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Principles of In Scope for s100 Planning Review

This guidance is to support an understanding of what is considered in scope for an internal review of a decision for Internal Review Officers (IROs) and Business Support Officers (BSOs).

The NDIA has more than one way to review a plan. Sometimes it is hard to understand which pathway is the right one to address a participant’s request for a review/reassessment of variation. This document can be used in conjunction with the Choose the Right Review Tool.

1. Recent updates

Date	What’s changed
May 2022	Additional example for scope of review and guidance for secondary disability

2. Index

• 3. What can be reviewed as part of the statement of supports
• 4. What is being reviewed
• 5. What will not be considered in an internal review
• 6. Additional evidence or information
• 7. Withdrawing internal review requests
• 8. Case examples
• 9. Out of Scope Conversation Prompts

3. What can be reviewed as part of the statement of supports

The statement of supports includes:

• what NDIS-funded supports are included in a participant’s plan
• how those supports are described

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• how long the plan goes for • how the funding in the plan is managed.

4. What is being reviewed

The intent of internal review is to determine if the original decision made was correct under the law.

When reviewing a decision about a participant’s plan, we . This look at their situation and disability support needs at the time of the original decision to approve their plan.

This means:

The participant circumstances will be considered as they were at the time of the original decision*; and

The supports in the plan will be considered in the context of the goals included in the plan at the time of the original decision.

Includes when a participant advised the planner of a change of circumstances that was due to occur before the plan end date.

The internal review team will seek to review the request based on the issue(s) at hand, and confine the scope of the review to those issue(s) that the participant wishes to raise as part of their request. If there are dependencies or related issues, these will also be considered.

The participant may request a review of all the funded supports in the plan. They may also identify a specific support they are seeking funding for. While it is preferable for the participant to have raised any specific requests with the original decision maker, it is not compulsory. Therefore there does not have to be an explicit request for a support made during the planning process for it to be considered as part of the internal review.

During a planning meeting the participant does not have to specifically request the supports they wish to be included in their plan. It is the planner’s responsibility to gather and review all information and documentation before making a decision about what funded supports will be included in the participant’s plan.

Other parts of the plan include how the funding is managed and how long the plan goes for. If a participant has discussed these with the planner and the planner has made a decision against the participant’s preferences, this should be considered as an internal review.

5. What will not be considered in an internal review

The following factors will not be considered in an internal review. Contact with the participant is required to discuss their options.

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Sometimes the factors below may occur at the same time as requesting an internal review or an internal review is already in progress. In these situations, a conversation with the participant to identify the correct pathway for the request is required. In this conversation, we must explain the scope of an internal review, their review rights and manage their expectations. Refer to the Conversation Prompts in section 9.

5.1 Change to circumstances occurring after the plan was approved

Where a participant’s disability support needs, informal supports, living arrangements, employment or compensation factors have changed, they should seek a review of the plan through a participant requested plan review.

Changes to goals: The statement of goals and aspirations is not a reviewable decision. Where a participant wants to add or change a goal but no changes are required to the supports funded, they do not need to have a plan review. Changes to the participant statement can be made to the existing plan and should be actioned by National Delivery. If the requested change also requires a reassessment of their support needs, then a participant requested review is the correct pathway.

Processing of assessments and quotes requested by the original delegate: The original decision is not considered to be completed until the assessment or quote requested has been received and considered. Where an assessment or quote has been asked for, the correct pathway to consider the funding is an agency initiated plan review as the intent of the planner was to consider the supports on receipt of the assessment.

6. Additional evidence or information

The reviewer will consider any existing evidence and the participant may also provide further information or evidence to support their request(s). Evidence that may have been obtained after the decision was made can be considered. All of the evidence will be considered in the context of the circumstances and the goals at the time of the original decision, irrespective of when the evidence or information was provided.

It is important to review the content of the information to determine whether there has been a change to the participant’s support needs since the original decision.

Difference between additional information and new information: A participant can request a support be considered in their internal review even if it was not requested at their planning meeting.

Information that is new does not always mean it should be actioned through the participant requested plan review. V3.0 2021-11-23 Principles of s100 Planning Review Page 3 of 12

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Let’s have a look at how the content of the new or additional information can help us determine what the next steps are for the request/s in the scenarios identified below.

A Progress Report has been submitted after plan approval recommending a higher level of speech and language pathology than what has been funded. The report talks about how the participant has progressed with their current plan and towards their goals. While this is new information, it relates to the participants support needs at the time of the original decision and can be used as evidence to support the internal review request. There is no mention in the report of a change to the participants’ functional capacity or circumstances since the original decision.

Assessment Report dated after the plan approval for a participant has been submitted. The assessment is recommending a support that has not been included in the original decision. On review of the plan, there was funding included for this assessment to be completed. An example of the comment in the plan may read “Support from an assessor to assist me to select, set up and use my assistive technology” or “Support to explore and design a potential Individualised Living Options”. The original planner has not made a decision on these supports. An internal review can only be completed after a decision is made. The correct pathway for the participant is therefore to have a plan review to assess support needs based on the provided assessment. This should be undertaken by national delivery through an agency initiated review. If no funding was provided for assessments then it must be assumed this assessment has been provided by the participant as evidence to support the internal review request.

A report has been provided stating the participant has had a significant decline in their functional capacity. The report states the participant now requires more access to daily living supports than what is provided in the current plan. The original planner could not anticipate the decline in the participant’s functional capacity. The decline started shortly after the plan was approved. The participant requires a reassessment of their support needs and therefore the correct pathway is a plan review due to this change in circumstances. An internal review can only consider the participants circumstances at the time of the original decision. This pathway should be discussed with the participant.

7. Withdrawing internal review requests

When an internal review request has been lodged, it cannot be withdrawn without the consent of the participant.

Where a participant does not consent to withdraw a request the internal review decision must be made.

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The internal review officer should provide clear and accurate advice about the achievable outcomes of the review and alternate pathway processes to support the participant to make a decision to progress or withdraw a request. Where a participant elects to progress with an internal review in circumstances where the original decision is incomplete, the circumstances changed after the decision date, or do not relate to a stated goal, the reviewer will consider the decision in the context at the time of the decision. Where the original decision was sound it would be confirmed.

8. Case examples

8.1 Example 1 – Both In and Out of Scope Requests

Bob has requested therapy funding for his son Charlie to support his communication goal. Bob has provided a speech therapy report obtained after his plan was approved. The report aligns with Charlie’s current goal and there is no indication of a change to Charlie’s support needs or circumstances. The approved plan did not contain any therapy support funding. Bob further advised they have moved house after the plan was approved and they need a new ramp to assist Charlie to access the house.

Is this in scope for IRT? The funding for therapy can be considered in the context of the goals and circumstances of the original plan, even though Bob didn’t ask for this in Charlie’s planning meeting. However, the additional home modifications are a result of changed circumstances and an original decision has not been made on this. A discussion with Bob (refer to Conversation Prompts in section 9) should occur to confirm that only the therapy can be considered and outline his review options. Bob could elect to withdraw the internal review and progress with a plan review to address the home modification needs and at the same time discuss with the planner Charlie’s therapy needs as part this review. If Bob remains dissatisfied with the funding in Charlie’s new plan he can request an internal review. Bob’s timeframe to request an internal review will be reset to when the new decision was made.

Alternatively, Bob could elect to progress with an internal review for the therapy request, understanding that funding for a ramp will not be included as no decision has previously been made.

What would the outcome be if internal review was elected? The internal review officer will consider all the information the planner initially had, Charlie’s situation and support needs at the time of the original decision, his current

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plan, and this new report to determine if speech therapy funding should have been included in Charlie’s plan. The ramp will not be included in the decision as per discussion with Bob and recorded in conversation. Bob will need to resubmit the request for a ramp once the internal review has been completed. Note: If Charlie’s functional capacity had changed since the original decision the funding for therapy should also be considered through a participant requested review.

8.2 Example 2 – Out of Scope: Change of Circumstances

Andrew has requested additional therapies for his son Luke as there has been a decline in his mobility after his plan was approved. Andrew has written in the internal review request the current level of funding for therapy is insufficient and does not meet Luke’s changed support needs.

Is this in scope for IRT?

No. From reviewing the internal review request, Andrew is very unhappy with the funding amount in Luke’s plan. Andrew has provided an allied health report outlining a decline in Luke’s functional capacity recently due to an unexpected complication of his disability. A change in Luke’s support needs has occurred since the original decision was made. The correct pathway to consider the request for therapy funding is a participant requested review pathway. As the initial request is for an internal review, you have a discussion with Andrew (refer to Conversation Prompts in section 9) to outline the different options and the likely outcomes of those pathways.

Andrew’s expectations regarding both options need to be managed. Andrew could elect to withdraw the internal review and progress with a plan review to address the change in Luke’s circumstances. If Andrew remains dissatisfied with the funding in Luke’s new plan he can then request an internal review. Andrew’s timeframe to request an internal review will be reset when the new decision was made. If Andrew still wishes to progress the request through internal review he needs to be aware the reviewer will consider Luke’s support needs at the time of the review and not take into account the change. If the original decision was sound, it would be confirmed and the plan remain unchanged. He would then need to submit a plan review request to consider the change in support needs.

8.3 Example 3 – Out of Scope: Goal Change

Joe has received an offer of employment through an Australian Disability Enterprise (ADE). Joe does not have a goal related to employment in his plan.

Is this in scope for IRT?

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No. The original decision maker would not have considered supports that do not relate to the goals in the plan. Joe needs to both update his goals and ask for new supports to be included to support this goal. This requires a reassessment of his entire plan and therefore the correct pathway is a plan review request. A delegate will make an original decision on the reasonable and necessary supports in relation to the employment goal through a participant requested or scheduled review.

Joe can insist on progressing his request through internal review but must be informed the internal review will only consider his situation and support needs at the time of the original decision. In this case, if the decision was sound based on the circumstances at the time, the original decision would be confirmed.

Example 4 – Out of Scope: Informal support change

Chris has requested additional supports for daily assistance as her mum has moved and is no longer able to assist her each day.

Is this in scope for IRT?

No. This is a change of circumstance. Chris can request a plan review to consider her new circumstances.

Chris can insist on progressing her request through internal review but must be informed the internal review will only consider her situation and disability support needs at the time of the original decision. In this case, if the decision was sound based on the circumstances at the time, the decision would be confirmed.

Note: If Chris had known her mum was going to move and advised the planner at the time the original plan was developed the planner is obliged to consider the known future change to circumstances in the plan, or set a review date closer to the date of the change to review Chris’s needs when the change occurred. In this case, the matter would be in scope for internal review as the participant had reflected the future change as part of their circumstances at the time. If you are unsure if this applies, seek instruction from your Assistant Director.

Example 5 – Out of Scope: Original decision incomplete

Harry has a goal to live independently and had funding provided in his plan to explore housing solutions. Harry has provided the assessment and now wants funding in his plan.

Is this in scope for IRT?

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No. The delegate has not completed an Reasonable and Necessary decision with respect to the housing and living options. Harry should be referred back to the planner for an agency initiated review to complete this request. Harry can insist on progressing the request through internal review but must be informed the internal review will only consider whether the decision not to include funding without assessments based on his situation and support needs at the time of the original decision was correct. In this case, if the decision would likely be confirmed.

8.6 Example 6 – In Scope: Plan management preference declined

Doug requested to self-manage all of the supports in his plan. The original delegate has only allowed some of the supports to be self-managed.

Is this in scope for IRT? Yes. Doug advised of his preferences at the planning meeting and they were not reflected in the plan. The internal review officer will undertake a review of whether the self-management decision was correct for all aspects of Doug’s plan.

8.7 Example 7 – In Scope: Original decision completed

Mary requested a powered wheelchair which was not included in her plan. The plan included funding for a manual wheelchair however; Mary does not think this will meet her needs. Mary has a goal to be more independent in the community.

Is this in scope for IRT? Yes. A decision has been completed and the support relates to the goals in the plan. Mary’s functional capacity has not changed since the original decision.

8.8 Example 8 – In Scope: Re-consideration of original decision

Lula disagrees with the total value of funding in her plan. She advised her disability is recorded incorrectly. Lula asks to update the disability type and review the funding in the plan.

Is this in scope for IRT?

Yes. Lula’s disability and functional capacity has not changed. The review should consider if the information available regarding her disability and functional capacity was considered in her plan.

Note: While this may appear to be a significantly new decision. The original decision maker has not considered the correct information when developing the plan. Note: If Lula had a recent / new diagnosis of an additional disability this would be a change of circumstances and should be addressed through a plan review. V3.0 2021-11-23

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Note: If you require assistance with updating the disability type and associated tasks please seek help from your Team Leader or Assistant Director.

9. Out of Scope Conversation Prompts

General Prompts

• Internal Review Officers look at your situation and disability support needs at the time the original plan decision was made.
• The internal reviewer stands in the shoes of the original decision maker and checks if we made the right decision the first time.
• If your situation or disability support needs have changed an internal review of the original decision may not provide the outcome you are seeking.
• You can ask for a plan review at any time. A plan review will look at your current situation and disability support needs.

Participant Requested Plan Review Prompts

• A participant requested plan review is the correct pathway for review when your circumstances have changed.
• I can submit a plan review request for you.
• A participant requested plan review (PRR) is not the same as a review of a decision. A plan review will look at your current situation and support needs. A review of a decision looks at whether the decision made was right under the law for the NDIS.
• If we lodge a plan review request for you, the NDIA will make a decision on the request within 14 days and will let you know the outcome in writing.
• The decision made will be whether a plan review should occur not a decision on the supports requested.
• If the plan review request is approved, a planner will contact you to undertake the plan review. You can discuss all of your requested supports at the same time.

Agency Initiated Plan Review Prompts

• An agency initiated plan review is still a plan review but does not require you to ask for it.

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• An agency initiated plan review is the correct pathway for review when the agency has asked for assessments or quotes, or to fix errors identified in the plan.
• Once you get your new plan if you are still unhappy you can ask for an internal review again.

Note: The participant’s consent is required to withdraw the internal review request. This means no decision will be made on the internal review request. If a PRR is lodged or an agency initiated review occurs they can then ask for an internal review if they disagree with the new plan.

After explaining the above if the participant wishes to progress with an internal review of a decision.

Confirm the in scope supports and explain it is these supports we will make a decision on and provide them with a written response.

We have discussed which requested support/s we can do an internal review on, can you confirm you understand that I will only be considering the following: .

If there are no in scope supports explain it may result in the same decision and no changes will be made to the plan. This is called a confirmed decision. Refer to additional prompts below depending on the request.

Following a decision the participant has the option to have this decision reviewed externally by the Administrative Appeals Tribunal (AAT) if lodged within 28 days, and provide information to the participant or authorised representative about how to lodge.

9.4 Changes to circumstances or disability support needs occurring after an approved plan

Additional prompts where a participant’s disability support needs, informal supports, living arrangements, employment or compensation factors have changed and these were not included in the original planning decision.

• I can see you are asking for <support/s> because your have changed. If we progress the internal review it is unlikely to provide the outcome you are seeking as I can only consider your <situation/support needs> at the time of the original decision.
• A participant requested plan review is the correct pathway for review when a participants circumstances have changed.

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• Would you like me to withdraw your internal review request and make a plan review request instead?

9.5 Changes to supports due to change in goals

Additional prompts when the participant is requesting a new support due to a change of goals, such as additional funding to seek employment.

• I can see you are asking for <support requested> as you now want to change your goal/s to include <goal change>. If we progress the internal review it is unlikely to provide the outcome you are seeking as I can only consider support to help you achieve the goals you had at the time of the original decision.

• A participant requested plan review is the correct pathway for review when you want to change your goals and different supports are needed to help you pursue that goal.

• Would you like me to withdraw your internal review request and make a plan review request instead?

9.6 Participant providing assessments and quotes requested by the original planner

Additional prompts when assessments or quotes have been requested by original decision maker. This will be evident in the plan comments printed on the plan. For example, funding provided for therapy assessment or AT assessment.

• I can see you are asking for <support requested> as you were provided funding to get those assessments at your planning meeting.

• The planner’s intent was to reassess your supports needs once the assessments became available.

• If we progress the internal review it is unlikely to provide the outcome you are hoping for as it needs to be considered by a planner delegate first. If you are still unhappy with that decision you can seek an internal review of that decision within 3 months.

• Are you happy for me to withdraw your internal review request and send these to the original planner to conduct a plan review?

10. Feedback

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Version control

If you have any feedback about this Standard Operating Procedure, please complete our Internal Review Team Quality and Continuous Improvement Form and email it to the Business Improvement Team. In your email, remember to include the title of the product you are referring to and describe your suggestion or issue concisely.

Version	Amended by	Brief Description of Change	Status	Date
1.0	DII394	Class 1 approval.	APPROVED	2021-02-03
2.0	CAP525	Class 1 approval.	APPROVED	2021-07-23
	DLL320
	SW0065
3.0	KMM575	Removed out of scope change of preference example. Move to new template. Class 1 approval.	APPROVED	2021-11-23

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