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Elective Surgery
Service Schedule
Operational Guidelines
August 2010
This is a living document and will be updated as required
Elective Surgery – Operational Guidelines
Contents
Introduction ............................................................................................................................................ 1
Who can hold this contract ..................................................................................... 1
What does the Elective Services Agreement cover ..................................................... 1
Completing a surgical Assessment Rehabilitation Treatment Plan (ARTP) .............................................. 2
Recommendations in the ARTP ............................................................................... 2
ARTP requirements ............................................................................................... 2
Treatment plan requirements ................................................................................. 3
Determine category of request ................................................................................................................ 3
Core list procedures .............................................................................................. 4
Red list procedures ............................................................................................... 4
How to apply for red list status ............................................................................... 4
Non-core treatment procedures .............................................................................. 4
Multiple procedure requests ................................................................................... 5
Eligibility criteria ................................................................................................... 5
Checking clinical priority ........................................................................................ 6
Increasing clinical priority ...................................................................................... 6
Transfer: Provider cannot meet timeframes ............................................................................................ 6
When this applies.................................................................................................. 6
Who can provide the treatment .............................................................................. 6
Scheduling the treatment ....................................................................................... 6
About non-contracted providers and lead providers ................................................................................ 7
Non-contracted providers ....................................................................................... 7
Lead providers ...................................................................................................... 7
About maximum contributions ................................................................................................................ 7
Private hospital ..................................................................................................... 7
District Health Board (DHB).................................................................................... 7
Contributions to the package of care ....................................................................... 7
Cost of implants is separate ................................................................................... 8
About co-payments ............................................................................................... 8
Contracted surgery ............................................................................................... 8
Regulation surgery (non contracted surgery) ............................................................ 8
Invoicing ................................................................................................................................................. 9
Retrospective funding requests ............................................................................... 9
Payment processing centre ....................................................................................... 9
Useful contact numbers ........................................................................................................................... 9
FAQ’s Elective Surgery Agreement ........................................................................................................ 10
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Elective Surgery – Operational Guidelines
Introduction
The following information is designed to help suppliers holding the ACC Elective Services
Agreement interpret the contract, and access it where appropriate. This is a living document
and updated versions will be made available on the ACC provider website as queries arise.
The Elective Services Agreement is used to fund surgical treatment by medical specialists in
surgical theatres.
Who can hold this contract
The Elective Services Agreement is usually held by hospitals and relates to the surgical
treatment of the injury.
The contract requires individual service providers, ie medical specialists, who will work under
the contract, to be named on the service agreement. A specialist can be named on more
than one Elective Services Agreement.
What does the Elective Services Agreement cover
These items are covered in the Elective Services Agreement:





surgical procedure and inpatient stay
post-discharge care by specialist for a period of six weeks
radiology during inpatient stay but not after discharge
inpatient physiotherapy
equipment for up to six weeks after discharge.
This includes manufactured items likely to help a client restore their independence in
daily living, including safety management. Examples include shower stools, crutches,
walking frames, wheelchairs.

orthotics for up to six weeks post-discharge.
This covers the fitting and fabrication of orthoses, and related technical aids used to
support or correct the function of the trunk, and upper and lower extremities.
Examples include splints, shoulder braces.

implants.
Note:
ACC pays for implants separately from the cost of treatment at their supply cost to the
supplier. The supplier gives proof of cost to the Elective Surgery Unit (ESU) in the form of an
invoice or similar evidence.
These items are not covered in the Elective Services Agreement:


prosthetics. These are provided as aids and appliances

diagnostic imaging services required after the date of discharge. (These are covered
by the high-tech imaging (HTI) contract, and the treatment costs regulations)


home help, attendant care, and childcare
outpatient physiotherapy and outpatient allied health follow-up after discharge. These
are covered by the treatment costs regulations.
transport and accommodation costs that are additional to the treatment for a client or
an escort
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Elective Surgery – Operational Guidelines

orthotics or long-term equipment for independence expected to be required for up to
six weeks after discharge.
Note:
Some of these services require prior approval. Assessment services are claimed via Cost of
Treatment Regulations or the Clinical Services contract.
Completing a surgical Assessment Rehabilitation
Treatment Plan (ARTP)
The ARTP serves as a request for approval of treatment. The report should provide ACC with
the crucial information it needs to make decisions on requested treatment procedures.
The Surgical ARTP online is the only version acceptable. If the ARTP does not meet
the standards, it will be returned with a request for further information.
Recommendations in the ARTP
If the provider recommends a surgical procedure they need to:


include details of it in the ARTP

send a copy of the ARTP to the client’s (GP) practitioner.
submit the ARTP to a lead provider who holds an Elective Services Agreement within
seven working days of the date of assessment. The lead provider then forwards the
ARTP to ESU
ARTP requirements
The following information should be completed:










client’s name, date of birth, address



whether this expectation has been communicated to and understood by the client
claim number
provider’s name and New Zealand Medical Council number
date of assessment
details of any diagnostics tests and imaging undertaken, and copies of the reports
injury diagnosis
clinical indications for the recommended treatment
recommended treatment plan
assessment of priority
prognosis, ie what the provider hopes to achieve with the recommended treatment
and the expected likelihood of return to work, return to independence, increased
function and reduced pain and suffering
details of any support services the client may require
details of any pre-existing conditions related to the existing injury. Details should
include:

a summary of any treatment or consultation related to the site of injury taking place
prior to date of injury

whether the client has been, or is being, treated by the provider prior to the date of
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injury

details and results of any diagnostic tests taken prior to date of injury.
Note:
This information should be written in language that is easily understood and free of jargon.
If the information cannot be understood, the provider will be contacted to clarify what they
mean.
Treatment plan requirements
The provider should send the treatment plan with the assessment report to ACC. The
following information is required in the plan:

the recommended services, detailing the surgical procedure (if appropriate) and the
clinical priority category

pre- and post-operative care, such as physiotherapy, aids, orthotic appliances, home
help, childcare, and so on

the name of the designated treatment surgeon who will be responsible for
undertaking any recommended surgery

any alternative treatment or other rehabilitation, including GP care, aids, orthotics,
physiotherapy, and non-surgical intervention

a certificate signed by the provider stating that:

the provider has taken all reasonable actions to give effect to the client’s rights and
comply with the duties in the Code of Health and Disability Services Consumers
Rights1

the treatment is required to treat a personal injury for which ACC has granted the
client cover

the provider has discussed the treatment options with the client, and advised why the
recommended treatment is the most appropriate.
Note:
If the essential requirements are not provided as described above, further information will
be requested. No additional payment to the provider for this information will be made. If in
doubt about entitlement or cover, the case manager/claims officer has the right to query the
contents of the ARTP.
Determine category of request
When a request is received for elective services, the first step is to determine what category
of treatment procedure it falls into. There are three categories:
Contracted

core

red list
Non-core

standard

red list

complex
Regulations
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Core list procedures
Core list procedures are less complex than red list procedures and are high volume.
Examples can include procedures associated with personal injury, or as a consequence of
pre-existing factors.
Red list procedures
Red list procedures are relatively complex, high cost, and low volume. Providers who carry
out red list procedures have a red list variation to their contract.
Only a specialist named in the contract can perform red list procedures.
How to apply for red list status
Contact Health Procurement at [email protected] and request an
application pack to be a red list provider. Application forms will be sent to you for
completion. Once these are returned to ACC they are forwarded to the relevant sub specialty
group for review and a recommendation, eg application to become a spinal red list specialist
would be sent to the NZOA spinal sub specialty group.
Written notification will be issued once a decision is made. It’s important to note that you
may not perform red list procedures until you have received this notification.
Non-core treatment procedures
Non-core treatment procedures are not included in the treatment procedure list and are
usually either:


a less common treatment procedure, or
a combination of a core treatment procedure listed in the tables and a procedure that
is not listed.
The non-core treatment procedures are also split up into two types, standard and complex.
If in any doubt about whether a request is standard non-core, or complex, please forward
the details of the query, and all the relevant supporting information, to the Non-core Pricing
Team at ACC Elective Services Centre. They will review the case and consider which type it
is.
Note:
Non-core procedures are not:


core procedures that the provider has not agreed to a contracted price for
core procedures by a non-contracted provider. This is regulation treatment, not noncore treatment.
Standard non-core procedures
These treatment procedures include elements such as:




multiple procedures involving three or more core procedures
standard types of surgery that cannot be fitted into a core procedure
procedures whose resources will be predictable
procedures that are not likely to require the client being in an ICU.
All contracted specialists who are named under an Elective Services Agreement can
undertake these treatment procedures.
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Complex non-core procedures
These treatment procedures are unusual or particularly complex procedures. They include
elements such as:

multiple procedures involving three or more core procedures, of which at least one
procedure is red


complex types of surgery that cannot be fitted into an equivalent red core procedure
procedures whose resources are unpredictable in nature.
Only a named red list specialist with a supplier, who holds a red list contract variation, can
perform these treatment procedures. In these cases ACC will agree on an estimated cost
with the supplier, but will then pay on the actual inputs used, ie the actual theatre time and
length of stay.
Regulations (non-contracted surgery)
ACC is liable to pay or contribute to the cost under regulation 18 of the Injury Prevention,
Rehabilitation and Compensation (Liability to Pay or Contribute to Cost of Treatment)
Regulations 2003 (‘non-contracted surgery’).
This includes all procedures listed on the Elective Surgery Service Schedule treatment
procedure list, eg codes AFT – WAH (includes red list procedures).
Private hospitals are paid at 60% of the contracted rate and DHBs are paid 100% of the
contracted rate.
This can also include standard and complex non core. Private hospitals are paid at 60% and
DHBs at 100%.
All implants are paid at 100%.
Multiple procedure requests
Requests may be made for a combination of core and non-core procedures, or of two
different types of core procedure, ie core and red list.
If a request …
consider it …
involves multiple procedures from more
than one list
under the requirements and restrictions
of the most complex list.
Example: If a request involves one
core list and one red list procedure,
treat this as a red list procedure.
is for multiple procedures which involve
a combination of core and non-core
procedures
as a non-core request
Eligibility criteria

ACC has discretion in approving contracted elective services. However, the following
criteria must guide these decisions:

Treatment must be necessary and appropriate, and meet all other eligibility criteria
for treatment

All documentation must be complete.
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Checking clinical priority
The clinical priority (that is, the urgency of the client’s need for the treatment) should be
clearly stated on the provider’s request.
Increasing clinical priority
The case manager can assign more urgency to the client’s treatment if the client meets any
of these criteria:

they could lose their current job because they cannot continue in paid employment
while waiting for treatment (and the treatment is likely to reverse the relevant loss of
function)



they are currently receiving weekly compensation
they are currently receiving a high level of social rehabilitation assistance
the treatment is likely to help restore the client’s independence in daily living
activities such as educational participation for a school student.
Transfer: Provider cannot meet timeframes
When this applies
If the involved parties cannot negotiate a suitable date for surgery, the lead provider needs
to refer the client to another lead provider, as agreed by ACC.
Who can provide the treatment
The type of treatment procedure determines who can provide the treatment.
Treatment procedure
Provider


core
any provider with a contracted supplier whose contract
non-core - standard
covers that treatment


core - red list
a red list provider specifically named in a contract to
provide that treatment, using those specific codes.
non-core - red list or
complex
Scheduling the treatment
Once the treatment is approved, the provider is responsible for arranging a mutually
appropriate date for treatment with the client.
If the provider cannot arrange this within the required timeframe for the contract and clinical
priority, ACC will arrange to transfer the client’s care to another provider who can meet the
timeframe.
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About non-contracted providers and lead providers
Non-contracted providers
A non-contracted provider is:

A provider who requests elective services treatment for a client, but who does not
have a contract with ACC to provide elective services treatment.
Lead providers
In the context of regulation elective surgery, the lead provider is the specialist medical
practitioner who submits the request for treatment.
The lead provider is responsible for:

negotiating a fee with the hospital and anaesthetist to determine the total price they
will charge for the procedure, therefore setting the co-payment the client will
ultimately pay


receiving the maximum contribution amount payable by ACC
distributing that payment to the hospital, anaesthetist, and so on.
About maximum contributions
A maximum contribution amount is the price that ACC is required to pay under the
treatment costs regulations for any elective services treatment undertaken by a noncontracted provider. The amount ACC will contribute depends on whether the service
provider is a private hospital or a district health board (DHB).
Private hospital
If the client has elective surgery in a private hospital, ACC contributes only a proportion of
the total cost of the treatment procedure.
District Health Board (DHB)
ACC pays the full cost for regulation elective services undertaken at a public hospital. ACC
has defined this as being the contracted amount agreed to by that particular DHB contract
for that procedure.
Note:
If the procedure is a non-core procedure, ACC pays the one-off price agreed.
Contributions to the package of care
The maximum contribution amount applies to the total package of care. The price covers:





surgical procedure and inpatient stay
post-discharge care by specialist for a period of six weeks
radiology during inpatient stay, but not after discharge
inpatient physiotherapy
equipment for independence for up to six weeks after discharge
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This includes manufactured items likely to help restore a client’s independence in
daily living activities, including safety management. Examples include shower stools,
crutches, walking frames and wheelchairs.

orthotics for up to six weeks post-discharge
This covers the fitting and fabrication of orthoses and related technical aids used to
support or correct the function of the trunk and upper and lower extremities.
The surgeon requesting approval for regulation surgery is responsible for ensuring that
payment is made to the hospital, anaesthetist and others from the maximum contribution
amount. The surgeon can request that a hospital takes on the lead provider role. If this is
the case, the hospital is responsible for distributing payments to all parties concerned.
ACC is not liable to pay any fees for the above outside this amount.
Cost of implants is separate
The cost of implants is separate from the cost of the treatment, and is not included in the
maximum contribution amount:


ACC pays the actual cost of implants, based on the supply cost to the provider
The provider has to invoice ACC separately for implants and provide a copy of the
invoice or similar evidence. Invoices must be sent by the provider within 12
months of the service provided or ACC will not pay.
About co-payments
The co-payment is the amount the client has to pay to cover the remaining costs between
ACC’s maximum contribution and the total amount charged by a non-contracted provider.
Contracted surgery
A contracted provider is one who requests elective services treatment for a client, and has a
contract with ACC to provide the type of treatment procedure in the request. This is the
standard method of applying for surgery to be approved. Fees are provided from allocated
budgets for contract holders, ie suppliers. The nationally agreed price paid for surgery
covers the surgical treatment and the six weeks post procedure care after discharge from
hospital. This includes the follow-up assessments, short term hire of equipment and majority
of pharmaceuticals required.
Regulation surgery (non contracted surgery)
All payments under regulation surgery cover the same period of treatment as contracted
surgery.
If the application is for surgery that ACC is liable to pay or contribute to the cost of under
regulation 18 of the Injury Prevention, Rehabilitation, and Compensation (Liability to Pay or
Contribute to Cost of Treatment) Regulations 2003 (‘non-contracted surgery’), an ARTP
needs to be completed and sent to ESU. The ARTP will need to indicate that this is a
regulation request.
Note:
The process for informing the client regarding the decision is important.
Clients must make the decision regarding the choice of regulation surgery dependant on
them having all the information available to them. This includes the amount ACC will
contribute to the surgery costs.
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ACC has a requirement to inform the client that surgery can be performed by a contracted
provider at no cost to the client. This information is provided directly to the client in a
decision letter. The client must sign the letter and return it to ACC to demonstrate
understanding and consideration of all of the options available.
The discussion regarding options will need to occur after the approval decision for surgery,
when all information is available. This will result in a second consultation regarding surgical
options.
ACC requires the completed documentation before any payments can be made for the
provision of surgery.
Invoicing
Retrospective funding requests
If on commencing an approved surgical procedure, it is found that an alternative
unanticipated procedure is necessary and more appropriate, the procedure may be carried
out. A detailed invoice requesting retrospective funding must be submitted to ACC.
This invoice must contain the following:


operation notes
other relevant supporting documentation.
Payment processing centre
The Elective Service Centre processes all surgical invoices.
The provider can submit their invoice for elective services treatment to the ESU for payment
from the date of discharge. All invoices must be sent within 12 months of the treatment
provided or they will not be paid.
Useful contact numbers
Provider helpline
Ph: 0800 222 070
Health Procurement
Ph: 0800 400 503
[email protected]
[email protected]
The Provider helpline staff can
assist with queries relating to
provider numbers, ARTP
updates and general enquiries
Health Procurement can provide
advice regarding appropriate
documentation in relation to the
application for contracts.
August 2011
Inquiry Service
Centre (ISC)
Ph 0800 101 996
For general enquiries,
ISC will answer your call
and refer you for further
assistance if required.
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FAQ’s Elective Surgery Agreement
Q.
Can I charge a co payment?
A.
No, not for contracted surgery. The price for each service is the amount chargeable
and no additional amount may be charged.
If the surgery is non-contracted and undertaken in a DHB ACC pays 100% and no copayment can be charged. If the non-contracted surgery is undertaken in a private
hospital ACC pays 60% of the contracted price and the client can be charged a copayment.
Q.
Where do I send the ARTP?
A.
All ARTPs are sent to the Elective Service Centre - [email protected]
Q.
The treatment I need to provide is not listed in this contract. What can I do?
A.
Complete an ARTP for a non core or complex non core procedure and submit to the
Elective Service Centre.
Q.
My patient does not have a case manager and requires further assistance from ACC.
Who do I contact?
A.
Contact the Inquiry Service Centre
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