Necessary and reasonable guideline

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View our individual guidelines to focus on the topics that matter to you. These are also available in plain language versions which are easier to understand (called MyGuides).

Necessary and reasonable guideline (PDF, 377KB)

MyGuide1: what we pay for (PDF, 161KB)

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• Definitions

  Defined terms are shown throughout in bold underlined text when they first appear.

  Accepted injury means a participant’s eligible injury, or another personal injury which the NIISQ Agency has decided should be supported under the National Injury Insurance Scheme, Queensland.

  Another personal injury means a personal injury sustained in the same motor accident which caused the participant’s eligible injury.

  Approved service means treatment, care and support stated in a participant’s MyPlan to be a necessary and reasonable treatment, care and support need as a result of a participant’s accepted injury.

  Eligible injury means the serious personal injury which entitles a person to support as a participant in the National Injury Insurance Scheme, Queensland (NIISQ).

  Information notice means a notice containing:

  • the decision made by the NIISQ Agency
  • the reasons for the decision made by the NIISQ Agency
  • the day the decision has effect, and how a person can apply for review
    of the decision.

  MyPlan means a support plan prepared by the National Injury Insurance Agency, Queensland (NIISQ Agency) and approved under section 26 of the National Injury Insurance Scheme (Queensland) Act 2016.

  MyPlanning is the process of assessing necessary and reasonable treatment, care and support needs under section 25-27 of the National Injury Insurance Scheme (Queensland) Act 2016.

  Motor accident means the incident resulting in the participant’s eligible injury.

  Provider includes registered and unregistered providers of treatment, care and support, but excludes a family member of the participant.

  Service request is a written request for treatment, care and support to be provided to a participant for a particular period made under section 28 of the National Injury Insurance Scheme (Queensland) Act 2016.

  State emergency services include but are not limited to services provided by Queensland Ambulance Service, Queensland Fire and Emergency Service and Queensland Police Service.

• Funding support under the National Injury Insurance Scheme, Queensland

  This guideline explains how the NIISQ Agency decides whether treatment, care and support for, or related to a participant’s treatment, care and support needs (see: treatment, care and support needs) are necessary and reasonable.

  There is a plain language version of this guideline which is shorter and uses simpler words. To access it, view MyGuide 1 – What we pay for.

  Once a treatment, care and support need has been decided as necessary and reasonable, it becomes an approved service, and is included in the participant’s MyPlan. The NIISQ Agency can then make payments for an approved service when the approved service is provided.

  The approach described in this guideline has general application to necessary and reasonable treatment, care and support decision making for both MyPlan and service request decisions.

• Treatment, care and support needs

  The National Injury Insurance Scheme (Queensland) Act 2016 defines a participant’s treatment, care and support needs to include (or relate to):

  • medical and/or pharmaceutical treatment
  • dental treatment
  • rehabilitation
  • ambulance transportation
  • respite care
  • attendant care and support services (which are services to help a person with everyday tasks)
  • aids and appliances, other than ordinary personal or household items
  • prosthesis
  • education or vocational training
  • home or transport modification.

  Example 1: Support that may be related to a treatment, care and support need could be: funding of mileage, a taxi fare or rideshare charge where the participant is required to travel for a medical or allied health appointment for their accepted injury.

  Example 2: Support that may be related to a treatment, care and support need could be the funding of some accomodation costs while home modifications are being undertaken to a participant’s home (see: Home Modifications guideline)

  How does the NIISQ Agency identify a participant’s treatment, care and support needs?

  The NIISQ Agency will identify a participant’s treatment, care and support needs shortly after they are accepted as a participant in the NIISQ as part of MyPlanning.

  Additional assessments will occur as a participant’s support needs change, and at least once a year.

  Identifying a participant’s treatment, care and support needs is done in collaboration with the participant, their family and/or other informal supports, and providers.

• Deciding whether treatment, care and support is necessary and reasonable

  The NIISQ Agency will fund the cost of treatment, care and support when the supports are decided by the NIISQ Agency to be ‘necessary and reasonable’. There are three steps involved in deciding whether each treatment, care and support is necessary and reasonable.

  Step 1: consider whether the treatment, care and support need is a result of the participant’s accepted injury

  The NIISQ Agency will decide whether treatment, care and support is for, or related to a treatment, care and support need that the participant has as a result of an:

  • accepted injury or
  • injury, condition or disability which has no connection to the motor accident.

  Where the need results from an injury, condition or disability that has no connection to the motor accident

  There may be circumstances where a participant does have treatment, care and support needs, but they do not result from their accepted injury and the treatment, care and support that the participant requires should be provided by a different service, for example through:

  • public sector health services
  • private health insurance arrangements
  • other statutory insurers, including the National Disability Insurance Scheme, My Aged Care, Comcare and Department of Veterans Affairs.

  Example 1: A participant requires a routine dental check-up which is unrelated to the injuries they sustained in a motor vehicle accident. The NIISQ will not pay for the participant’s dental consultation, and the participant will need to pay the costs themselves or use private health insurance (where available).Example 2: A participant has a pre-injury mobility impairment which is not directly related to the treatment, care and support need. The participant receives support under the National Disability Insurance Scheme for their pre-injury mobility impairment.

  Step 2: consider whether the treatment, care and support is excluded under the NIISQ

  Excluded treatment, care and support is generally not funded under the NIISQ. Excluded treatment, care and support is treatment, care and support which is proposed to be provided in certain circumstances.

  These circumstances are where the treatment, care and support:

  • is normally provided without a charge
  • is provided in circumstances where the participant is a child, and falls within the ordinary costs of raising a child
  • must be provided by a provider registered under the National
    Injury Insurance Scheme (Queensland) Act 2016, but is provided by a person who, at the time the treatment, care and support was provided, was not a registered provider. This includes any of the following:
    • attendant care and support services
    • supports related to home modifications
    • support coordination service.
  • is provided as a part of a medical trial (including clinical trials) or on another experimental
  • is treatment, care and support ordinarily provided by public sector health service, or state emergency services.

  If the treatment, care and support is provided in one or more of the circumstances above then it will meet the definition of excluded treatment, care and support. While excluded treatment, care and support is not required to be funded under the NIISQ, the NIISQ Agency may decide to fund in certain circumstances.

  Step 3: assess the support against the necessary and reasonable criteria

  The National Injury Insurance Scheme (Queensland) Regulation 2016 describes four matters which the NIISQ Agency will consider when it assesses whether treatment, care and support is necessary and reasonable.

  Benefit to the participant

  What the NIISQ Agency will consider when deciding if the treatment, care and support is likely to have a benefit to a participant

  What are the factors that would indicate that the treatment, care and support is likely to benefit a participant

  Whether the treatment, care and support is likely to maximise the participant’s independence, participation in the community and employment and; Whether the treatment, care and support will assist the participant in managing the injury

  The treatment, care and support relates directly to any goals identified during the participant’s needs assessment The treatment, care and support will improve or maintain the participant’s ability to conduct daily activities, or participate in the community or employment If the treatment, care and support has been provided previously, that it has resulted in an improvement, or has assisted with the management of the participant’s accepted injury That the treatment, care and support has a measurable outcome That the participant has agreed (or is likely to agree) that the treatment, care and support will benefit them Risks associated with the treatment, care and support to the participant, when weighed against the expected benefit of the treatment, care and support to the participant

   

  Appropriate service 

  What the NIISQ Agency will consider when deciding if the treatment, care and support is appropriate for a participant

  What are the factors that would indicate that a treatment, care and support is appropriate for a participant

  Whether the treatment, care and support is consistent with other treatment, care and support received by the participant and; Whether the treatment, care and support is consistent with current clinical practice and other industry best practice for similar injuries

  That the treatment, care and support is consistent with the participant’s expected future treatment, care and support needs That the treatment, care and support relates directly to any goals identified by the participant and/or identified in the participant’s support plan That the treatment, care and support is not harmful to the participant Where similar treatment, care and support is already being provided to the participant, that it does not duplicate any approved services, or other support available to the participant under another service system That there is evidence that supports the effectiveness of the treatment, care and support (see: evidence-based interventions)

  Appropriate provider

  What the NIISQ Agency will consider when deciding if the treatment, care and support will be provided by an appropriate provider

  What are the factors that would indicate that treatment, care and support is provided by an appropriate provider

  Whether the treatment, care and support is provided by an appropriate provider

  That the provider, and the provider’s staff are appropriately qualified That the provider is appropriate for the participant That the provider is acceptable to the participant That there is no conflict of interest for the provider to provide the support to the participant That the provider’s fees are reasonable That the provider is registered to provide the support (see: consider whether the support for the treatment, care and  support is excluded under the NIISQ)

   

  Cost-effective treatment, care and support

  What the NIISQ Agency will consider when deciding cost effectiveness

  What are the factors that would indicate that treatment, care and support is cost effective

  Whether the treatment, care and support is cost effective

  That the benefit of the participant receiving the treatment, care and support outweighs the cost of providing the support That providing the treatment, care and support is more cost effective compared to the same or similar support provided by other suitable providers That providing the treatment, care and support is more cost effective than any alternative That the cost of the treatment, care and support is reasonable for the period of time that it is to be provided

  The NIISQ Agency may decide that there are other matters which are relevant to an assessment and take those additional matters (if any) into account where the NIISQ Agency considers it appropriate to do so.

  Providers to adopt the nationally-recognised clinical framework

  Clinical providers that are providing treatment, care and support should adhere to the nationally-recognised Clinical Framework for the Delivery of Health Services.

  This framework is based on five principles which are intended to support clinical providers to deliver the right treatment to participants in the NIISQ. The five principles are:

  • measurement and demonstration of the effectiveness of treatment
  • adoption of a biopsychosocial approach
  • empowering the injured person to manage their accepted injury
  • implementing goals focused on optimising function, participation and return to work
  • basing treatment on best-available evidence (including considering evidence supporting the effectiveness of treatment under the levels published by the National Health and Medical Research Council).

  When the NIISQ Agency decides whether treatment, care and support is necessary and reasonable, it will relate these five principles to the necessary and reasonable criteria specified in the National Injury Insurance Scheme (Queensland) Regulation 2016.

• Guideline limitations and review of decisions

  The Treatment, care and support guidelines are the NIISQ Agency’s interpretation of the implementation of the National Injury Insurance Scheme (Queensland) Act 2016 and National Injury Insurance Scheme (Queensland) Regulation 2016, and are intended to guide decision-making on necessary and reasonable treatment, care and support. The treatment, care and support guidelines are designed to improve the quality and consistency of NIISQ Agency decisions while promoting transparency and public trust in the NIISQ.

  The Treatment, care and support guidelines are a set of policies created by the NIISQ Agency, and they are not law. While substantial efforts have been made to ensure consistency with; the NIISQ statutory framework, other applicable legislation (including the Human Rights Act 2019), and court rulings, in circumstances where there is a conflict or inconsistency, the legislation or court ruling (where facts are the same or substantially similar) will have preference over the Treatment, care and support guidelines. The treatment, care and support guidelines will be updated over time.

  Guidelines not to be applied inflexibly

  To ensure that they are not applied inflexibly, the Treatment, care and support guidelines do not prevent a decision-maker exercising discretion where this is permitted under the National Injury Insurance Scheme (Queensland) Act 2016, and decision-makers are not constrained from reaching a particular decision by taking into account all relevant considerations for a participant’s particular circumstances. It is the NIISQ Agency’s intent that the Treatment, care and support guidelines provide guidance for the exercise of discretionary power.

  Guidelines limited to necessary and reasonable treatment, care and support

  The Treatment, care and support guidelines describe how the NIISQ Agency makes decisions about funding necessary and reasonable treatment, care and support. The guidelines exclude funding treatment for injuries other than an accepted injury in accordance with the matters listed in section 26(1)(e) of the National Injury Insurance Scheme (Queensland) Act 2016, which is another way the NIISQ Agency may provide funding for treatment, care or support.

  Review of particular decisions made by the NIISQ Agency

  If a person disagrees with a decision made by the NIISQ Agency, there may be an option for the decision to be reviewed. Reviewable decisions are provided as an information notice, which includes reasons for the decision made by the NIISQ Agency. Ordinarily, a review can be requested within 28 days of the date a person receives notice of a decision. The NIISQ Agency will adhere to the principles of procedural fairness in relation to decisions which might adversely affect a person by ensuring the person has an adequate opportunity to provide information on a relevant issue before the NIISQ Agency makes the decision. There are additional review pathways available to a person who does not agree with an internal review decision, including through the Queensland Civil and Administrative Tribunal, and/or the Medical Assessment Tribunal. More information about internal reviews can be found on the NIISQ website.

  Common definitions used in all guidelines

  The following definition is used in all other guidelines:

  • ‘Accepted injury’ has the same meaning as given to it in this guideline, the Necessary and reasonable guideline.