Approval, payment risk and urgent care
Do I need insurer approval before starting CTP treatment?
For non-urgent treatment, obtain written approval before assuming the insurer will pay
You should not assume that a referral, diagnosis or claim number means every treatment invoice will be paid. For planned non-urgent treatment, ask the provider to submit the treatment request and obtain the insurer’s written decision before starting where practicable. Under Guidelines 4.78–4.79, an insurer may approve limited treatment after injury notification but before a claim is made, at its discretion and only within the first 28 days after the accident. Further treatment after day 28 requires a statutory benefits claim. Do not delay urgent medical attention solely because approval has not yet arrived.
The insurer considers whether the proposed treatment and care is reasonable and necessary in the circumstances and relates to the accident injury. The request should make the proposed service, provider, frequency, cost, goals and clinical reasons clear. A vague referral or invoice after treatment may leave both the claimant and provider uncertain about payment.
Approval is also not permanent or unlimited. It may identify a number of sessions, a date range, a provider, a fee basis or a review point. Read the actual written decision and give a copy to the provider before treatment begins.
Reviewed by Herman Chan, Stephen Young Lawyers
What should written approval tell you?
A useful approval identifies the service, provider, number or period approved and any condition that affects payment. It should be matched to the treatment request. If the decision approves physiotherapy but the request includes hydrotherapy, equipment or a specialist review, do not assume the additional items are included.
Ask the provider whether the approved fee covers the full charge and whether it will invoice the insurer directly. The CTP insurer’s approval and the provider’s billing arrangement are different matters. Resolve any proposed gap before the appointment rather than discovering it after several sessions.
What evidence supports a treatment request?
The evidence should identify the accident-related diagnosis or working diagnosis, examination findings, functional problem, treatment already tried, proposed service and expected measurable benefit. The practitioner should explain why the type and frequency are clinically appropriate and how progress will be reviewed.
A request is less persuasive when it merely states that treatment would be helpful. Where the insurer relies on an independent examination or says recovery has plateaued, the treating practitioner should answer that reason directly rather than sending the same original request again.
What can be approved before the full claim is lodged?
After notification of injury, Guidelines 4.78–4.79 allow the insurer to approve treatment before the statutory benefits claim is made, but that approval is discretionary and confined to the first 28 days after the accident. SIRA’s claimant guidance describes a GP visit and two further treatment sessions as care the insurer can approve without the claim form or further documents. This is not an automatic entitlement to any provider, service or price.
If treatment beyond that early allowance is required, lodge the statutory benefits claim and provide the clinical request. Under Guideline 4.106 the insurer must decide a treatment or care payment request in writing as soon as possible and no later than 10 days after receiving it. If information is missing, the insurer must identify what is required and give a reasonable opportunity to supply it. Urgent and emergency treatment should still be guided by medical need.
Practical next steps
A practical approval sequence
Keep the clinical request, insurer decision and provider billing arrangement aligned.
Obtain the referral or treatment request
Ask the practitioner to identify the injury, clinical findings, proposed service, frequency, goals and expected review point.
Send it to the correct insurer
Retain the email, portal receipt or other proof showing exactly what was submitted and when.
Read the written decision
Check the approved provider, service, sessions or period, fee basis and any excluded item.
Confirm billing with the provider
Ask whether the provider accepts the insurer payment as full payment and whether any gap or cancellation fee may apply.
Review progress before approval ends
If further treatment is proposed, submit an updated progress-based request before the existing approval is exhausted.
Evidence
Treatment approval checklist
Keep one complete record from clinical recommendation to invoice.
- Referral and current diagnosis or working diagnosis.
- Treatment request showing service, frequency, cost, goals and clinical reason.
- Insurer acknowledgement and written approval, partial approval or refusal.
- Provider confirmation of fees, direct billing and any possible gap.
- Progress notes and objective or functional outcome measures.
- Invoices and receipts showing each service date and amount.
- Any independent medical report or insurer evidence relied on.
- Later request for additional sessions and the updated clinical rationale.
Common misunderstandings
- A claim number is not approval for every treatment proposed during the claim.
- A GP referral does not itself bind the CTP insurer to pay the provider’s full fee.
- Approval for one provider or service should not be treated as transferable without written confirmation.
- Starting planned treatment before approval can expose the claimant to an invoice if the insurer refuses payment.
- Urgent care should not be delayed for legal strategy; seek clinical advice and document the circumstances.
Timing
Claim and decision timing
The treatment request sits within the broader personal injury benefits claim.
- The general period for lodging the statutory personal injury benefits claim is three months after the motor accident.
- Pre-claim treatment approval under Guidelines 4.78–4.79 is discretionary and is limited to the first 28 days after the accident; it does not replace claim lodgement.
- Guideline 4.106 requires a written decision on a treatment or care payment request as soon as possible and no later than 10 days after receipt.
- If approved, the insurer must identify the costs it agrees to meet and pay an invoice or qualifying reimbursement request as soon as possible, no later than 20 days after receipt.
- A refusal or partial approval should be checked immediately for the internal-review and PIC process stated in the notice. Do not rely on a generic dispute deadline.
Frequently asked questions
- Can I see my GP before approval?
- Seek medically appropriate care. Payment for consultation and later treatment is assessed under the scheme, but urgent health decisions should not be delayed solely for insurer correspondence.
- Does approval of one session approve the whole treatment plan?
- No. Read the scope of the written decision. It may cover only an assessment, a limited number of sessions or a defined period.
- Can the insurer choose my treating practitioner?
- The scheme has provider and cooperation requirements, but an insurer-arranged examiner is not your treating practitioner. Check the proposed provider, reason and current SIRA guidance rather than assuming either complete control or no insurer involvement.
- What if the provider charges more than the approved amount?
- Ask the provider and insurer to clarify the fee before treatment. Approval does not necessarily mean the insurer accepts every amount charged.
- Can approval be withdrawn?
- A later decision may change future funding based on evidence and the scheme. Ask for written reasons, the effective date and review rights.
- Will starting treatment prove it was necessary?
- No. Attendance or improvement can be relevant, but the statutory test and supporting clinical evidence still apply.
Related NSW CTP guides
Official sources
- Motor Accident Injuries Act 2017 (NSW), current in-force version
- SIRA Motor Accident Guidelines, current published version
- SIRA Motor Accident Guidelines Part 4: claims
- SIRA: medical expenses after a NSW motor crash
- SIRA: fees and approval for motor crash health services
- Personal Injury Commission: medical disputes
Assessment source: Motor Accident Injuries Act 2017 (NSW), section 3.24 and the current SIRA Motor Accident Guidelines Part 4. The insurer must apply the statutory test and current Guidelines to the individual treatment request and evidence.
Check the written decision
Unsure whether your treatment has actually been approved?
Send the treatment request, insurer response and provider fee information. We can identify what is approved, what remains undecided and whether a review issue has arisen.
General information only: This page is general NSW CTP information, not legal or medical advice. It does not promise approval, reimbursement, a particular provider or a dispute outcome. Urgent medical care should not be delayed while waiting for legal advice.