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. Medical Services Agreement

Commercially Confidential

SCHEDULE 4 SECTION 4.2 SERVICE DESCRIPTION

INCAPACITY BENEFIT/INCOME SUPPORT/HOUSING BENEFIT/COUNCIL TAX BENEFIT AND OTHER RELATED ADVANTAGES

Schedule 4 Section 4.2 Final Version

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Schedule 4 Section 4.2 Final Version

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Medical Services Agreement

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SCHEDULE 4 SECTION 4.2 SERVICE DESCRIPTION

INCAPACITY BENEFIT/INCOME SUPPORT/HOUSING BENEFIT/COUNCIL TAX BENEFIT AND OTHERRELATED ADVANTAGES

.1. GENERAL

1.1 The CONTRACTOR shall adhere to the medical and common business requirements detailed in Section 4.1· of this Schedule 4 and the Service Levels set out in Schedule 5.

1.2 The CONTRACTOR shall ensure that:

a) the provision of advice on exemption is provided by Approved Health Care Professionals

b) PCA physical (and mental) examinations are undertaken by Approved Health Care Professionals .

c) advice on exceptional circumstances within the IB85 report is provided by Approved Health Care Professionals

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 as agreed with the AUTHORITY. .

2. SPECIFICS

2.1 Referrals to the Customer Service Desk

2.1.1·· CH Referral for Clarification of Incapacitv

2.1;1.1

The CONTRACTOR will receive the appropriate documentation from the AUTHORITY.

2.1.1.2

Upon receipt of the Referral documents the CONTRACTOR shall:

'\

a} advise as. to when any future Referral to the CONTRACTOR by the AUTHORITY should be made where the Own Occupation Test applies;

b} advise certification of exemption from the Personal Capability Assessment if appropriate; and

c) give a Prognosis.

2.1.2 CM Mental Health Referral

2.1.2.1

The CONTRACTOR will receive the appropriate Referral documents from the Claimant's Medical Practitioner.

Upon rec~ipt of the Referral documents the CONTRACTOR shall determine the severity of the Claimant's mental incapacity and shall give a Prognosis.

2.1.2.2

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2.1.3.1

2.1.3 CN Referral to Determine If Incapacity is Pregnancy Related

The CONTRACTOR will receive the appropriate Referral documents from the Claimant's Medical Practitioner.

Upon . receipt of the Referral documents the CONTRACTOR shall determine if the Claimant's incapacity is related to her pregnancy.

2.1.4 CP Referral. Claimant's Incapacity indicates Potential Exemption

2.1.3.2

2.1.4.1

2.1.4.2

The CONTRACTOR will receive the appropriate Referral documents from the Claimant's Medical Practitioner.

Upon receipt of the Referral documents the CONTRACTOR shall advise if the Claimant is suffering from an exempt incapacity and shall give a Prognosis.

2.1.5.1

2.1.5 CO Referral where Claimant is potentially Terminally III

2.1.5.2

The CONTRACTOR will receive the appropriate Referrals documentation from the Claimant's Medical Practitioner.

Upon receipt of the Referral documents, the CONTRACTOR shall advise the AUTHORITY if the Claimant is Terminally III, shall give a prognosiS and shall advise certification.

2.1.6.1

2.1.6 CR Claimant's Incapacity in doubt

2.1.6.2 a)

b)

~)

d)

The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY.

Upon receipt of the Referral documents the CONTRACTOR shall:

determine if the Claimant is suffering from a specific mental or physical disablement and,if so, determine the incapacity;

advise as to when any future Referral to the CONTRACTOR by the AUTHORITY should be made where the Own Occupation Test applies;

advise Certification of Exemption from the Personal Capability Assessment if appropriate; and

give a Prognosis.

2.1.7 CS Illegible Incapacitv on medical certification from Claimant's certifying Medical

. Practitioner·- .

2.1.7.1

2.1.7.2

The CONTRACTOR will receive all appropriate Referral documents from the AUTHORITY.

Upon receipt of the Referral documents the CONTRACTOR shall:

a) b)

determine the certified cause of incapacity

give an opinion as to when any future Referral to the CONTRACTOR by the AUTHORITY should be made where the Own Occupation Test applies;

c)

advise Certification of EXemption from the Personal Capability Assessment if appropriate; and

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d)

give a Prognosis.

2.1.8 CT Terminal Illness under Special Rules

2.1.8.1

The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY or the appropriate form from the Claimant's Medical Practitioner.

2.1.8.2

Upon receipt of the Referral documents the CONTRACTOR shall determine if the Claimant is Terminally III and, if so, when this position was reached. Where the CONTRACTOR determines that the Claimant is not Terminally'" a full explanation shall be given in the reply to the AUTHORITY.

2.1.9 CU Incapacity is not listed in the Incapacity Reference Guide

2.1.9.1

The CONTRACTOR will receive the appropriate Referral documents and any other relevantinformation from the AUTHORITY.

Upon receipt of the Referral documents the CONTRACTOR shall:

2.1.9.2

a)

advise as to when any future Referral to the CONTRACTOR by the AUTHORITY should be made where the Own Occupation Test applies;

b)

advise Certification of Exemption from. the Personal Capability Assessment if appropriate; and

c)

give a Prognosis.

2.1.10 CV Scrutiny of Medical Reports for Harmful Information

2.1.10.1 The CONTRACTOR will receive the appropriate Referral" documents from the AUTHORITY.

2.1.10.2 Upon receipt of the Referral documents the CONTRACTOR shall determine whether any Harmful Information is contained therein and dearly indicate the same.

2.1.11 CY Advice on Certification of Exemption

2.1.11.1 The CONTRACTOR will r.eceive the appropriate Referral documents from the AUTHORITY.

2.1.11.2 Upon receipt of the Referr.al documents the CONTRACTOR shall advise whether or not the Claimant is suffering from one of the exempt incapacities as set out in 'Incapacity Benefit Handbook for Medical Service Registred Medical Practitioners', as listed in Schedule 28, and shall give a prognosiS.

2.1.12 SR reference for further information in connection with an appeal or reconsideration

2.1.12.1 . The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY which will detail the areas for clarification; and where appropriate, shall include any additional evidence held which was not available at the time of the Decision Maker's decision.

2.1.12.2 Upon receipt of the Referral documents the CONTRACTOR shall

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clarify the areas of doubt as outlined in the Decision Maker's minute and take appropriate action in the light of any Further Medical Evidence

obtained. .

. 2.1.13 CZ reference for further advice to Decision Maker pre decision

2.1.13.1 The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY which will detail the areas for clarification and where appropriate, shall include any additional evidence held which was not available at the time of the original referral.

2.1.13.2 Upon receipt of the Referral documents the CONTRACTOR shall clarify the areas of doubt as outlined in the Decision Maker's minute and take appropriate action in the light of any Further Medical Evidence obtained.

2.1.14 Terminal Illness - entitlement to the Disabilitv Premium within Income Support.

Housing Benefit and Council Tax Benefit

2.1.14.1

The procedure shall be the same as that set out in Paragraphs 2.1.8.1 to 2.1.8.2 of this Section 4.2 of Schedule 4.

3. REFERRALS(FOR SCRUTINY

3.1 General

3.1.1 The CONTRACTORshall 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 materially support the Claimant's stated incapacity, the CONTRACTOR shall use reasonable endeavours to ensure that any Further Medical Evidence it may gather materially contributes 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.

3.1.2 The CONTRACTOR shall ensure that authorisation for the examination shall be given by Health Care Professionals Approved by the Secretary of State.

3.1.3 When a file is referred for examlnatlon by the CONTRACTOR, the CONTRACTOR shall adhere to the provision of Paragraph 4 of this Section 4.2 of Schedule 4.

3.1.4 The CONTRACTOR will receive the appropriate Referral documents from .the AUTHORITY.

3.1.5 The CONTRACTOR shall provide the advice requested by the AUTHORITY.

3.2 Speci~cs

3.2.1 SA - OOT Scrutiny Initial Referral

3.2.1.1 The CONTRACTOR will receive the appropriate Referral documentation from the AUTHbRITY and a detailed description of the activities included in the Claimant's occupation.

3.2.1.2 The CONTRACTOR shall advise as to whether or not the Claimant is capable of their own occupation and if not, when a significant improvement cpuld be expected ..

3.2.2 SA - OOT Scrutiny Re-Referrals

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3.2.2.1 The CONTRACTOR will receive the appropriate Referral documentation from the AUTHOR~TY.

3.2.2.2 The CONTRACTOR shall advise in accordance with the provisions of Paragraphs 3.1;1 and 3.1 .2 of this Section 4.2 as to whether or not the Claimant is capable of his/her own occupation and if not, when a significant improvement could be expected.

3.2.2.3 The CONTRACTOR shall advise in accordance with the Provisions of . Paragraphs 3.1.1 and 3.1.2 of this Section 4.2 or refer for a Personal Capability Assessment to be carried out.

3.2.3 SC - PCA Scrutiny Initial Referrals

3.2.3.1 The CONTRACTOR will receive the appropriatEiReferral documentation from the AUTHORITY.

3.2.3.2 The CONTRACTOR shall provide the advice requested by the AUTHORITY. 3.2.3.3 The CONTRACTOR shall advise as to whether or not the Claimant is capable of their own occupation and if not, when a significant improvementcould be

expected. '

3.2.4 SC - PCA Scrutiny Re-Referrals

3.2.4.1 The CONTRACTOR will receive the appropriate Referral documentation from the AUTttO~ITY.

I

3.2.4.2 In cases where the Claimant was exempted from the PCA assessment at the

previous referral, the documentation will include the appropriateform from the ClaimOant's.GP, when it has been obtained or the date of issue of the form to the Claimanfs GP. The CONTRACTOR shall allow a reasonable time for the form to be returned from the Claimant's Medical Practitioner where appropriate.

3.2.4.3 The CONTRACTOR shall advise in accordance with the provisions of Paragraphs 3.1.1 and 3.1.2 of this Section 4.2 or refer for a Personal Capability Assessment to be carried out.

3.205 SO - PCA for Scrutiny where form MEO 4 not held by the AUTHORITY

3.2.5.1 The CONTRACTOR will receive the appropriate Referral documentation from the AUTHORITY.

3.2.5.2 The CONTRACTOR shall provide the advice requested by the AUTHORITY. 3.2.5.3 The CONTRACTOR shall advise in accordance with the provisions of Paragraphs 3.1.1 and 3.1.2 of this Section 4.2 or refer for a Personal Capability Assessment to be carried out.

3.2.6 SG - Change in Incapacity for those cases covered by Section 102 of the SS Contributions and Benefits Act1992

3.2.6.1 The CONTRACTOR will receive the appropriate .Referraldocumentation from the AUTHORITY which will include the approprlateforrn from the Claimant's GP, when it has been obtained or, the date of issue of the form to the

Claimant's GP. .

3.2.6.2 Upon receipt of the Referral documentation from the AUTHORITY, the CONTRACTOR will allow a reasonable time for the form to be returned from the Olaimant's Medical Practitioner where appropriate and then proceed as

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described in paragraph 3.2.6.3 of this section of this Schedule 4.2.

3.2.6.3 The CONTRACTOR shall: ,

• advlse as to whether or not the Claimant's incapacity continues to be as a result of the Industrial Accident or Prescribed Disease, which is detailed on the appropriate form

• provide advice in relation to the Personal Capability Assessment where the AUTHORITY has indicated that this is for consideration.

3.2.7 SO - Disputed Pregnancy-Related Incapacities

3.2.7.1 The 'CONTRACTOR will receive the appropriate Referral documentation from the AUTHORITY which will include the appropriate form from the Claimant's GP, when it has been obtained or, the date of issue of the form to the Claimant's GP.

3.2.7.2 Upon receipt of the Referral documentation 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 as in paragraph 3.2.7.3 below.

3.2.7.3 The CONTRACTOR shall advise as to whether the Claimant's incapacity is 'wholly or partly pregnancy-related.

3.2.8 Entitlement to Income Support for Disabled Workers under the 75% Rule as described in Income Support General Regulations

'3.2.8.1 The CONTRACTOR will receive the appropriate Referral documentation from the AUTHORITY.

3.2.8.2 The CONTRACTOR shall advise as to whether or not the Claimant is suffering from a physical or mental disability which is likely to reduce its ability to work by 75% or its earnings by 75%.

3.2.9 IBSK - Scrutiny of Mental Health Re-referral cases

3.2.9.1 The CONTRACTOR will receive the appropriate Referral documentation.

3.2.9.2 The CONTRACTOR shall provide the advice requested by the AUTHORITY. 3.2.9.3 The CONTRACTOR shall advise in accordance with the Provisions of Paragraphs 3.1.1 and 3.1.2 of this Section 4.2 or refer for a Personal Capability Assessment to be carried out. to be carried out.

4. REFERRALS FOR EXAMINATION

4.1 General

4.1.1 The CONTRACTOR shall undertake medical examinations for: Incapacity Benefit Referrals for the Own Occupation Test by the one hundred and ninety sixth (196th) day of the Period of Interruption of Work as indicated by the AUTHORITY on the appropriate form, irrespective of the Service Level Targets as detailed in Schedule 5. Referrals for the Own Occupation Test will be sent to tile CONTRACTOR by the AUTHORITY no later than ten (10) weeks before the one hundred and ninety sixth

(196th) day of the Period of lnterruption of Work. ,

4.1.2 Where the AUTHORITY requires the CONTRACTOR to provide both an

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assessment of the level of disablement for Severe Disablement Allowance and advice on the incapacity question for the Personal Capability Assessment, the CONTRACTOR shall adhere to the procedures as set out in Section 4.3 of this

Schedule 4. .

4.1.3 The CONTRACTOR will receive the appropriate Referral documents from the AUTHORITY.

4.1.4 Upon receipt of the Referral documents from the AUTHORITY, the CONTRACTOR shall use reasonable endeavours to advise the AUTHORITY whether the claimant is suffering from an exempt incapacity and obtain Further Medical Evidence where appropriate, toenable it to do so, prior to arranging the examination.

4.1.5 Where the CONTRACTOR is unable to advise exemption, the CONTRACTOR shall arrange for a Personal Capability Assessment examination to be carried out.

4.1.6.1

4.1.6 In respect of Claimants who are Unable to Attend

4.1.6.2

4.1.6.3

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.

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.

The CONTRACTOR shall record the reasons for non-attendance on the appropriate form and details of all .attempts to contact the Claimant on the appropriate form which shall be included in the documentation to be returned to the AUTHORITY .

4.1.7.1

. 4.1.7 In respect of Claimants who Do Not Attend

4.1.7.2

4.1.7.3

4.2 Specifics

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.

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.

The CONTRACTOR shall record the reasons for non-attendance and details of all attempts to contact the Claimant on the appropriate form which shall be included in the documentation to be returned to the AUTHORITY.

'.

4.2.1 EB - Personal Capability Assessment for Examination

4.2.1.1

4.2.1.2

The CONTRACTOR will receive the appropriate Referral documentation from the AUTHORITY.

Upon receipt of the Referral documentation from the AUTHORITY, the CONTRACTOR shall use reasonable endeavours to advise the AUTHORITY whether the Claimant is suffering from an exempt incapacity and obtain Further Medical Evidence where appropriate, to enable it to do so, prior to arranging the examination.

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4.2.1.3 Where the CONTRACTOR is unable to advise exemption, the CONTRACTOR MUST arrange for a Personal Capability Assessment examination to be carried out.

4.2.2.1

4.2.2 - EE - Own Occupation Test

4.2.2.2

4.2.2.3

The CONTRACTOR will receive the appropriate Referral documentation from the AUTHORITY containing any relevant previous Referral papers.

The CONTRACTOR shall arrange for an Own Occupation Test examination to be carried out.

The CONTRACTOR shall reply in the format required by the AUTHORITY and shall include a description and requirements of the Claimant's job.

4.2.3 EF - Own Occupation Test where there is doubt on Claimant's Continuing

Incapacity .

4.2.3.1

4.2.3.2

The CONTRACTOR will receive the appropriate Referral documentation from the AUTHORITY.

The CONTRACTOR shall arrange for an Own Occupation Test examination to be carried out.

The CONTRACTOR shall reply in the format required by the AUTHORITY which shall include a description and requirements of the Claimant's job.

4.2.4 EX - Personal Capability Assessment without questionnaire (Mental Health)

4.2.3.3

4.2.4.1

4.2.4.2

4.2.4.3

The CONTRACTOR will receive the appropriate Referral documentation from the AUTHORITY.

Upon receipt of the Referral documentation from the AUTHORITY, the CONTRACTOR shall use reasonable endeavours to advise the AUTHORITY whether the Claimant is suffering from an exempt incapacity and obtain Further Medical Evidence where appropriate, to enable it to do so,prior to arranging the examination.

Where the CONTRACTOR is unable to advise exemption the CONTRACTOR shall arrange for a Personal Capability Assessment examination to be carried out.

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