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Understand claim verification

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DOCUMENT 14 FOI 24/25-1942

Understand claim verification SGP KP Publishing

Exported on 2025-05-12 00:08:21

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FOI 24/25-1942 SGP KP Publishing – Understand claim verification

Table of Contents

1 Recent updates …………………………………………………………………………………………………….. 4 2 Before you start …………………………………………………………………………………………………….. 5 3 Understand the claim verification process …………………………………………………………….. 6 3.1 How participants know they have claims to verify …………………………………………………….. 6 4 Help the user verify claims through the my NDIS participant portal ………………………… 7 4.1 Help the user dispute a claim ………………………………………………………………………………… 7 4.2 Help the user accept claims ………………………………………………………………………………….. 7 4.2.1 To accept individual claims …………………………………………………………………………………………….. 7 4.2.2 To accept all claims, or accept the remaining claims not being disputed ……………………………….. 8 5 Help the user verify claims through the my NDIS app …………………………………………… 10 5.1 Help the user accept claims ………………………………………………………………………………… 10 5.1.1 To accept all claims from the Claims screen ……………………………………………………………………. 10 5.1.2 To accept individual claims from the Claims screen …………………………………………………………. 10 5.2 Help the user dispute a claim ………………………………………………………………………………. 10 6 Next steps …………………………………………………………………………………………………………… 11

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FOI 24/25-1942 SGP KP Publishing – Understand claim verification

This article provides guidance for the National Contact Centre, payments officer, complaints officer, planner delegate, planner (non-partnered area), participant support officer, business support officer, local area coordinator, early childhood partner, quality officer or home and living delegate to:

• understand the claim verification process • help the user verify claims through the my NDIS participant portal • help the user verify claims through the my NDIS app.

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1 Recent updates

31 March 2025 Guidance updated to inform staff that to keep participant information safe, users of the my NDIS app (the app) will be prompted to repeat the Verify it’s you step from time to time.

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2 Before you start

You have confirmed:

• the participant’s preferred contact method • the participant or authorised representative is verifying a claim for Agency-managed funds. To help the user submit a self-managed claim in the my NDIS app, go to article Support the participant to submit a self-managed claim.

You have read and understood:

• Making claims (external) • Provider compliance (external) • article my NDIS app learning tool • article Access parallel view of the my NDIS portal.

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3 Understand the claim verification process

The claim verification process is how we record the participant or authorised representative’s decision to accept or dispute claims. Claims are submitted by providers for NDIS supports that have Agency-managed funding. These providers aren’t recorded as my providers.

The user can accept or dispute claims in the my NDIS participant portal (my NDIS portal). Authorised representatives must hold Verify a Service permission. This is the permission to confirm a service, such as supports provided by a provider. All Agency staff and partners (except for access officers) can record the decision of the participant or authorised representative to accept or dispute claims. To learn more, go to article Manage claim verification.

Accepted claims will move to a pending payment and we’ll pay them in line with business payment processing.

Disputed claims are placed on hold and are automatically routed to a claim review officer. The claim remains on hold until a claim review officer investigates and decides to pay or reject the claim.

The claim review officer will make sure:

• the claim has valid details • the participant or their authorised representative has agreed to the support.

To learn about adding a my provider, go to article Add or update a provider relationship.

Providers can make a request for a my provider relationship with participants who have Agency- managed funds to pay for NDIS supports. Participants can accept or decline these relationship requests in their my NDIS portal. Learn more in article my NDIS portal – Understand provider relationships and consent to share information.

3.1 How participants know they have claims to verify

We notify participants via text message (SMS) when they have claims to verify. SMS are sent once a day at 2pm. If there are multiple claims, we’ll send them in a batch SMS. If someone is authorised representative for more than one participant, they’ll receive a separate SMS for each participant.

Participants and authorised representatives have 6 calendar days from when the provider submits the claim to accept or dispute it. If the participant or authorised representative doesn’t respond within 6 days, claims waiting for verification will proceed to automatic payment.

Note: we send an SMS to everybody with the correct permission in PACE to verify claims. For example, multiple child representatives who all hold Verify a Service permission will each receive the SMS. Only one person needs to accept or dispute the claim. For example, if one parent accepts the claim, the other parent won’t see the claim in the Pending claims list. Once the claim has been actioned, the participant or their authorised representative have view only access for their past claims in Claim history.

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4 Help the user verify claims through the my NDIS participant portal

To help the user view the claim in their my NDIS portal, ask them to Sign in to myGov (external). Next they’ll go to Linked services and select National Disability Insurance Scheme (NDIS).To learn more, go to article my NDIS portal – Register and sign in through a myGov account.

From the Home page in the my NDIS portal:

  1. Select Your tasks, then select You have a provider claim to check.
  2. At Pending claims, you’ll see all pending claims. The oldest claim will be listed first.

If the user disputes any claims on their list, they’ll need to submit the dispute before any remaining claims can be accepted.

4.1 Help the user dispute a claim

  1. Select Dispute on the right of the listed claim.
  2. At Dispute reason, the user can choose to enter a reason.

Note: entering a reason is optional but the claim review officer will consider any information included here when deciding to pay the claim or investigate it further.

  1. Select Submit. The claim has been disputed.

Note: the user can dispute a submitted claim to show the level of service wasn’t as expected but the service was provided. Encourage them to talk about their concerns with the provider. They can also contact the NDIS Quality and Safeguards Commission (external) to talk about service quality and their rights.

4.2 Help the user accept claims

Participants and authorised representatives can accept individual claims or accept all remaining claims that aren’t being disputed.

4.2.1 To accept individual claims

  1. Select Accept on the right of the listed claim.
  2. The Option to auto-verify screen will display.
  3. At Auto-verify: Would you like to verify this provider as a my provider to allow them to claim from your plan without verification, the answer auto-fills as No. The user can choose to change the answer to Yes.
  4. Select Submit.

If No was selected, the claim is accepted and they’ll see a success message. If Yes was selected:

  1. The Proposed relationship – my provider screen will display.

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  1. At Auto-verify: Would you like to verify this provider as a my provider to allow them to claim from your plan without verification, the answer auto-fills as Yes. The user can change to No if they don’t want to auto-verify future claims from this provider.
  2. At Would you like this relationship to be ongoing? The user must choose Yes or No. They can change the auto-filled answer to match their choice if required.

Note: selecting Yes means the provider will be automatically paid for future claims they submit. This will continue until the user or provider ends the relationship. Selecting No means the user chooses the period they’ll allow the provider to be automatically paid for claims. The Start Date will be today’s date. When the user enters an End Date this means automatic claim payments to the provider will end on that date.

  1. At Information in your plan you will share with this provider, the user can view the information they’re sharing with the provider.

Note: when a my provider relationship is created, the participant’s basic details are automatically shared with the provider. The provider will see:

o name o date of birth o contact details o communication preferences o authorised representative (if they have one) o plan start and reassessment dates. Basic consent to share is only withdrawn when the participant or provider ends the my provider relationship. To learn more, go to article my NDIS portal - Understand provider relationships and consent to share information.

  1. At Plan - goals, select Yes or No for consent to share plan goals.
  2. At Do you agree with this request?, select Submit.

Note: when a participant chooses to auto-verify a provider during the claims process, it creates a my provider relationship. The my NDIS portal views auto-verification in the same way as a relationship request.

  1. The claim and provider relationship have been accepted. A success message will display Success: You have successfully updated your relationship with . The user will now see this relationship in their Active relationships tab.

4.2.2 To accept all claims, or accept the remaining claims not being disputed

  1. Go to Step 2: Accept and select Accept remaining claims.
  2. An Accept claims confirmation will appear. Select Confirm. The claims are accepted.

Note: if the user chooses to accept all claims, they won’t be asked any questions about auto-accepting future claims or provider relationships during this process. If the user needs more information, they can select Claim ID. This will show:

o description o amount

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o management type o ABN (Australian Business Number) o support budget o support category o item number o the NDIS Price Guide o submitted by (the provider who made the claim).

Note: if the user needs help, they can contact their support coordinator, recovery coach, my NDIS contact or call the National Contact Centre on 1800 800 110.

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5 Help the user verify claims through the my NDIS app

To help the participant or authorised representative view claims in their my NDIS app, ask the user to open the app and sign in. Users of the app may be prompted to repeat the Verify it’s you step from time to time to make sure their information remains safe. To learn more, go to article my NDIS app – Register, sign in and connect to a myGov account.

5.1 Help the user accept claims

The app user can review a claim from the Claims, View pending claims, View claims history, Notifications (bell), or Budget screens.

5.1.1 To accept all claims from the Claims screen

  1. Select Claims.
  2. Select View pending claims. The number showing in brackets is the number of claims to verify. A message will display if there are no claims to verify.
  3. The list of claims will open. If there are more than 20 claims to verify, select Load more to see the remaining claims.
  4. Select Accept all claims to verify and accept all the listed claims.
  5. Select Confirm. A success message will display to confirm the claims have been accepted.

5.1.2 To accept individual claims from the Claims screen

  1. Select Claims.
  2. Select View pending claims. The number showing in brackets is the number of claims to verify. A message will display if there are no claims to verify.
  3. Select View on an individual claim to view the claim information.
  4. Scroll down and select Accept. A success message will display to confirm the claim has been accepted.

5.2 Help the user dispute a claim

  1. Select Claims.
  2. Select View pending claims. The number showing in brackets is the number of claims to verify. A message will display if there are no claims to verify.
  3. Select View on an individual claim to view the claim information.
  4. Scroll down and select Dispute.
  5. At Dispute Reason, the user can choose to enter a reason. Select Submit. The claim has been disputed and will be reviewed.

Note: entering a reason is optional but the claim review officer will consider any information included here when deciding to pay the claim or investigate it further.

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6 Next steps

• If the user accepts a claim, it will move to pending payment immediately and be paid. • If the user disputes a claim, the claim status will move to pending review. A claim review officer will investigate and decide to pay or reject the claim. The claim review officer may contact the participant, authorised representative, or provider for more information about the claim. To learn more about the claim review process, go to article CP – Resolve a Claim and Payment Verification Case for Claim Review Officer. • If the claim is not accepted or disputed, it will move to pending payment after 7 days. The provider may receive payment outside of 7 days. • Talk to the participant about providers they use regularly. They may want to add these providers as a my provider to allow them to be automatically paid. To learn more, go to article Add or update a provider relationship.

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