Review after long-term care transfer
How can I challenge a CTP Care treatment or care decision?
Start with the written CTP Care decision and use the review process that matches the issue
Ask for the written decision, reasons, evidence relied on and internal-review information. A CTP Care decision about whether treatment is accident-related or reasonable and necessary may ultimately involve a medical dispute; a cost question may be a merit issue. The current CTP Care Guidelines govern review and disputes after transfer. A service complaint can address delay or conduct but does not replace internal review or a PIC application about entitlement.
After transfer, the Lifetime Care and Support Authority acts as the relevant insurer for treatment and care. The legal test remains connected to the Motor Accident Injuries Act 2017, but the decision-maker, correspondence and review administration change. Do not simply send an old licensed-insurer review form without checking the CTP Care decision and current Guidelines.
A refusal may concern the injury connection, clinical necessity, frequency, provider, price, service category or available alternative. A partial approval may accept the treatment but limit sessions or cost. The review should identify the exact part to be changed and support it with the evidence appropriate to that question.
Reviewed by Herman Chan, Stephen Young Lawyers
What should the CTP Care decision contain?
The decision should identify the requested service, what is approved or refused, reasons, evidence and review rights. SIRA’s CTP Care information states that decisions are made within 10 calendar days. If the letter is unclear, ask CTP Care to confirm whether the problem is causation, reasonable necessity, amount, provider or missing information.
Compare the decision with the actual request. A refusal based on no specialist recommendation may be answered by a focused report; a refusal based on lack of progress may require outcome and functional evidence; a cost refusal may require itemised quotes and fee material. Sending the same unchanged request rarely addresses a specific reason.
If the decision was made by the licensed insurer before transfer but the review crosses the transfer date, identify both entities and the current party. The CTP Care Guidelines address responsibility after transfer and possible procedural substitution. Do not create competing reviews unless the process requires it.
Preparing an internal review
An internal review should state the decision challenged, the different decision sought and why. Attach only material that answers the reasons: current clinical findings, treatment plan, functional evidence, provider qualifications, cost comparison, prior response and accident causation. Use an indexed bundle and short chronology rather than unlabelled records.
If the service has changed since the original request, say so. A revised frequency, trial, alternative provider or updated quotation may justify a new decision as well as or instead of challenging the old one. Preserve the review date while clarifying how CTP Care wants the revised material handled.
Internal review is not a meeting about general dissatisfaction. It is a reconsideration of an identified decision. Keep complaints about unanswered calls, staff conduct or invoice administration in a separate section so they do not obscure the entitlement question.
When may PIC or a complaint be relevant?
If internal review does not resolve an eligible treatment or care dispute, the Personal Injury Commission may assess the issue through the stream created by Schedule 2. Medical questions include whether treatment is reasonable and necessary or related to the accident. Merit review can address specified cost questions. The application must match the decision rather than ask PIC to manage the whole care plan.
A complaint to icare/CTP Care, or an insurer complaint to the Independent Review Office (IRO), can address service quality, delay or communication. Official icare material says feedback may be provided in a preferred language and interpreter or translation support can be arranged. A complaint cannot substitute for the legal review route or extend its deadline.
Continue medically appropriate safety planning with the treating team while the dispute proceeds. Neither a review request nor legal contact guarantees interim funding. If stopping care creates an immediate risk, identify that risk in writing and ask for an urgent response or interim arrangement.
Practical next steps
A focused CTP Care challenge
Organise the file around one decision and the legal question it answers.
Obtain the complete decision
Confirm the requested service, approved part, refused part, reasons, evidence and review instructions.
Identify the issue type
Separate accident causation, clinical necessity, service scope, provider, amount and administration.
Ask for the different decision
State exactly what treatment, frequency, period or amount should replace the existing decision.
Build a reason-matched bundle
Use focused clinical, functional and cost evidence with an index and short chronology.
Choose review, PIC or complaint correctly
Use internal review and the relevant PIC stream for entitlement; use the complaint process for service conduct.
Evidence
CTP Care review evidence checklist
The strongest review answers the written reason rather than repeating the original request.
- CTP Care decision and proof of the date received.
- Original request, treatment plan and provider quotation.
- Current medical findings and accident-causation explanation.
- Functional goals, progress measures and consequences of refusal.
- Alternative services, trials or cost comparisons considered.
- Prior licensed-insurer approvals and transfer documents where relevant.
- Internal-review application, indexed attachments and decision sought.
- Separate chronology of delay, communication or invoice complaints.
Common review mistakes
- Using the licensed insurer’s old contact or form without checking the post-transfer process.
- Treating every refusal as a medical dispute when the actual issue is price or administration.
- Submitting an entire file without identifying the decision and evidence that answers it.
- Relying on a service complaint to preserve internal-review or PIC rights.
- Assuming a prior approval proves the same service remains necessary indefinitely.
Timing
Act from the decision date
The precise review period must be taken from the current decision and CTP Care Guidelines.
- SIRA’s CTP Care fact sheet states that treatment and care decisions are made within 10 calendar days.
- The refusal or partial approval should explain internal review. Lodge within the stated period or obtain advice immediately about any delay.
- A later PIC application can depend on completion or outcome of internal review and the dispute type. Check the current procedural requirements before filing.
- A complaint, provider resubmission or request for reasons does not automatically extend a review deadline.
Frequently asked questions
- Can I ask CTP Care to reconsider without an internal review?
- You can clarify or submit updated material, but do not assume informal reconsideration preserves formal rights. Follow the review instructions in the decision.
- Can PIC decide whether treatment is reasonable and necessary?
- The Act classifies that question as a medical assessment matter. The application must meet the current review and procedural requirements.
- What if only the treatment price is disputed?
- Cost reasonableness is classified separately as a merit issue. Separate the price evidence from the clinical-necessity evidence.
- Can I complain about delayed CTP Care communication?
- Yes. Use the feedback or complaint process, but separately protect any review right concerning the underlying treatment decision.
- Can care continue while the review is underway?
- There is no universal automatic funding rule. Ask for an interim arrangement and explain clinical or safety risk, but do not assume the review itself authorises payment.
- Who is named in a PIC matter after transfer?
- It depends on the issue and transfer date. The current Guidelines address the relevant insurer and possible joinder or substitution; check before filing or amending.
Related NSW CTP guides
Official sources
- Motor Accident Injuries Act 2017 (NSW), current in-force version
- SIRA: CTP Care information for injured people
- SIRA Motor Accident Guidelines - CTP Care, current published version
- icare: CTP Care feedback and complaints
- Personal Injury Commission: medical disputes
- Personal Injury Commission: merit review disputes
The current legislation, SIRA Guidelines and official CTP Care material linked above are the public-source basis for this page. Treatment and care decisions remain fact-specific and should be checked against the written request, clinical evidence, accident date and insurer reasons.
CTP Care decision review
Has CTP Care refused or reduced treatment or care?
Send the decision, original request, current clinical evidence, provider quote and transfer documents. We can identify the internal-review and PIC issue without confusing it with a service complaint.
General information only: This page explains the NSW motor accidents scheme in general terms and is not legal or medical advice. It does not guarantee approval, reimbursement, continued funding, a review outcome or damages. Keep acting on any date stated in an insurer, CTP Care or PIC notice while obtaining advice.