange for an Occupational Health Assessment to be
undertaken.
2.3
The CONTRACTOR shall ensure that Occupational Health Assessments are carried out by
appropriately qualified Registered Medical Practitioners.
2.4
The CONTRACTOR shall provide Registered Medical Practitioners who are:
a)
fully registered, without restrictions or conditions, on the Principal List of the GMC;
and in addition
b)
from the date on which the GMC issues licences to practice, hold a current licence
to practice.
2.4.1
In addition they must have three years post-registration experience as a minimum.
In individual cases, solely at the discretion of the AUTHORITY’s CMA, the
requirement that:
a)
no conditions be attached to registration; and
b)
Registered Medical Practitioners must have a minimum of three years post-
registration experience,
may be waived.
2.5
The requirement for Registered Medical Practitioners to have experience in broad based
medical practice is not required, however in addition to meeting the requirements in
paragraph 2.4, the CONTRACTOR shall provide Registered Medical Practitioners who also
have the following training, qualifications and experience that are pertinent to providing
Occupational Health Assessments:
a)
experience in providing occupational health; plus either
b)
DDAM; or
c)
a higher occupational health qualification (Associateship of the Faculty of
Occupational Medicine (AFOM), Membership of the Faculty of Occupational
Medicine (MFOM)).
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2.5.1
The CONTRACTOR acknowledges that the Diploma in Occupational Medicine
(DoccMed) on its own is not sufficient.
2.6
The CONTRACTOR shall ensure that all Medical Personnel employed by, or contracted to,
the CONTRACTOR for the provision of Services, shall be Approved by the AUTHORITY
acting on behalf of the Secretary of State.
2.7
The CONTRACTOR shall use reasonable endeavours to ensure that any Registered Medical
Practitioner who has previously been involved in advising or examining the Jobseeker in
connection with previous claims for benefit is excluded from conducting the Occupational
Health Assessment.
2.8
The CONTRACTOR shall
provide the AUTHORITY with a fully completed report on the
appropriate AUTHORITY form.
2.9
The CONTRACTOR shall ensure that the completed report provides a full response to all the
questions raised by the AUTHORITY.
2.10
The CONTRACTOR shall
provide typed reports (which for the purpose of this Agreement
shall include word processed documents in electronic or paper form).
2.11
Retention cases
2.11.1
The CONTRACTOR will receive the appropriate Referral documents from the
AUTHORITY.
2.112
Upon receipt of the Referral documents the CONTRACTOR shall arrange for an
Occupational Health Assessment to be undertaken.
2.11.3
In certain retention cases the CONTRACTOR shall arrange to visit the employee in
their workplace and shall conduct the Occupational Health Assessment there, if
directed to do so by the AUTHORITY.
2.11.4
The
CONTRACTOR
shall
provide the AUTHORITY with a fully completed report on
the appropriate AUTHORITY form.
2.11.5
The CONTRACTOR shall ensure that the completed report provides a full response
to all the questions raised by the AUTHORITY.
2.11.6
The CONTRACTOR shall
provide typed reports (which for the purpose of this
Agreement shall include word processed documents in electronic or paper form).
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SCHEDULE 4 SECTION 4.8
SERVICE DESCRIPTIONS
HM REVENUE and CUSTOMS CHILD TRUST FUND
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SCHEDULE 4 SECTION 4.8
SERVICE DESCRIPTIONS
HM REVENUE and CUSTOMS CHILD TRUST FUND
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR will receive the appropriate Referral documentation from the
AUTHORITY.
2. SPECIFICS
2.1
The CONTRACTOR shall provide the AUTHORITY with advice as to whether the Claimant is
Terminally Ill as defined by Disability Living Allowance legislation.
2.2
The CONTRACTOR shall highlight any Harmful Information contained within the
documentation being returned to the AUTHORITY. The CONTRACTOR shall identify on a
separate form if appropriate, any Harmful Information contained in the documentation being
returned to the AUTHORITY.
2.3
The CONTRACTOR shall return all Referral documentation received from the AUTHORITY or
gathered on behalf of the AUTHORITY in the same format as received, unless instructed to
do otherwise by the AUTHORITY.
2.4
The CONTRACTOR shall return all referral documentation received from the AUTHORITY or
gathered on behalf of the AUTHORITY in the same format as received, unless instructed to
do so by the AUTHORITY.
2.5
Where the referral is by facsimile from the AUTHORITY, the CONTRACTOR shall destroy all
referral documentation in the manner as detailed in Schedule 20.
2.6
The CONTRACTOR acknowledges that all other Further Medical Evidence gathering will
remain the responsibility of the AUTHORITY.
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SCHEDULE 4 SECTION 4.9
SERVICE DESCRIPTIONS
INDUSTRIAL INJURIES DISABLEMENT BENEFITS
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SCHEDULE 4 SECTION 4.9
SERVICE DESRIPTIONS
INDUSTRIAL INJURIES DISABLEMENT BENEFITS
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR shall use reasonable endeavours to ensure that any hospital case notes
loaned from any third party are returned to the third party once all action has been completed
and within ten (10) working days of receipt. The CONTRACTOR shall ensure that once all
action has been completed in relation to X-Rays, the X Ray Disc is destroyed in accordance
with the DWP Security Policy.
1.3
The CONTRACTOR shall provide advice on any appropriate disablement, diagnosis or
Recrudescence questions arising on an industrial injuries disablement benefit claim in
accordance with all relevant Social Security legislation as set out in Paragraph 1.1 of Section
2.4 of Schedule 2.
1.4
The CONTRACTOR shall not provide an opinion on any questions referred to it if the
Claimant fails to attend, unless the CONTRACTOR has the Claimant’s prior written consent.
1.5
The CONTRACTOR shall record its opinions on appropriate form(s) approved by the
AUTHORITY. The forms are designed to lead the CONTRACTOR to give an opinion on the
questions posed by the AUTHORITY. The CONTRACTOR shall ensure that all relevant parts
of the forms are fully completed. The CONTRACTOR shall ensure that no other form(s) are
used without the prior approval and consent of the AUTHORITY.
1.6
The CONTRACTOR shall ensure that where, during the consideration of any question, it has
taken into account consultants reports, verbatim extracts of hospital case notes or other
medical evidence, the report contains a record of the fact.
1.7
To assist in the determination of entitlement to reduced earnings allowance, the AUTHORITY
shall require written medical advice from the CONTRACTOR relating to a Claimant’s capacity
to perform their regular occupation and/or suitable alternative work. When such advice is
required at the same time that the CONTRACTOR is providing an opinion on the disablement
benefit claim the CONTRACTOR shall ensure that it proceeds to complete any additional
advice from which the AUTHORITY has included in the Referral Documents.
1.8
If the CONTRACTOR’s opinion is that disablement is assessed at ninety five percent (95%) or
more the CONTRACTOR shall ensure that it completes the appropriate report form to provide
details of the Claimant’s attendance needs and shall provide written medical advice to the
AUTHORITY advising on the nature and amount of attendance needed by the Claimant.
1.9 The
CONTRACTOR
shall attach priority to, and handle urgently at all stages, Referrals where
there is evidence to suggest that the Claimant is Terminally Ill.
1.10
The CONTRACTOR shall
provide an opinion on all PD D3 Referrals, on the basis of evidence
either submitted by the AUTHORITY or obtained by the CONTRACTOR where appropriate.
For the avoidance of doubt the CONTRACTOR shall
not arrange for an examination to be
undertaken for this type of Referral, except in exceptional circumstances.
1.11
Where the original report is not typewritten or electronically produced by the CONTRACTOR,
the CONTRACTOR shall when required by the AUTHORITY provide a typed copy on request.
This may include but not be limited to, responses to requests by Claimants or their
representatives for type written copies, and responses in connection with submissions to
Tribunals Service.
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1.12
Where appropriate, the AUTHORITY will provide details of existing disablement assessments
that are available and will provide all previous BI8(s) for the information of the
CONTRACTOR.
1.13
When a Claimant dies before the CONTRACTOR has given an opinion on the case, the
CONTRACTOR shall immediately suspend further action and
shall
return all Referral
Documents, including any further evidence obtained, to the AUTHORITY.
1.14
When the Referral is made in respect of a Claimant who is deceased, the Referral Documents
will include a notice from the AUTHORITY appointing another person (the appointee) to act
on the Claimant’s behalf. The CONTRACTOR shall
ensure that all appropriate
communication in these types of Referrals is undertaken with the named appointee.
2.
INDUSTRIAL ACCIDENT REFERRALS
2.1
Accident Declaration Referrals
2.1.1 The CONTRACTOR will receive the appropriate Referral Documents which will
contain a variety of information and documentation which will include but is not limited
to the appropriate claim form.
2.1.2
SO 1 - Referral for Advice to Assist With The Determination Of An Accident Question
– Service Required
2.1.2.1
The CONTRACTOR will receive the appropriate Referral Documents
from the AUTHORITY. The AUTHORITY will include in the
documentation a written submission, which will include specific details
of the facts, which the Decision Maker has accepted, and the advice
required. This advice will generally include:
a)
whether it is more probable than not that the Claimant has
suffered a pathological change for the worse as a result of
the claimed accident;
b)
whether the change is likely to have been caused or
materially contributed to by any factor of the Claimant’s
work (as described in the Referral Documents).
c)
obtaining medical evidence from the Claimant’s GP or
hospital to confirm that the accident occurred
2.1.2.2
Upon completion of all necessary actions the CONTRACTOR shall
return all documentation to the AUTHORITY.
2.2
Industrial Accident Assessments
2.2.1
General
2.2.1.1
The CONTRACTOR will receive a completed Referral file form BI 8
from the AUTHORITY which will contain a variety of information and
documentation which will include but is not limited to the appropriate
claim form and the medical report(s) forms to be completed. The
BI8(s) will include details of any existing disablement assessments and
will be accompanied by all previous BI8(s) for the information of the
CONTRACTOR.
2.2.2
EI 1 Industrial Accident – Initial Assessment – Service required
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2.2.2.1
Before an industrial accident case is referred to the CONTRACTOR for
advice on the disablement questions, the AUTHORITY will normally
have accepted that the Claimant has sustained an industrial accident.
The Referral Documents sent to the CONTRACTOR by the
AUTHORITY will include a description of the accepted industrial
accident and the date it occurred. Where the AUTHORITY requires
assistance in determining an accident question, a Referral will be made
for advice as on paragraph 2.1 of this Section 4.9 of Schedule 4.
2.2.2.2
The CONTRACTOR will receive the appropriate Referral Documents
from the AUTHORITY.
2.2.2.3
The CONTRACTOR shall
make all necessary arrangements for a
medical examination to be undertaken, to provide an opinion on the
relevant loss of faculty and the disablement questions, and for full
completion of the medical report form(s).
2.2.2.4
Upon completion of all necessary actions the CONTRACTOR shall
return all documentation to the AUTHORITY.
2.3
Industrial Accident – Reassessments
2.3.1
General
2.3.1.1
Before the end of the period of a provisional assessment the
AUTHORITY will return the Referral file form BI8 to the
CONTRACTOR. The information on the file cover will have been
updated, where appropriate, by the AUTHORITY and will include all
previous Referral Documents and all previous assessment forms.
2.3.1.2
If the CONTRACTOR’s opinion is that a further assessment is
appropriate it shall ensure that the opinion given on the further
assessment commences on the next day following the day of expiry of
the previous assessment.
2.3.1.3
Upon completion of all necessary actions the CONTRACTOR shall
return all documentation to the AUTHORITY.
2.3.2
EO 1 Industrial Accident Reassessment – Service Required
2.3.2.1
The CONTRACTOR will receive the appropriate Referral Documents
from the AUTHORITY at least two (2) months before the end of the
period of a provisional assessment.
2.3.2.2
The CONTRACTOR shall make all necessary arrangements for a
medical examination to provide an opinion on whether the accident still
results in any relevant loss of faculty, an opinion on the disablement
questions and full completion of the appropriate medical report form(s).
2.3.2.3
If the CONTRACTOR’S opinion is that a further assessment is
appropriate, it shall ensure that the opinion given on the further
assessment commences on the next day following the day of expiry of
the previous assessment.
2.3.2.4
The CONTRACTOR shall ensure that it completes all necessary
actions and returns the file to the AUTHORITY at least five (5) Working
Days before the expiry of the previous assessment.
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3
PRESCRIBED
DISEASES
3.1
General
3.1.1
Before this type of case is referred to the CONTRACTOR to arrange for the
provision of a medical report, the AUTHORITY will normally have accepted that the
Claimant has worked in an employment that is prescribed in relation to the disease
claimed. This may not be the case for certain Diffuse Mesothelioma (PD D3)
referrals or for specific diseases when its known that the claimant is Terminally Ill.
3.1.2
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY completed as necessary and which will include details of the
prescribed disease which has been claimed. On Referrals where the AUTHORITY
has completed its prescription enquiries the documentation will include a
description of the accepted prescription and a form of enquiry addressed to the
Claimant’s employer. The current BI8(s) will include details of any existing
disablement assessments that are available and will be accompanied by all
previous BI8(s) for the information of the CONTRACTOR.
3.1.3
Where appropriate the BI8 will contain a variety of Referral Documents together
with any relevant x-rays already held by the AUTHORITY for the information of the
CONTRACTOR.
3.1.4
If the CONTRACTOR’s opinion is that the Claimant is not suffering from the
Prescribed Disease claimed, but the CONTRACTOR considers that the Claimant is
suffering from an (other) PD (s), the CONTRACTOR shall provide an opinion as in
paragraph 3.2 of this Section 4.9 of Schedule 4.
3.1.5
When the CONTRACTOR is considering a diagnosis question, in relation to a claim
in respect of any PD numbered D1 (when asbestosis), D3, D8 and D9, the
CONTRACTOR must advise in its opinion, which one if any is diagnosed.
3.2
SI 1 Initial Assessment Prescribed Diseases (excluding the diseases numbered A10 and D12)
3.2.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
3.2.2
The CONTRACTOR shall make all necessary arrangements for a medical
examination to provide an opinion on the diagnosis/recrudescence question and
any disablement questions that arise.
3.2.3
The CONTRACTOR shall,
in the first instance, provide an opinion as to whether or
not the disease claimed is diagnosed.
3.2.4
Where the CONTRACTOR’S opinion is that the disease(s) claimed is/may be
diagnosed the CONTRACTOR shall provide an opinion on any diagnosis or
recrudescence question that arises.
3.2.5
Where, in the CONTRACTOR’S opinion, the PD(s) or a sequela thereof is
diagnosed, the CONTRACTOR shall
record the date from when the Claimant first
suffered from the disease(s).
3.2.6
Where the CONTRACTOR’S opinion is that a first or fresh contraction of the
disease is diagnosed, the CONTRACTOR shall record an opinion as to whether
this is due to the nature of the Claimant’s employment, for the information of the
AUTHORITY.
3.2.7
If the opinion of the CONTRACTOR is that the disease claimed is not diagnosed,
the CONTRACTOR
shall advise the AUTHORITY to that effect and shall return all
documentation to the AUTHORITY.
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3.2.8
If having considered the diagnosis/recrudescence question, any disablement
questions arises; the CONTRACTOR shall provide an opinion and fully complete all
appropriate forms.
3.2.9 In respect of PD A11 Referrals, in circumstances where the clinical evidence
suggests severe sensorineural damage due to vibration, the Contractor shall
undertake sensorineural testing to confirm the severity of vibration damage before
giving an opinion on the diagnosis or whether or not PD A11 is diagnosed.
3.2.10 In circumstances where the clinical evidence suggests severe sensorineural damage
due to vibration, the Contractor shall undertake sensorineural testing, before giving
an opinion on the diagnosis or not PD A11 is diagnosed.
3.2.11 To protect the customer’s personal information the Contractor shall ensure that the
PD A11 Lap Top computers used to undertake the PD A11 examination are fully
encrypted to DWP standards to comply with DWP Security Policy in accordance with
Schedule 20 of the AGREEMENT. The Lap Top must also be stored in a secure
locked cabinet when not in use in accordance with the DWP Clear Desk Policy. Once
the examination details have been transmitted to the AUTHORITY the customer’s
details must be deleted from the Lap Top within 24 hours.
3.3
EO 1 - Prescribed Diseases (excluding the diseases numbered A10 and D12
Reassessments).
3.3.1
The procedures for reassessment Referrals for PDs are similar to those for
Industrial Accidents, except that any form used by the CONTRACTOR to record its
opinion is determined by the PD claimed.
3.3.2
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
3.3.3
The CONTRACTOR shall make all necessary arrangements for a medical
examination of the Claimant, shall provide an opinion on whether the PD results in
any relevant loss of faculty and an opinion on the disablement questions, and fully
complete all of the appropriate medical report forms.
3.3.4
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
3.4
FN 1 - Prescribed Disease Numbered D12- initial assessment
3.4.1
The definition of PD D12 includes a description of the screening test (hereinafter
referred to as the diagnostic screening test), which the CONTRACTOR shall apply
on claims for this disease, ensuring that the equipment adheres to standards as
defined by the British Society of Audiology.
3.4.2
Before this type of case is referred to the CONTRACTOR, the AUTHORITY will
normally have accepted that the Claimant has worked in an employment that is
prescribed in relation to the disease claimed. This may not have been the case if
the AUTHORITY is aware that the Claimant is Terminally Ill.
3.4.3
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
3.4.4 The
CONTRACTOR
shall
make all necessary arrangements for a medical
examination to provide an opinion on the diagnosis/recrudescence question and
any disablement questions that arise.
3.4.5
The CONTRACTOR shall not proceed to consider the diagnosis question for this
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disease until it has been established that the diagnostic screening test has been
applied and shown to be compatible with the presence of the PD.
3.4.6
The CONTRACTOR shall provide advice based on existing evidence of a
diagnostic screening test, evidence from a new test or, if a test cannot be
performed, give reasons for this and provide an opinion on what the test would
have shown, if applied.
3.4.7
If the evidence indicates that the diagnostic screening test is not satisfied the
CONTRACTOR shall complete the appropriate report form and return all
documentation to the AUTHORITY.
3.4.8
If the CONTRACTOR is of the opinion that the diagnostic screening test is satisfied,
it shall complete the report accordingly and provide an opinion on the diagnosis
question.
3.4.9
If in the CONTRACTOR’s opinion the prescribed disease is diagnosed, it shall
record in its report the date from which the Claimant first suffered from the disease.
3.4.10
If, having provided an opinion on the diagnosis question, a disablement question
needs to be considered the CONTRACTOR shall fully complete all appropriate
forms.
3.4.11
When the Claimant has an assessment of disablement in respect of the PD D1 (or
where an Appeal Tribunal awards disablement benefit based on an assessment of
disablement), which took account of increased disablement resulting from the
effects of chronic bronchitis and/or emphysema, the AUTHORITY will include the
appropriate adjustment form.
3.4.12
The CONTRACTOR shall ensure that the appropriate adjustment form is completed
for the information of the AUTHORITY if an opinion on any assessment of
disablement is given for the PD D12.
3.4.13
On completion of all of its necessary actions the CONTRACTOR shall return the
documentation to the AUTHORITY.
3.5
EO 1 - Prescribed Disease Numbered D12 – Reassessments
3.5.1
The procedure for reassessment Referrals for PD D12 is similar to those for
Industrial Accidents, except that the form used by the CONTRACTOR to record its
opinion is determined by the PD claimed.
3.5.2
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
3.5.3
The CONTRACTOR shall adhere to the provisions set out in paragraph2.3 of this
Section 4.9 of Schedule 4 when providing this service except that the words “the
disease” are substituted for the words “the accident”.
3.5.4
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
3.6
SI 1 Prescribed Disease Numbered A10 – Initial Assessment
3.6.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
3.6.2
The CONTRACTOR shall make all necessary arrangements for a medical
examination to be conducted to provide an opinion on the diagnosis question,
based on an audiometric report. Where appropriate, the CONTRACTOR shall
provide an opinion on the assessments of the level of any disablement on the basis
of the Claimant’s hearing loss in accordance with the provisions and scales of
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assessment laid down in regulations.
3.6.3
If, in the opinion of the CONTRACTOR, the audiometric report indicates that the PD
A10 is not diagnosed, the CONTRACTOR shall return any reports and all
documentation to the AUTHORITY.
3.6.4
If, in the opinion of the CONTRACTOR, the audiometric report indicates that the PD
A10 may be diagnosed, the CONTRACTOR shall provide an opinion on the
diagnosis question and the validity of the audiometric results and, where
appropriate, the disablement question.
3.6.5
If in the CONTRACTOR’s opinion the PD numbered A10 is diagnosed, it shall
record in its report the date from which the Claimant first suffered from the PD. The
CONTRACTOR shall ensure that it does not record a date earlier than the date of
claim.
3.6.6
If, having provided an opinion on the diagnosis question, a disablement question
needs to be considered, the CONTRACTOR shall provide an opinion on the
disablement question(s) which arise and on any relevant loss of faculty, and fully
complete all appropriate medical report forms.
3.6.7
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
4
FURTHER REFERRALS TO MEDICAL SERVICES
4.1
General
4.1.1
The CONTRACTOR shall receive the appropriate Referral Documents from the
AUTHORITY.
4.1.2
For the avoidance of doubt, the CONTRACTOR is required to provide an opinion as
to whether or not the Claimant’s condition has improved or deteriorated since the
last opinion was provided.
4.2
SO 1 Request for Advice where Claimant’s condition may have changed – Service required
4.2.1
The CONTRACTOR will receive the appropriate Referral Documents form the
AUTHORITY
4.2.2
The CONTRACTOR shall make all necessary arrangements for a medical
examination to be conducted to provide an opinion on all relevant questions posed
by the AUTHORITY and to fully complete all appropriate forms.
4.2.3
On completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
4.3
SO 1 Request for Advice where Claimant provides Further Medical Evidence – Service
Required
4.3.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
4.3.2
The CONTRACTOR shall provide an opinion as to whether the further medical
evidence supplied warrants a change to the previous opinion provided.
4.3.3
If the CONTRACTOR’s opinion is that the previous opinion cannot be changed it
shall records its opinion on the appropriate form and return all documentation to the
AUTHORITY.
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4.3.4
If the CONTRACTOR’s opinion is that the previous opinion can be changed it shall
then proceed forthwith to provide an opinion on any diagnosis (where appropriate),
recrudescence or disablement questions that arise on the appropriate forms.
4.3.5
For the avoidance of doubt, where in the CONTRACTOR’s opinion a further
medical examination is required in order to provide a revised opinion, because of
the nature of the further evidence provided, it shall make all necessary
arrangements to undertake the examination without reference back to the
AUTHORITY.
4.3.6
On completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
5
REDUCED EARNINGS ALLOWANCE REFERRALS
5.1
General
5.1.1
The AUTHORITY may request medical advice to assist in the determination of
entitlement to reduced earnings allowance.
5.1.2
The CONTRACTOR shall receive the appropriate Referral Documents from the
AUTHORITY. Where the standard form is not appropriate, the AUTHORITY will
provide an appropriate written format which will detail the specific questions
requiring medical advice.
5.2
SO 1 Reduced Earnings Allowance Referrals – Service Required
5.2.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
5.2.2
The CONTRACTOR shall answer all questions posed by the AUTHORITY.
5.2.3
On completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY
6
CONSTANT ATTENDANCE ALLOWANCE AND EXCEPTIONALLY SEVERE
DISABLEMENT ALLOWANCE REFERRALS
6.1
General
6.1.1
The AUTHORITY may request medical advice to assist in the determination of
entitlement to Constant Attendance Allowance.
6.1.2
When it is considering an award of Constant Attendance Allowance at a rate higher
than the normal maximum, the AUTHORITY may request medical advice relating to
the permanent nature of the Claimant’s attendance needs to assist the
AUTHORITY in the consideration of entitlement to Exceptionally Severe
Disablement Allowance.
6.2
SO1 – Constant Attendance Allowance and Exceptionally Severe Disablement Allowance
Referrals
6.2.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY, which will include any information relating to the attendance needs of
the Claimant.
6.2.2
The CONTRACTOR shall make all necessary arrangements for the provision of
medical advice to the AUTHORITY relating to the Claimant’s attendance needs. If
the CONTRACTOR’S opinion is that a medical examination is required it shall
make all necessary arrangements for the examination and provision of a medical
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report.
6.2.3
When it is considering an award of Constant Attendance Allowance at a rate higher
than the normal maximum, the AUTHORITY may request medical advice relating to
the permanent nature of the Claimant’s attendance needs to assist the
AUTHORITY in the consideration of entitlement to Exceptionally Severe
Disablement Allowance.
6.2.4
The CONTRACTOR shall ensure that all appropriate forms are completed for these
types of cases.
6.2.5
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
7
MISCELLANEOUS REFERRALS REQUIRING MEDICAL ADVICE
7.1
The AUTHORITY shall, from time to time, require from the CONTRACTOR written medical
advice in a variety of circumstances which will include but will not be limited to:
a)
advice to help resolve conflicting medical opinion;
b)
advice as to whether a particular medical report contains any Harmful Information;
and
c)
advice to interpret the contents of a particular medical report.
7.2
The CONTRACTOR will receive a Referral file from the AUTHORITY that may but will not
always be accompanied by any other appropriate file. The Referral file will contain a variety
of documentation dependant on the circumstances of the case. The AUTHORITY will include
in the Referral Documents a written submission that will clearly set out what information is
required.
8
“OLD CASES” REFERRALS
8.1
Referrals Under The Workmen’s Compensation (Supplementation) Scheme
8.1.1
General
8.1.1.1
The Scheme will be administrated in a similar manner to the
industrial injuries scheme unless any Articles contained in the
Workmen’s Compensation (Supplementation) Scheme 1982
expressly provide otherwise.
8.1.1.2
When the Claimant is deceased the Referral Documents will include
a notice from the AUTHORITY appointing another person (the
appointee) to act on the Claimant’s behalf.
8.1.1.3
The CONTRACTOR shall answer all questions posed by the
AUTHORITY.
8.2
SI 1 Workmen’s Compensation (Supplementation) Scheme – Claim for Lesser or Major
Incapacity Allowance for an Accident or a Disease other than Pneumoconiosis
8.2.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY
8.2.2
The CONTRACTOR shall make all necessary arrangements to provide written
medical advice to the questions posed on the appropriate form included in the
Referral Documents by the AUTHORITY.
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8.2.3
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
8.3
SI 1 Claim for Lesser or Major Incapacity Allowance for Pneumoconiosis
8.3.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
8.3.2
The CONTRACTOR shall make all necessary arrangements for a medical
examination to be conducted in order to provide an opinion on total disablement, or
if the Claimant is not totally disabled, an opinion on the incapacity for work.
8.3.3
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
8.4
SI 1 Referrals under the Pneumoconiosis, Byssinosis and Miscellaneous Diseases Benefit
Scheme
8.4.1
General
8.4.1.1
The CONTRACTOR shall administer the scheme in a similar manner
as the industrial injuries scheme unless any Articles contained in the
Pneumoconiosis, Byssinosis and Miscellaneous Diseases Benefit
Scheme 1983 expressly provide otherwise.
8.4.1.2 The
CONTRACTOR will receive a Referral folder from the
AUTHORITY which will include the appropriate claim form and report
form to be completed.
8.4.1.3
If the claim is for a respiratory prescribed disease the Referral
Documents may include any relevant x-rays already held by the
AUTHORITY for the information of the CONTRACTOR.
8.4.1.4
The CONTRACTOR shall attach priority to, and handle urgently at all
stages, Referrals submitted by the AUTHORITY in respect of claims
based on asbestos exposure.
8.4.1.5
When the Claimant is deceased the Referral Documents will include a
notice from the AUTHORITY appointing another person (the appointee)
to act on the Claimant’s behalf.
8.5
SI 1Claim for Death Benefit under the Pneumoconiosis, Byssinosis and Miscellaneous
Diseases Benefit Scheme
8.5.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
8.5.2
The CONTRACTOR shall make all necessary arrangements to provide written
medical advice to the questions posed on the appropriate report form included in
the Referral Documents by the AUTHORITY which will generally be whether death
was due to or materially accelerated by the relevant disease.
8.5.3
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
8.6
SI 1 Referral Relating to a Claim for Disablement Allowance of Pneumoconiosis Reference for
Medical Report
8.6.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
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8.6.2
The CONTRACTOR shall make all necessary arrangements for the provision of a
written report, based on x-ray or other radiological evidence, that indicates whether
or not pneumoconiosis is diagnosed.
8.6.3
If in the opinion of the CONTRACTOR the report indicates that pneumoconiosis is
not diagnosed the CONTRACTOR shall give written advice to that effect to the
AUTHORITY.
8.6.4
If in the opinion of the CONTRACTOR pneumoconiosis is diagnosed the
CONTRACTOR shall automatically, without reference back to the AUTHORITY,
make all necessary arrangements for a medical examination to be conducted.
8.6.5
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
8.7
SI 1 Referral Relating to a Claim for Disablement Allowance for Pneumoconiosis, Byssinosis
– Service Required
8.7.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY.
8.7.2
The CONTRACTOR shall make all necessary arrangements for a medical
examination to be conducted to provide an opinion on the extent of disablement
from the disease claimed. If the CONTRACTOR is of the opinion that the Claimant
is totally disabled, advice on the Claimant’s attendance needs should be provided.
8.7.3
Upon completion of all necessary actions the CONTRACTOR shall return all
documentation to the AUTHORITY.
8.8
SI 1 Referral Relating to a Claim for Disablement Allowance for a Miscellaneous Disease
8.8.1 Service
Required
8.8.1.1
The CONTRACTOR will receive the appropriate Referral Documents
from the AUTHORITY
8.8.1.2
The CONTRACTOR shall make all necessary arrangements for
completion of the appropriate medical report form included in the
Referral Documents by the AUTHORITY.
8.8.1.3
Where the CONTRACTOR considers that the Claimant is totally
disabled it shall provide advice relating to the Claimant’s attendance
need on the appropriate report form and advise on the nature and
amount of the Claimant’s attendance needs to the AUTHORITY.
8.8.1.4
Upon completion of all necessary actions the CONTRACTOR shall
return all documentation to the AUTHORITY.
8.9
Miscellaneous Referrals under the Workmen’s Compensation (Supplementation) or
Pneumoconiosis, Byssinosis and Miscellaneous Disease Benefit Schemes
8.9.1
General
8.9.1.1
The CONTRACTOR shall provided written medical advice to the
AUTHORITY when required on a variety of circumstances which will
include but will not be limited to:
a)
advice relating to the attendance needs of a Claimant to help it
determine whether entitlement to Constant Attendance
Allowance/Exceptionally Severe Disablement Allowance is appropriate;
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b)
advice on the Claimant’s capacity for work to help it determine
entitlement to Unemployability Supplement;
c)
advice relating to total or partial incapacity and whether this results
from the relevant accident/disease to help it determine certain
allowances under the Workmen’s Compensation (Supplementation)
Scheme.
8.9.1.2
The CONTRACTOR will receive a Referral file from the AUTHORITY
that may but will not always be accompanied by any other appropriate
file. The Referral file will contain a variety of documentation dependent
on the circumstances of the case. The AUTHORITY will include in the
Referral Documents a written submission that will clearly set out in
circumstances of the case, the reason for reference and will specify
exactly what advice is required.
8.9.1.3
The CONTRACTOR shall answer all questions posed by the
AUTHORITY.
9
ANALOGOUS INDUSTRIAL INJURIES SCHEME – OPERATED BY THE DEPARTMENT
FOR WORK AND PENSIONS AND THE MINISTRY OF DEFENCE
9.1 General
The Service required by the AUTHORITY is the same as that for industrial injuries Referrals
and the relevant actions described at Paragraphs 1 to 7.2 of this Section 4.9 of Schedule 4
shall be followed dependent on the type of Referral.
9.2
Department for Work and Pensions
9.2.1 A person who is injured or contracts a prescribed disease whilst working in
employment which is not employed earners employment may be entitled to an
analogous benefit if they are a non-employed trainee under a government sponsored
scheme.
9.3
Ministry of Defence
9.3.1
A person who sustains an injury during the course of undertaking authorised cadet
duties for an Army, Navy or RAF Cadet Force or a Combined Cadet Force may be
entitled to an analogous benefit.
9.3.2
General
9.3.2.1
The Service required by the AUTHORITY is the same as that for
industrial injuries Referrals and the relevant actions described at
Paragraph 1 to 7.1.2 of this Section 4.9 of Schedule 4 shall be followed
dependent on the type of Referral.
9.4
Analogous Industrial Injuries Scheme – Claimant has expressed Dissatisfaction with a
Decision given by the Decision Maker – Service Required
9.4.1 The CONTRACTOR will receive a completed Referral file form BI 8 from the
AUTHORITY which will contain a variety of information and documentation which will
include the appropriate claim form, any previous medical advice given, any
appropriate assessment forms and the Claimant’s reasons for dissatisfaction.
9.4.2
The Analogous Industrial Injuries Scheme does not have a statutory appeals system
and the CONTRACTOR shall provide a further opinion from Medical Personnel who
have not previously been involved with the case and a written report as to the
appropriateness of the opinion with which the Claimant is dissatisfied.
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SCHEDULE 4 SECTION 4.10
SERVICE DESCRIPTION
TRIBUNALS SERVICE
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SCHEDULE 4 SECTION 4.10
SERVICE DESCRIPTION
TRIBUNALS SERVICE
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
2
SPECIFICS
2.1
The CONTRACTOR shall complete the “Examining Medical Practitioner Report” form by
means of an examination conducted by domiciliary visit.
2.2
All Examining Medical Practitioner Reports shall be completed appropriately and must include
responses to all questions which have been raised by the AUTHORITY.
2.3
The CONTRACTOR shall identify separately, in writing, any Harmful Information obtained
during the examination.
2.4
When obtaining Examining Medical Practitioner Reports the CONTRACTOR shall use
Registered Medical Practitioners with the required medical qualifications.
2.5
The CONTRACTOR shall return a correctly completed Examining Medical Practitioner Report
to the AUTHORITY with all the Referral documents.
3
REQUESTS FOR EXTRACTS FROM HOSPITAL CASE NOTES
3.1
The CONTRACTOR shall, upon receipt of the appropriate Referral documents from the
AUTHORITY request the appropriate Hospital Case Notes from the appropriate source.
3.2
Upon obtaining the HCNs the CONTRACTOR shall complete a typed extract from the HCNs,
relating to the medical condition in question and for the periods as directed by the
AUTHORITY.
3.4
The CONTRACTOR shall return to the AUTHORITY a completed typed report using extracts
from HCN’s which answers all questions posed by the AUTHORITY, with the Referral
documents.
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SCHEDULE 4 SECTION 4.11
SERVICE DESCRIPTION
INTERNATIONAL PENSIONS CENTRE
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SCHEDULE 4 SECTION 4.11
SERVICE DESCRIPTION
INTERNATIONAL PENSIONS CENTRE
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements set out
in Schedule 4.
1.2
The CONTRACTOR shall limit the gathering of any Further Medical Evidence to that evidence
available in the United Kingdom.
1.3
The CONTRACTOR shall liaise with the AUTHORITY in order to arrange a medical
examination which coincides with the Claimant’s visit to the United Kingdom for Claimants
who elect to return to the United Kingdom for their medical examination.
1.4
The AUTHORITY will make referrals clerically and referrals will not be registered on MSRS.
1.5
The AUTHORITY shall provide all the relevant IB and ESA referral documentation, including
the Claimant questionnaire and any FME.
2
INCAPACITY
BENEFIT
2.1
In respect of IB, the CONTRACTOR shall follow the procedures, as set out in Schedule 4.2.
2.2
Using the Claimant Questionnaire and FME provided by foreign doctors on forms E213 or
ESA-N-54C, the CONTRACTOR shall advise the AUTHORITY:
2.2.1
whether the Claimant is suffering from an exempt incapacity: or
2.2.2
whether the Claimant meets the threshold for incapacity: or
2.2.3
whether further FME is required.
3
EMPLOYMENT AND SUPPORT ALLOWANCE
3.1
In respect of ESA, the CONTRACTOR shall follow the procedures, as set out in Schedule
4.23.
3.2
The CONTRACTOR shall not complete a WFHRA in respect of IPC referrals.
4.0 SEVERE
DISABLEMENT
ALLOWANCE
4.1
In respect of Severe Disablement Allowance the CONTRACTOR shall follow the procedures
as set out in Section 4.3 of Schedule 4.
5
INDUSTRIAL INJURIES DISABLEMENT BENEFITS
5.1
In respect of Industrial Injuries Disablement Benefits the CONTRACTOR shall follow the
procedures as set out in Section 4.9 of Schedule 4.
5.2
Where a provisional assessment of disablement is provided by the CONTRACTOR, the
CONTRACTOR shall also advise if any Further Medical Evidence is to be gathered by the
AUTHORITY prior to the subsequent Referral to the CONTRACTOR for reassessment.
6
MEDICAL EXAMINATIONS AND FURTHER MEDICAL EVIDENCE GATHERING ON
BEHALF OF THE AUTHORITY WHEN THE AUTHORITY IS ACTING ON BEHALF OF
FOREIGN AUTHORITIES
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6.1
The CONTRACTOR shall perform medical examinations and/or gather Further Medical
Evidence on behalf of the AUTHORITY when the AUTHORITY is acting on behalf of foreign
authorities for Claimants who reside within the United Kingdom.
6.2
The CONTRACTOR will receive the appropriate Referral Document from the AUTHORITY.
Upon receipt, the CONTRACTOR shall arrange for an examination to be undertaken or
Further Medical Evidence to be gathered as required. The CONTRACTOR shall complete
and return all appropriate forms to the AUTHORITY. The CONTRACTOR acknowledges that
in certain cases, reports shall be typed and three copies shall be provided.
7
JAMAICA AND BARBADOS CASES
7.1
Claimants who are seen before departure
7.1.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY. Upon receipt of the Referral Documents the CONTRACTOR shall
advise as to whether or not the Claimant is permanently incapable of work on the
expected date of departure from the United Kingdom. Where advice cannot be
given on the basis of documentary evidence available the CONTRACTOR shall
undertake an examination.
7.1.2
The CONTRACTOR shall reply in the format required by the AUTHORITY and shall
return the same to the AUTHORITY.
7.2
IB Claimants who have already left the UK for Jamaica/ Barbados
7.2.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY. Upon receipt of the Referral Documents the CONTRACTOR shall
advise as to whether or not the Claimant was permanently incapable of work on the
date of departure from the United Kingdom.
7.2.2
Where the CONTRACTOR is unable to advise on the basis of the Referral
Documents, it shall gather Further Medical Evidence as is necessary to enable it do
so.
7.2.3
The CONTRACTOR shall reply in the format required by the AUTHORITY and shall
return the same to the AUTHORITY.
8
PRO-RATA BENEFIT CASES
8.1
IVB Pro-Rata Cases
8.1.1
The CONTRACTOR will receive the appropriate Referral Documents from the
AUTHORITY. Upon receipt of the Referral Documents, the CONTRACTOR shall
advise, on the basis of the Referral Documents only, as to whether or not the
Claimant is capable of all work or fit within limits, as set out in the Social Security
(Unemployment/Sickness and Invalidity Benefit) Regulations 1983.
8.1.2
The CONTRACTOR shall reply in the format required by the AUTHORITY and shall
return the same to the AUTHORITY.
8.2
Incapacity Benefit Pro-rata Cases
8.2.1
In respect of Incapacity Benefit Pro-Rata Cases the CONTRACTOR shall follow the
procedures set out in Section 4.2 of Schedule 4 with the provisions as set out in
Paragraph 2.2 of this Section 4.11 of Schedule 4
.
9
ADVICE FOR CLAIMANTS WHO LIVE ABROAD
9.1
The CONTRACTOR will receive the appropriate Referral Documents from the AUTHORITY.
Upon receipt of the Referral Documents the CONTRACTOR shall advise as required. Where
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the CONTRACTOR is unable to advise, it shall determine the most appropriate source and
nature of the additional evidence required and identify all relevant questions to be answered
to enable it to do so and shall return all documentation to the AUTHORITY.
9.2
Upon receipt of the documentation requested by the CONTRACTOR in accordance with
Paragraph 8.1 above, the CONTRACTOR shall advise as required and return all
documentation to the AUTHORITY.
9.3
The CONTRACTOR shall reply in the format required by the AUTHORITY and shall return the
same to the AUTHORITY.
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SCHEDULE 4 SECTION 4.12
SERVICE DESCRIPTION
DISABILITY LIVING ALLOWANCE/ATTENDANCE ALLOWANCE
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SCHEDULE 4 SECTION 4.12
SERVICE DESCRIPTION
DISABILITY LIVING ALLOWANCE/ATTENDANCE ALLOWANCE
1
. General
1.1
The CONTRACTOR shall adhere to the medical and common business requirements
detailed in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR shall provide examinations, reports and medical advice to the
AUTHORITY.
1.3
The CONTRACTOR shall provide to the AUTHORITY a written medical advice service.
1.4
The CONTRACTOR shall provide to the AUTHORITY a daily face to face medical advice
service as required by the AUTHORITY, on the AUTHORITY’s premises in agreed areas.
1.5
For the avoidance of doubt the CONTRACTOR shall provide a written response to the
face to face advice request as required.
1.6
The CONTRACTOR shall provide to the AUTHORITY appropriately completed Examining
Health Care Professional’s Reports upon request.
1.7
The CONTRACTOR shall provide an audiogram report with relevant advice upon request.
1.8
The CONTRACTOR shall provide MSRS access to IB85 and ESA 85 medical reports. If
the IB85 is not viewable by the AUTHORITY in MSRS, the CONTRACTOR shall provide
electronic copies as requested by the AUTHORITY.
2.
Advice
2.1
General Advice
2.1.1
The CONTRACTOR shall provide advice on any aspect of the Claimant’s
medical condition, claimed needs or on the existing medical evidence held
when requested to do so by the AUTHORITY. The CONTRACTOR shall in all
instances have regard to the Decision Maker’s (DMs) support guidance
available to DMs.
2.1.2
The CONTRACTOR shall provide a complete response to the questions
posed in that request which shall include but not be limited to:
(a)
an interpretation of medical evidence;
(b)
whether the claimed needs match the evidence;
(c)
what is the Prognosis;
(d)
a description of the usual effects of a particular medical condition;
(e)
deciphering medial jargon or difficult handwriting;
(f)
resolving conflicts in evidence;
(g)
any other medical issues raised;
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(h)
whether Further Medical Evidence is required and if so the most
appropriate source;
(i)
whether the questions posed are relevant and complete; and
(j)
details of drugs prescribed in relation to the medical condition(s) as
stated in the claim form.
2.1.3
The CONTRACTOR shall provide the advice in writing or verbally as
specified by the AUTHORITY.
2.1.4
If the CONTRACTOR is unable to give advice to the AUTHORITY based on
the documentary evidence available, the CONTRACTOR shall be explicit in
advising the type of Further Medical Evidence that may be required. The
CONTRACTOR shall give clear advice to the AUTHORITY as to where the
Further Medical Evidence may be obtained.
2.2
Advice On Suspected Fraud
2.2.1
Where the AUTHORITY requires advice on cases of suspected fraud the CONTRACTOR
shall give advice, solely on the medical issues, based on all the evidence presented.
2.3
Advice On Cases Referred Under The Special Rules Provision
2.3.1
The CONTRACTOR shall provide the AUTHORITY with advice as to whether the
Claimant is Terminally Ill as defined by Disability Living Allowance or Attendance
Allowance legislation.
2.3.2
The CONTRACTOR shall establish the date that the Claimant became Terminally Ill and
shall advise the AUTHORITY of that date on the appropriate documentation.
2.3.3
In cases relating to a Disability Living Allowance claim while considering the effect of the
medical condition on the care aspect of a claim, the CONTRACTOR shall advise the
AUTHORITY whether the medical conditions identified are likely to cause the mobility
problems as stated in the available information.
2.3.4
The CONTRACTOR shall identify on a separate form if appropriate, any Harmful
Information contained in the documentation being returned to the AUTHORITY.
2.4
Severely Mentally Impaired (Deeming Provision)
2.4.1
The CONTRACTOR will receive from the AUTHORITY the appropriate Referral
Documents that shall include but not be limited to all the relevant documentary evidence
available.
2.4.2
The CONTRACTOR shall provide the AUTHORITY with advice as to whether the
Claimant is suffering from a severe mental impairment and displays severe behavioural
problems as defined in the relevant Disability Living Allowance Regulations and Case
Law.
2.4.3
If the CONTRACTOR advises that additional medical information is required in order to
respond in full to the requirement question(s), the CONTRACTOR shall advise the
AUTHORITY of the most appropriate source for gathering the information required.
2.5
Advice on Cases referred under Special Rules (Terminally ill Pilot)
2.5.1
The CONTRACTOR shall provide the AUTHORITY with advice as to whether current
medical evidence supports a decision that the customer meets the Special Rules
Provision.
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3
EXAMINING HEALTH CARE PROFESSIONALS’S REPORTS
3.1
The CONTRACTOR will receive from the AUTHORITY the appropriate Referral
Documents.
3.2
The CONTRACTOR shall not make arrangements for an EMP examination without the
explicit approval of the AUTHORITY.
3.3
The CONTRACTOR shall provide a fully completed EMP report in the format required by
the AUTHORITY which provides the AUTHORITY with a full response to the specific
questions raised within that report with full justification of all opinions given.
3.4
The CONTRACTOR shall ensure that Claimants who are invited to attend examinations
in the examination centres are selected in accordance with criteria agreed with the
AUTHORITY (See Appendix 1 to this Schedule for current applicable criteria)
3.4.1
The CONTRACTOR shall ensure that where a Claimant declines the invitation to attend an
examination in an examination centre and requests a Domiciliary Visit that such a request is complied
with".
3.5
Where the CONTRACTOR is unable to gain access to the Claimant’s notified address on
the second occasion, the CONTRACTOR shall deliver to the Claimant at the second
abortive visit, a form for the Claimant to complete giving reasons for the Claimant’s non-
availability.
3.6
The CONTRACTOR shall consider the needs of the Claimant and if the Claimant is under
the age of sixteen (16) years or unable to manage their own affairs, then the
CONTRACTOR shall ensure that arrangements for the medical examination are
conducted via the legal guardian, or in the case of Claimants over the age of sixteen (16),
a suitable representative.
4
DEAFNESS CASES – AUDIOGRAM REQUIRED
4.1
The CONTRACTOR will receive from the AUTHORITY the appropriate Referral
Documents that shall include but not be limited to the Claimant details and
request for an audiogram
4.2
The CONTRACTOR shall perform audiometric tests where appropriate which shall be
conducted by qualified audiometric technicians.
4.3
The CONTRACTOR shall provide the AUTHORITY with the written results of the
audiometric test and the audiogram, performed when the Claimant is wearing any artificial
aid which is usually worn or is suitable in their case, which shall show the average overall
hearing loss in both ears at one (1), two (2) and three (3) KHZ.
4.4
Upon completion of the audiometric test the CONTRACTOR shall provide the
AUTHORITY with an interpretation of the audiogram and an assessment of the
Claimant’s percentage overall hearing loss occurring in both ears.
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Appendix 1
Below is a list of conditions deemed unsuitable for calling to a MEC for a DLA/AA Examination.
• Terminal illness [if an assessment for mobility component is required]
• Age under 12 years or over 75 years
• Agoraphobia [if confirmed by corroborative evidence]
• Tetraplegia, paraplegia, or dense hemiplegia*
• Severe involuntary disorders of movement or ataxia (eg cerebellar ataxia)*
• Severe and progressive neurological disease (eg multiple sclerosis, muscular
dystrophy, Parkinson’s disease – at the stage where there is significant disability)*
• Severe and persistent limitation of effort tolerance as a result of a cardiorespiratory
condition (eg COPD)*
• Dementia [other than very early stages]
• Double
amputees
• Blind
and deaf
• Severe learning disability*
• Multiple severe impairments
* Suggest that HCP advice is sought to confirm if these conditions should be excluded.
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SCHEDULE 4 SECTION 4.13
SERVICE DESCRIPTION
HM REVENUE and CUSTOMS TAX CREDIT
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SCHEDULE 4 SECTION 4.13
SERVICE DESCRIPTION
HM REVENUE and CUSTOMS TAX CREDIT
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR will receive telephone requests for medical advice and written requests
for medical advice and / or examinations from the AUTHORITY.
2.
HM REVENUE and CUSTOMS WORKING TAX CREDITS SERVICES REQUIRED
2.1
Telephone Service
2.1.1
The CONTRACTOR will receive telephone requests from the AUTHORITY for
advice. The questions posed shall include but shall not be limited to;
a)
clarification and amplification of medical documentary evidence held;
b)
advice as to whether the medical evidence described would enable the
Claimants to satisfy the disability test as prescribed in regulations; and
c)
medical advice in relation to employment and the Claimant’s prescribed
medical condition including clarification of the medical condition.
2.1.2
The CONTRACTOR shall respond to the questions raised by the AUTHORITY and
the CONTRACTOR shall either resolve the questions or alternatively advise the
AUTHORITY to make a written Referral to the CONTRACTOR for its further
consideration and advice.
2.2
Medical Advice and/or Examination
2.2.1
The CONTRACTOR will receive the appropriate Referral Documentation from the
AUTHORITY.
2.2.2
The CONTRACTOR shall provide the AUTHORITY with an appropriately
completed written report that gives a complete response to the question(s) raised
by the AUTHORITY.
2.2.3
The CONTRACTOR shall make all reasonable endeavours to give advice and
opinion on the documentary evidence available.
2.2.4
In the event that the CONTRACTOR is unable to give advice based on the
documentary evidence available, the CONTRACTOR shall take action to gather the
Further Medical Evidence required.
2.2.5
The CONTRACTOR shall highlight any Harmful Information contained within the
documentation being returned to the AUTHORITY. The CONTRACTOR shall
complete a separate form setting out this information if requested to do so by the
AUTHORITY.
2.3
Harmful Information
2.3.1
The AUTHORITY will at any time refer Referral Documentation to the
CONTRACTOR for consideration and identification of any Harmful Information
contained within the Referral Documentation.
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SCHEDULE 4 SECTION 4.14
SERVICE DESCRIPTIONS
SERVICE PERSONNEL & VETERANS AGENCY – EMP/SPECIALIST/REGIONAL CONSULTANT
& AUDIOLOGY REPORTS
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SCHEDULE 4 SECTION 4.14
SERVICE DESCRIPTIONS
SERVICE PERSONNEL & VETERANS AGENCY – EMP/SPECIALIST/REGIONAL CONSULTANT
& AUDIOLOGY REPORTS
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR will receive Referrals from the AUTHORITY when the AUTHORITY
requires additional medical evidence to be gathered by the CONTRACTOR in order for the
AUTHORITY to determine a UK Claimant’s (for Audiology only this also includes Northern
Ireland, Channel Islands, Isle of Man and the Scilly Isles) entitlement and/or supplementary
allowances and determine the assessment of War pension disablement (impairment).
1.3
The CONTRACTOR will receive from the AUTHORITY all appropriate Referral Documents.
1.4
The CONTRACTOR shall obtain Further Medical Evidence by way of an Examining Medical
Practitioner, Medical Specialist, British Dental Registered Specialist, Regional Consultant or
Audiology report as and when directed by the AUTHORITY.
1.5
The CONTRACTOR shall ensure that all Examining Medical Practitioners shall be Approved
by the AUTHORITY acting on behalf of the Secretary of State.
1.6
The CONTRACTOR shall provide the AUTHORITY with an appropriately completed written
report that gives a complete response to all the question(s) raised by the AUTHORITY.
2
WAR PENSIONS SERVICE REQUIREMENTS
2.1
Medical Examination (Examining Medical Practitioner)
2.1.1
The CONTRACTOR will receive from the AUTHORITY Referral Documents
relevant to the questions raised including those relating to individual supplementary
allowances where appropriate.
2.1.2
The CONTRACTOR shall provide the AUTHORITY with an appropriate written
report on the relevant forms giving the Claimant’s medical history and clinical
examination, in accordance with the War Pension Handbook for Examining Medical
Practitioners. The CONTRACTOR shall include a clinical diagnosis of all conditions
found together with answers to the specific questions raised by the AUTHORITY.
2.1.3
The CONTRACTOR shall provide the AUTHORITY with a written response on the
relevant forms in respect of any questions raised on the individual supplementary
allowances which are under consideration by the AUTHORITY.
2.1.4
The CONTRACTOR shall note that no opinion shall be given to the AUTHORITY
on aetiology: that is the cause of a Claimant’s medical condition or on any question
regarding benefit entitlement or on the percentage of an assessment against the
benefit claimed.
2.1.5
The CONTRACTOR shall provide the AUTHORITY with any additional clinical
information as required by the AUTHORITY.
2.2
Specialist Report
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2.2.1
The AUTHORITY will provide the CONTRACTOR with Terms of Reference, the
clinical history as known to the AUTHORITY, specific questions relating to the
individual Referral and where appropriate, copies of relevant evidence.
2.2.2
The CONTRACTOR shall provide the AUTHORITY with a written report, completed
by an appropriate Medical Specialist or in appropriate circumstances by a British
Dental Registered Specialist that gives a full response to the specific questions
raised. For the avoidance of doubt, the AUTHORITY shall have sole discretion to
decide if the author of the report is appropriate.
2.3
Regional Consultant Report
2.3.1
The AUTHORITY will provide the CONTRACTOR with Referral Documents that
shall include but not be limited to: a covering minute, Statement of Case, Terms of
Reference and specific questions that are relevant to the individual Referral.
2.3.3
The Contractor shall provide the AUTHORITY with a written report, completed by
an appropriate Regional Consultant, that gives a full response to the specific
questions raised. The AUTHORITY shall have sole discretion to decide if the author
of the report is appropriate.
3
ARMED FORCES COMPENSATION SCHEME
3.1
From April 2005 War Pensions was replaced by the Armed Forces Compensation Scheme
(AFCS) for incidents and conditions for which the onset post-dates April 2005. Under the new
scheme, Specialist reports, Regional Consultant reports, EMP examinations and Audiology
reports may occasionally be required in a manner identical to those required for the War
Pensions Scheme.
3.2
There is still a requirement to deal with cases under the War Pensions Scheme, where the
onset date is pre-April 2005, in the existing manner and there is no time limit proposed for
claiming in these situations. There is, therefore, a long term ongoing requirement for
Specialist reports, Regional Consultants reports, Audiology reports and EMP examinations for
these cases which the CONTRACTOR shall comply with.
4
AUDIOLOGY
REQUIREMENT
4.1
The CONTRACTOR will receive from the AUTHORITY the appropriate Referral Documents
that shall include but not be limited to: Claimant details and any relevant forms stating clearly
what sort of medical evidence is required.
4.2
The CONTRACTOR shall provide the AUTHORITY with diagnostic audiological testing,
performed by an appropriate audiologist and using equipment and standards as defined by
the British Society of Audiology.
4.3
The tests to be performed by the CONTRACTOR shall comprise:
• Standard Test, audiogram, this shall always be carried out
• Tympanometry and acoustic reflex threshold testing, when appropriate
• Cortical evoked response audiometry, when appropriate
5
THE AUDIOLOGY TEST
5.1
The testing site shall be an environment where the ambient noise level is less than 35dBA.
The only exception to this will be for domiciliary audiograms carried out on an exceptional
basis at the request of Service Personnel and Veterans Agency or the claimant. In these
circumstances, the Authority requires that every effort be made to record the audiogram in an
ambient noise level of less than 35dBA and the before and after ambient noise levels to be
recorded on the report.
5.2
Audiometry shall be preceded by otoscopic examination of both ears and the state of the ear
canals (including the presence of wax) and tympanic membranes are to be recorded by the
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audiometrician. This shall not be an opinion but a statement of facts as seen by the
audiometrician in accordance with British Society of Audiology published procedures.
5.3
All audiometry shall be carried out using a manually Operated Pure-Tone Audiometer, either
Type I or Type ii, biologically calibrated weekly.
5.4
The audiological test performed shall, in all cases, comprise:
• Completion of history and examination on form WPA0301
• Pure-tone audiogram, air and bone conduction. Air conduction over 250Hz, 550Hz, 1, 2,
3, 4, 6 and 8kHz and bone conduction over 500Hz, 1, 2, 3 and 4kHz, with masking as
appropriate.
5.5
The CONTRACTOR shall complete the first part of the form after discussion with the
Claimant, and ensure the Claimant signs and dates the declaration in their presence.
5.6
The CONTRACTOR shall complete the second part of the form during the examination, and
shall sign and date the form.
5.7
The CONTRACTOR shall ensure the completion and return of all appropriate forms following
each test.
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SCHEDULE 4 SECTION 4.15
SERVICE DESCRIPTION
VACCINE DAMAGE PAYMENT SCHEME
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SCHEDULE 4 SECTION 4.15
SERVICE DESCRIPTION
VACCINE DAMAGE PAYMENT SCHEME
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR shall provide a medical service which supports the Vaccine Damage
Payment Scheme (VDPS) procedures. This includes medical opinion and examinations.
1.3
The CONTRACTOR will receive from the AUTHORITY the appropriate Referral Documents.
2
SPECIFICS
2.1
Advice
2.1.1
The CONTRACTOR shall give an opinion based on the documentary evidence
available. This may include, but not be limited to, medical / Specialist reports along
with vaccination, education, Special Needs and social worker reports.
2.1.2
In the event that the CONTRACTOR is unable to give advice based on the
documentary evidence available, the CONTRACTOR shall gather Further Medical
Evidence as required and advise the AUTHORITY of it’s action. .
2.2
Examinations
2.2.1
The CONTRACTOR shall meet the needs of the Claimant as communicated by the
AUTHORITY and shall have regard to all factors, including age, which may render
a person claiming a Vaccine Damage Payment unable to act for themselves.
2.2.2
The CONTRACTOR shall give consideration to the age of the Claimant and if the
Claimant is a child under the age of sixteen (16) years the CONTRACTOR shall
ensure that arrangements for medical examination are conducted via the legal
guardian namely the person who completed the claim form on behalf of the
Claimant.
2.2.3
Where the Claimant is over the age of sixteen (16) and unable to manage their own
affairs, as advised by the AUTHORITY, the CONTRACTOR shall ensure that the
arrangements for medical examination are conducted via a suitable representative.
2.2.4
The CONTRACTOR shall acknowledge that if the person for whom the claim to
Vaccine Damage Payment has been made resides in a residential school, home or
hospital, the AUTHORITY shall require written notification of the arrangements for
examination to be issued to a representative of the named establishment at the
same time the written notification is issued to the legal guardian.
2.2.5
The CONTRACTOR shall ensure that terms of reference are prepared to
accompany any report form they issue explaining the specific questions that require
answering at the examination, along with specification of who exactly the Claimant
needs to see. All examinations shall be carried out by a Medical Specialist. These
examinations should be arranged as detailed in current operational guidance.
2.2.6
The CONTRACTOR shall inform the AUTHORITY that a medical examination is to
be arranged but is not required to obtain the agreement of the AUTHORITY to carry
out the examination.
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2.2.7
In new claims and reversals the CONTRACTOR shall use their own form on which
to record the examination. Where the examination has been requested by an
Appeal Tribunal the AUTHORITY will provide the report form for completion by the
CONTRACTOR.
2.3
Harmful Information
2.3.1
The CONTRACTOR shall provide the AUTHORITY as required written advice and
identification where necessary in respect of any Harmful Information contained in
the Referral information.
2.3.2
The CONTRACTOR shall complete a separate form setting out this information if
required to do so by the AUTHORITY.
2.4
New Claim For A Vaccine Damage Payment
2.4.1
The CONTRACTOR shall provide the AUTHORITY with a completed report form
which provides a complete response to all of the questions raised by the
AUTHORITY, particularly that of whether on the balance of probability the person
named on the documentation is severely disabled, that is they suffer disablement to
the extent of sixty per cent (60%) or more as a result of vaccination against one of
the diseases specified in section 1 (2) of the Vaccine Damage Payment Act 1979
(as amended).
2.4.2
The CONTRACTOR acknowledges that disablement to the extent of sixty per cent
(60%) or more, is as assessed for the purposes of section 103 of the Social
Security Contributions and Benefits Act 1992 on new claims submitted by the
AUTHORITY.
2.4.3
The CONTRACTOR shall complete the appropriate Department of Health form in
relation to the individual case to contribute to the Department of Health reporting
system for adverse vaccination reactions. This form will be supplied by the
AUTHORITY when the circumstances of the case deem it appropriate.
2.5
Reversal of a Vaccine Damage Payment Decision Under Section 3A Of The Vaccine Damage
Payments Act 1979
2.5.1
The CONTRACTOR shall provide the AUTHORITY with a completed report form
which provides a full response to all questions raised by the AUTHORITY,
particularly whether new or additional medical evidence gives rise to the possibility
that a decision could be reviewed by the AUTHORITY.
2.5.2
If the CONTRACTOR considers that a review may be undertaken by the
AUTHORITY the CONTRACTOR shall provide the AUTHORITY with a response to
the requirement question particularly that of whether on the balance of probability
the person named on the documentation is severely disabled, that is they suffer
disablement to the extent of sixty per cent (60%) or more as a result of vaccination
against one of the diseases specified in section 1 (2) of the Vaccine Damage
Payment Act 1979 (as amended).
2.5.3
The CONTRACTOR acknowledges that disablement to the extent of sixty per cent
(60%) or more, is assessed for the purposes of section 103 of the Social Security
Contributions and Benefits Act 1992, on reversals submitted by the AUTHORITY.
2.5.4
If the CONTRACTOR is of the opinion that the decision subject to the application
for a reversal needs to be re-examined, the CONTRACTOR shall consider how the
original determination has been affected by the application for reversal and advise
the AUTHORITY appropriately.
2.6
Appeals
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2.6.1
Where an appeal request is received the case may be submitted for consideration
of a Section 3A reversal prior to submission to the Appeal Tribunal. The process
will be the same as paragraph 2.5 above.
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SCHEDULE 4 SECTION 4.16
THIS SCHEDULE IS NOT USED
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SCHEDULE 4 SECTION 4.17
SERVICE DESCRIPTION
COMPENSATION RECOVERY SCHEME
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SCHEDULE 4 SECTION 4.17
SERVICE DESCRIPTION
COMPENSATION RECOVERY SCHEME
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The AUTHORITY shall provide to the CONTRACTOR the appropriate Referral Documents
that shall include but not be limited to: the Benefit History Sheet when available, all relevant
medical evidence and any other relevant information.
1.3
The CONTRACTOR shall highlight any Harmful Information contained in the medical report
and in any other supporting medical evidence available. The CONTRACTOR shall complete
a separate form setting out this information if requested to do so by the AUTHORITY.
2 SPECIFICS
2.1
The CONTRACTOR shall receive from the AUTHORITY Referral Documents relevant to the
questions raised. However, most cases tend to involve the following circumstances:
2.1.1
cases in which the Specialist medical report(s) provided by the injured person
appear to conflict with the Specialist medical report(s) provided by the
compensator, and the Compensation Recovery Unit is seeking an independent
view;
2.1.2
when, in medical negligence cases, there is disagreement over the point in time at
which the patient would have recovered from his injury or disease had it not been
for the alleged medical negligence;
2.1.3
cases in which it has been alleged that a pre-existing medical condition has
contributed to the condition for which compensation is being sought, or that the
symptoms the injured person is experiencing are entirely the consequence of a pre-
existing condition. In such cases the Compensation Recovery Unit would be
seeking advice on the likely progress of the pre-existing conditions in question.
2.2
In addition the CONTRACTOR shall provide advice to the AUTHORITY where a solicitor or
insurance company agree a set period of time that a Claimant would have been unfit for work
due to an accident, injury or disease, and incapacity benefits have been paid for longer than
the agreed period.
2.3
The CONTRACTOR shall also provide advice
on these cases regarding the duration of the
incapacity for work as a consequence of the injury or disease.
2.4
The CONTRACTOR shall
ensure that an appropriate Medical Specialist in the appropriate
field provides this advice to the AUTHORITY.
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SCHEDULE 4 SECTION 4.18
SERVICE DESCRIPTION
CHILD SUPPORT AGENCY
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SCHEDULE 4 SECTION 4.18
SERVICE DESCRIPTION
CHILD SUPPORT AGENCY
1
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR shall provide the AUTHORITY, namely the Child Support Agency
Monitoring and Guidance Unit, with medical advice based on submitted medical evidence.
2
CHILD
SUPPORT
AGENCY
SPECIFIC REQUIREMENTS
2.1
The CONTRACTOR will receive requests for medical advice from the AUTHORITY.
2.2
The CONTRACTOR will receive from the AUTHORITY Referral Documents which shall
include but not be limited to:
a)
the relevant file with all supporting evidence, including details of the Claimant’s
disablement or long-term illness;
b)
a prepared pro-forma giving grounds for the “Departure” application; and
c)
the medical question(s) to be answered.
2.3
The CONTRACTOR shall advise the AUTHORITY in writing whether the need(s) of the
Claimant, as stated, is/are consistent with the medical condition presented. The
CONTRACTOR shall provide the AUTHORITY with a written explanation in order to qualify its
response.
2.4
The CONTRACTOR shall advise the AUTHORITY in writing whether the Claimant’s medical
condition is likely to last at least fifty two (52) weeks from the date of the application or for life,
or if it is likely to last less than fifty two (52) weeks.
2.5
In the event that the CONTRACTOR is unable to give advice based on the documentary
evidence available, the CONTRACTOR shall be explicit in identifying to the AUTHORITY the
type of Further Medical Evidence required, the most appropriate source of the Further
Medical Evidence and the specific questions to be asked of the Claimant.
2.6
Upon completion of all necessary actions the CONTRACTOR shall
return to the AUTHORITY
all documentation received from the AUTHORITY or gathered on behalf of the AUTHORITY
in the same format as received, unless instructed to do otherwise by the AUTHORITY.
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__________________________________________________________________________
SCHEDULE 4 SECTION 4.19
SERVICE DESCRIPTION
PROVISION OF IB LiMA DATA STRIP TO INFORMATION ANALYSIS DIRECTORATE
(IAD)
1.
GENERAL
1.1.
The Logic integrated Medical Assessment (LiMA) system is a system with national
coverage, which supports the Evidence Based Medicine (EBM) approach to IB
Personal Capability Assessment (PCA) Examinations. It contains categorical
information concerning the customer’s condition, incapacity and capabilities. It also
contains their score following examination, which is used by Decision Makers in their
decision as to whether to disallow benefit or not.
2.
SPECIFICS
2.1
The CONTRACTOR shall provide a LiMA data strip on a monthly basis.
2.2
The CONTRACTOR will provide a list of QA checks that are in place during data
capture and a summary of version history with dates of releases and sites using the
release.
2.3
To enable IAD to fully understand and analyse the data the CONTRACTOR shall
provide documentation for all data (including metadata) – This will show what is
available, what it is called on the database, labels and any values, formats and
lengths.
2.4
The CONTRACTOR shall provide IAD with a data strip containing all customer
details, which include the NINO if possible. Registered Medical Practitioner’s personal
information will be excluded. Each table provided will contain a unique identification
code that will assist in the merging of tables, enabling IAD to follow a customer
through the process.
2.5
The CONTRACTOR shall provide copies of any regularly produced reports that are
appropriate and which will help IAD Data Support Unit (DSU) to QA the data they
receive and ensure that the data is used in the correct way.
2.6
The product shall contain the appropriate technical and organisational measures to
make sure that all personal data is protected against accidental loss, destruction or
damage.
2.7
For each monthly data table provided to IAD, the CONTRACTOR shall include details
of the size of each data table, the number of spells and the number of customers.
2.8
The CONTRACTOR shall provide information on a monthly basis which will enable a
cross check to be made that the information sent to IAD is the data which arrives
Final Version Schedule 4 Section 4.19 Dated: 13th April, 2005
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__________________________________________________________________________
Final Version Schedule 4 Section 4.19 Dated: 13th April, 2005
Subject to Contract Commercially Confident
______________________________________________________________
SCHEDULE 4 SECTION 4.20
SERVICE DESCRIPTION
REGENERATION OF IB85s FOR PPPDCS
1 GENERAL
1.1
PPPDCS require electronic copies of IB85 Reports from the
CONTRACTOR in cases where the PPPDCS Decision-Maker
considers the IB85 Report could be used as evidence in a claim for
DLA.
1.2
The IB 85 Report provided by the CONTRACTOR will be of the Logic
integrated Medical Assessment (LiMA) type that is held electronically,
is less than 2 years old and completed no earlier than September
2003.
2 SPECIFIC
REQUIREMENTS
2.1
PPDCS will request IB85 reports from the CONTRACTOR via the
PPDCS Group e-mail facility.
2.2
The CONTRACTOR will regenerate an IB85 within two working days of
the receipt of the e-mail from the PPDCS group email facility. The
Actual Average Clearance Time of requests will be available in monthly
MI reports.
2.3
The CONTRACTOR must ensure that the regenerated IB85 report will
be identical to the original report provided to IB Decision Maker.
Subject to Contract Commercially Confident
______________________________________________________________
2.4
The CONTRACTOR will return an email to the PPDCS group e-mail
facility indicating where no IB85 report is available.
2.5
Where a request for the regeneration of an IB85 fails, the
CONTRACTOR must alert PPDCS via an email being returned to the
PPDCS group email facility.
2.6 The Contractor must ensure that any sensitive information, as defined
in Schedule 4.1 Para 12.7.1 to 12.7.2, identified by the Registered
Medical Practitioner when completing the IB85 report, is brought to the
attention of the DM under separate cover.
3 Volumes
3.1
50,000 requests per annum
Medical Services Agreement
Commercially Confidential
SCHEDULE 4 SECTION 4.22
SERVICE DESCRIPTIONS
IB PATHWAYS TO WORK
1. GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements
detailed in Section 4.1 of Schedule 4.
2. IB PATHWAYS SPECIFICS
2.1
Capability Reports shall only be produced on initial Referrals which have been identified
by the AUTHORITY with a tick in the relevant pathways indicator box for normal or fast
track referrals.
2.2
For Referrals which have been identified with a tick in the relevant pathways indicator
box for normal or fast track referrals received from a Pathways District, the
CONTRACTOR shall also provide an opinion on whether the Claimant should refrain
from undertaking certain specified rehabilitation courses. For cases completed at
examination this shall be provided on the Capability Report. For cases cleared at the
Scrutiny stage, this shall be provided on the appropriate Scrutiny Report form.
2.3
The CONTRACTOR shall, after taking full account of current guidance decide if an
examination is appropriate. Having completed such an examination the CONTRACTOR
shall complete electronically produced forms IB85 and CRI where appropriate and
practical in accordance with current guidance for IB Approved HCPs.
2.4
The CONTRACTOR shall produce Capability Reports on form CR1 on Referrals which
have been identified by the AUTHORITY and which have been the subject of a Personal
Capability Assessment examination. The CONTRACTOR shall perform both the
Personal Capability Assessment examination and the Capability Report examination as
one single, seamless examination. The CONTRACTOR shall ensure that the completion
of this extra report does not in any way affect the completion of the Personal Capability
Assessment. For the avoidance of doubt, a Capability Report shall not be completed
where the examining HCP recognises at examination that the Claimant satisfies the
conditions for Exemption.
2.5
The CONTRACTOR shall provide full justification of the medical opinion expressed in
each Capability Report.
2.6
The CONTRACTOR shall ensure that Capability Reports are only completed by
Approved HCPs.
2.7
The CONTRACTOR shall separate the IB85 and the Capability Report and return the
Capability Report to the address identified by the AUTHORITY on the CR1 Return
Label.
2.8
The AUTHORITY will identify the address to which the CONTRACTOR shall return the
completed Capability Reports. The CONTRACTOR shall insert this address at the
appropriate section of the Capability Report and return the Capability Report using the
CR1 Return label.
2.9
The AUTHORITY shall provide the CONTRACTOR with supplies of the Capability
Reports, for use only in the event of electronic system failure and/or unavailability, and
the CONTRACTOR shall ensure that it maintains an adequate stock at all times.
2.10
The CONTRACTOR shall use a new Rework Referral code to identify to the
AUTHORITY Capability Reports returned for Rework.
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15 March 2005
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2.11
The AUTHORITY in its sole discretion shall decide if a completed Capability Report is
Fit For Purpose (in accordance with Schedule 4.1 para. 4.1.2).
2.12
The CONTRACTOR shall ensure that any Capability Reports which cannot be made Fit
For Purpose are destroyed in a confidential manner. In all such cases the
CONTRACTOR shall notify the AUTHORITY, using the appropriate documentation, that
the Capability Report has been destroyed and shall provide an explanation as to why
the Capability Report had to be destroyed.
2.13
The AUTHORITY will not accept a Capability Report as being Fit For Purpose until the
IB Examination (IB85) element of the same examination has also been accepted as Fit
For Purpose. (The CONTRACTOR shall complete a new Capability Report in all cases
where the previously completed IB Examination (IB85) report has been returned for
Rework and this has necessitated the CONTRACTOR re-examining the Claimant.)
Schedule 30 Final Version
15 March 2005
Page 2 of 2
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SCHEDULE 4 SECTION 4.23
SERVICE DESCRIPTIONS
EMPLOYMENT AND SUPPORT ALLOWANCE (ESA)
1. GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements
detailed in Section 4.1 of Schedule 4 of the Medical Services Agreement.
1.2
The CONTRACTOR shall ensure that HCPs completing Work Capability Assessments
(WCA) are Approved by the AUTHORITY.
1.3
At any stage following receipt of a Referral from the AUTHORITY, where the
CONTRACTOR becomes aware that the Claimant is Terminally Ill, it shall suspend all
actions and advise the AUTHORITY. Where appropriate, the CONTRACTOR shall notify
the Claimant not to attend an arranged appointment or not to return any documentation.
1.4
At any stage following receipt of a Referral from the AUTHORITY, where the
CONTRACTOR becomes aware that the Claimant meets the criteria for LCWRA, it shall
suspend all actions and advise the AUTHORITY,. Where appropriate, the CONTRACTOR
shall notify the Claimant not to attend an arranged appointment or not to return any
documentation.
1.5
Upon completion of all the necessary actions, the CONTRACTOR shall return all
documentation received from the AUTHORITY or gathered on behalf of the AUTHORITY.
2.0
Referrals where the Claimant is claiming ESA under the TI provision
2.1.
The AUTHORITY shall advise the CONTRACTOR at the point of registration whether
the Claimant is potentially Terminally Ill.
2.2
Where the AUTHORITY provides the appropriate document (DS1500), the
CONTRACTOR shall advise whether the Claimant is Terminally Ill or meets the
criteria for LCWRA.
2.3
Where the AUTHORITY is unable to provide the appropriate documentation
(DS1500), the CONTRACTOR shall check if advice has previously been provided to
PDCS that the Claimant is Terminally Ill no more than 6 months prior to the WCA
Referral. Where the CONTRACTOR has previously provided a report to the
AUTHORITY in respect of a Terminally Ill status, the CONTRACTOR may deem a
similar output for WCA.
2.4
If the CONTRACTOR is unable to determine whether the Claimant is Terminally Ill
with the documentary evidence available, the CONTRACTOR shall use reasonable
endeavours to attempt to obtain FME as quickly as possible.
2.5
Where the CONTRACTOR is able to determine that the Claimant is Terminally Ill, the
CONTRACTOR shall advise the AUTHORITY.
2.6
Where the CONTRACTOR is unable to determine that the Claimant is Terminally Ill,
the CONTRACTOR shall issue the ESA50 questionnaire to the Claimant.
3.0
LCWRA only Referrals
3.1
The CONTRACTOR will receive the appropriate Referral documentation from the
AUTHORITY.
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3.2
The CONTRACTOR shall advise the AUTHORITY whether the Claimant meets the
criteria for LCWRA.
3.3
If the CONTRACTOR is unable to determine whether the Claimant meets the criteria for
LCWRA with the documentary evidence available, the CONTRACTOR shall use
reasonable endeavours to attempt to obtain FME.
3.4
Where the CONTRACTOR is unable to determine that the Claimant meets the criteria for
LCWRA, the CONTRACTOR shall issue an ESA50A questionnaire to the Claimant or
their representative.
3.5
The CONTRACTOR shall issue a reminder to the Claimant or their representative if the
ESA50A is not returned to the CONTRACTOR after twenty eight (28) calendar days of
having provided it to the Claimant or their representative.
3.6
On receipt of the ESA50A questionnaire, the CONTRACTOR shall advise whether or not
the Claimant meets the criteria for LCWRA using the appropriate clerical form and shall
return all Documentation to the AUTHORITY.
3.7
Where the CONTRACTOR is unable to advise on the documentary evidence alone, the
CONTRACTOR shall arrange with the Claimant for an LCWRA assessment to be carried
out.
3.8
If the Claimant or their representative does not return the completed ESA50A
questionnaire within forty three (43) calendar days of its issue, the CONTRACTOR shall
advise the AUTHORITY that the Claimant does not meet the criteria for LCWRA and
complete the appropriate clerical form and return all documentation to the AUTHORITY.
3.9
Where the CONTRACTOR is able to determine that the Claimant meets the criteria for
LCWRA, the CONTRACTOR shall advise the AUTHORITY in the appropriate format.
4.0 Advice
Referrals
4.1
The CONTRACTOR shall provide medical advice or clarification of medical advice that
the AUTHORITY requests. Where the AUTHORITY requires advice e.g. can't read Med
3, these shall be faxed to the CONTRACTOR who will then provide the appropriate
advice in the same manner.
5.0
WCA Referrals
5.1
Issuing the questionnaire
5.1.1
On receipt of the Referral the CONTRACTOR shall issue the ESA50 questionnaire to the
Claimant or their representative.
5.1.2
The CONTRACTOR shall automatically issue a reminder to the Claimant or their
representative if the ESA50 questionnaire is not returned to the CONTRACTOR after
twenty eight (28) calendar days of having provided it to the Claimant or their
representative.
5.1.3 If the Claimant or their representative does not return a completed ESA50 questionnaire
within forty three (43) calendar days of its issue, the CONTRACTOR shall advise the
AUTHORITY, except where Mental Health conditions have been notified by the
AUTHORITY.
5.1.4
Where Mental Health conditions have been notified by the AUTHORITY and an ESA50
questionnaire is not returned within forty three (43) calendar days of its issue, the
CONTRACTOR shall undertake a “Pre-Board check” for initial referrals and scrutiny for
re-referrals as detailed in Paragraph 6.and Paragraph 7 of this Section 4.22.
Schedule 4 Section 23
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6.0
Pre-Board Check – Initial Referrals
6.1.
On receipt of a completed ESA50 questionnaire, the CONTRACTOR shall undertake a
preliminary Pre Board check on initial Referrals and in accordance with Paragraph 4.1.4
of this Section 4.22, to establish whether the Claimant has LCW and meets the criteria for
LCWRA on the basis of documentary evidence or whether an LCW/LCWRA assessment.
6.2.
Specifically, the CONTRACTOR shall establish whether:
6.2.1
the ESA 50 has been completed with all the relevant information;
6.2.2
FME is required to establish whether the Claimant has LCW and meets
the criteria for LCWRA;
6.2.3
a LCW/LCWRA assessment is required;
6.2.4
If an LCW/LCWRA assessment is required, whether it more appropriate
to be conducted by a Registered Nurse or Medical Practitioner in
accordance with agreed criteria; and
6.2.5
if an LCW/LCWRA assessment is required, whether it is appropriate for
an examination in a Medical Examination Centre (MEC), or, where FME
is required and has been obtained pursuant to paragraph 6.2.2, where a
Domiciliary Visit is appropriate.
6.3
The CONTRACTOR shall advise the AUTHORITY as to whether the Claimant’s level of
functional activity, due to a physical or mental disablement, is such that they have LCW
and LCWRA. For avoidance of doubt, LCW advice must always accompany LCWRA
advice.
6.4
The CONTRACTOR shall use reasonable endeavours to obtain any missing relevant
information or obtain FME to enable it to advise the AUTHORITY whether the Claimant’s
level of functional activity, due to a physical or mental disablement, is such that they have
both LCW and meet the criteria for LCWRA.
6.5
If the CONTRACTOR is unable to obtain any missing relevant information or obtain FME,
or where it determines that the Claimant does not meet the criteria for LCWRA, it shall
make all necessary arrangements to complete a LCW/LCWRA assessment .
7.0 Re-Referrals
7.1
Re-Referrals where the Claimant previously met the criteria for LCWRA
7.1.1
The CONTRACTOR shall complete a Scrutiny check for Re-Referrals where the Claimant
previously met the criteria for LCWRA to establish whether:
7.1.1.1
the ESA 50 has been completed with all the relevant information;
7.1.1.2
FME is required to establish whether the Claimant has LCW and meets the
criteria for LCWRA;
7.1.1.3
a LCW/LCWRA assessment is required;
7.1.1.4
if an LCW/LCWRA assessment is required, whether it more appropriate to be
conducted by a Registered Nurse or Medical Practitioner in accordance with
agreed criteria: and
7.1.1.5
if an LCW/LCWRA assessment is required, whether it is appropriate for an
examination in a Medical Examination Centre (MEC), or where FME is
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required and has been obtained pursuant to paragraph 7.1.1.2, whether a
Domiciliary Visit is appropriate.
7.1.2
The CONTRACTOR shall advise whether or not the Claimant continues to meet the
criteria for LCWRA based on documentary evidence.
7.1.3
Where there is evidence of improvement in the Claimant’s functional abilities or mental
disablement, the CONTRACTOR shall make all necessary arrangements to undertake an
LCW/LCWRA assessment.
7.2
Re Referrals where the Claimant previously met the LCW threshold but did not meet the
criteria for LCWRA
7.2.1
The CONTRACTOR shall complete a Scrutiny check to establish whether:
7.2.1.1 the ESA50 questionnaire has been completed with all the relevant information;
7.2.1.2
there is adequate evidence to support that the Claimant’s specific mental
or physical disablement continues to meet the LCW threshold;
7.2.1.3
FME is required to establish whether the Claimant’s specific mental or
physical disablement continues to meet the LCW threshold;
7.2.1.4
there is evidence of improvement in the Claimant’s functional abilities or
mental disablement since the last assessment and a further LCW/LCWRA
assessment is required;
7.2.1.5
if an LCW assessment is required, whether it more appropriate to be
conducted by a Registered Nurse or Medical Practitioner in accordance with
agreed criteria; and
7.2.1.6
if an LCW/LCWRA assessment is required, whether it is appropriate for an
examination in a Medical Examination Centre (MEC), or where FME is
required and has been obtained pursuant to paragraph 7.2.1.3, whether a
Domiciliary Visit is appropriate.
7.2.2
Where the CONTRACTOR is able to determine that the Claimant continues to meet the
LCW threshold, the CONTRACTOR shall advise the AUTHORITY. That advice shall
also include whether or not the Claimant meets the criteria for LCWRA.
7.2.3
Where the CONTRACTOR is unable to determine that the Claimant continues to meet
the LCW threshold, it shall make all necessary arrangements to complete a
LCW/LCWRA assessment.
8.0 LCW/LCWRA
Assessment
8.1
Where the CONTRACTOR is unable to advise that the Claimant has LCW or meets the
criteria for LCWRA, the CONTRACTOR shall arrange an LCW/LCWRA assessment.
8.2
If during the course of the LCW assessment, the Claimant meets the criteria for LCWRA,
the CONTRACTOR shall curtail the assessment and advise the AUTHORITY.
10.0 Domiciliary
Visits
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10.1
In addition to the provisions of Paragraphs 6.2.5, 7.1.1.5 and 7.2.1.6 of this Schedule
4.22 the CONTRACTOR shall undertake a Domiciliary Visit in accordance with the
provisions of Paragraph 5.15 of Schedule 4.1 (Part One).
10.2
Where the Claimant declines the invitation to attend an assessment in a Medical
Examination Centre and requests a Domiciliary Visit, the CONTRACTOR shall advise the
Claimant to provide medical evidence to support their request.
10.3
The CONTRACTOR shall record all attempts made to contact the Claimant or their
representative and any reasons given by the Claimant or their representative for non
availability.
10.4
Where the CONTRACTOR is unable to gain access to the Claimant’s notified address,
the CONTRACTOR shall issue the appropriate form to the Claimant or their
representative, which seeks to obtain the reasons for non-availability within twenty four
(24) hours of the Claimant’s non-availability for the arranged appointment.
11.0
In respect of Claimants who are Unable to Attend
11.1
The CONTRACTOR shall offer a further appointment without reference back to the
AUTHORITY to those Claimants who are Unable to Attend the first arranged
appointment.
11.2
The CONTRACTOR shall ensure that the second arranged appointment is left open until
the end of the day of the date of that second arranged appointment, to allow for the
possibility that the Claimant may be able to attend. If the Claimant does not attend the
second arranged appointment, the CONTRACTOR shall use reasonable endeavours to
despatch by email or post or make available through MSRS all documentation to the
AUTHORITY, within twenty four (24) hours of the second arranged appointment date,
which shall include a record of reasons given by the Claimant for non attendance and all
attempts made to contact the Claimant.
12.0
In respect of Claimants who Do Not Attend
12.1
If the Claimant Does Not Attend an arranged appointment, the CONTRACTOR shall use
reasonable endeavours to despatch to the AUTHORITY all documentation within twenty
four (24) hours of the date of that arranged appointment, which shall include a record of
reasons given by the Claimant for non attendance and all attempts made to contact the
Claimant.
12.2
The CONTRACTOR shall use reasonable endeavours to despatch by email or post to
those Claimants who Did Not Attend the arranged appointment, the appropriate form to
the Claimant which seeks to obtain the reasons for non attendance within twenty four (24)
hours of the Claimant not attending the arranged appointment.
13.0 Change
of
Circumstances
13.1
Upon receipt of notification of any relevant change to a Claimant’s circumstances, the
CONTRACTOR shall advise the AUTHORITY. If directed to do so by the AUTHORITY,
the CONTRACTOR shall despatch all requested documentation to the AUTHORITY by
no later than the next Working Day.
13.2
Upon notification of a change of circumstances of the Claimant by the AUTHORITY, the
CONTRACTOR shall use best endeavours to take appropriate and timely action to avoid
inconvenience to the Claimant.
13.3
Upon receipt of notification of any relevant change to a Claimant’s circumstances, the
AUTHORITY shall promptly advise the CONTRACTOR.
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14.0 Claimant
Expenses
14.1
The CONTRACTOR shall, at all times, operate within the parameters of Medical Services
Common Business Requirements, as set out in the Paragraph 13 of Schedule 4 Section
4.1 Part 1 of this Agreement, when considering the appropriate payment of any expenses
incurred by a Claimant and/or Companion in travelling to attend an arranged
appointment.
15.0 Temporary
National
Insurance
Numbers
15.1
The CONTRACTOR shall ensure that Referrals with a Temporary National Insurance
Number can be registered on the MSRS.
16.0 ESA
Documentation
16.1
The CONTRACTOR shall provide the Authority with copies of any documentation the
CONTRACTOR issues on behalf of the AUTHORITY at the AUTHORITY’S request.
16.2
The CONTRACTOR shall undertake a face to face assessment, either LCW/LCWRA or
LCWRA alone when specifically requested by the AUTHORITY
17.0
ESA Military Personnel
17.1
The Contractor will receive the appropriate referral documentation from the Authority,
including the ESA Claimant questionnaire and any FME, to advise whether the claimant
meets the criteria for LCWRA.
17.2
The Contractor shall advise the Authority of whether the Claimant meets the criteria for
LCWRA within 2 working days of receipt of the referral.
17.3
Where the Claimant does not meet the criteria for LCWRA, all the relevant paperwork
should be returned to the Authority.
Schedule 4 Section 23
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SCHEDULE 4 SECTION 4.21
SERVICE DESCRIPTIONS
FINANCIAL ASSISTANCE SCHEME
Schedule 4 Section 4.21
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Schedule 4 Section 4.21
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SCHEDULE 4 SECTION 4.21
SERVICE DESCRIPTIONS
FINANCIAL ASSISTANCE SCHEME
1.
GENERAL
1.1
The CONTRACTOR shall adhere to the medical and common business requirements detailed
in Section 4.1 of this Schedule 4.
1.2
The CONTRACTOR will receive the appropriate Referral documentation from the
AUTHORITY.
2.
Special Rules Advice
2.1
The CONTRACTOR shall provide the AUTHORITY with advice as to whether the Claimant is
Terminally Ill as defined by Disability Living Allowance or Attendance Allowance legislation.
2.2
In the event that the CONTRACTOR is unable to give advice on the documentary evidence
available, The CONTRACTOR will make one telephone call to the treating doctor in an effort
to secure further evidence, if it is a reasonable assumption that the evidence can be provided
over the telephone. If not, then the CONTRACTOR will identify what is required and return the
Referral to the AUTHORITY to request the further medical evidence.
2.3
The CONTRACTOR shall return all Referral documentation received from the AUTHORITY or
gathered on behalf of the AUTHORITY in the same format as received, unless instructed to
do otherwise by the AUTHORITY.
3.
Severely Ill Health Advice
3.1
The CONTRACTOR shall provide the AUTHORITY with advice as to whether the Claimant
suffers from a progressive disease and as a consequence can reasonably be expected to die
within five years.
3.2
The AUTHORITY will provide the CONTRACTOR with the Claimant’s Hospital contact details
and the CONTRACTOR shall obtain the Hospital case notes.
3.3
Upon completion of the referral, the CONTRACTOR shall destroy any copies of Hospital case
notes they have received or return any originals to the Hospital.
3.4
The CONTRACTOR shall provide Severely Ill Health Advice within 35 days from receipt of the
referral. For the avoidance of doubt, the Service Levels and Financial Remedies specified
within schedule 5 and schedule 25 shall not apply to Severely Ill Health Advice Referrals.
3.5
The CONTRACTOR shall the provide monthly to the AUTHORITY details of referrals
processed which will include claimant NINO, claimant name, date received, rejection reason,
clearance outcome, date cleared.
Schedule 4 Section 4.21
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