Provider Choice Challenging NDIA Funding Decisions for Support Coordinators User Guide

Provider Choice Challenging NDIA Funding Decisions for Support

Coordinators

Product Information

Specifications:

• Product Name: Guide to Challenging NDIA Funding Decisions for Support Coordinators
• Website: www.providerchoice.com.au

Product Usage Instructions

Reasonable and Necessary Criteria:
The NDIS will fund a support if it meets the following criteria:

1. Assist to pursue goals, objectives, and aspirations
2. Assist with social and economic participation
3. Represent value for money
4. Be effective and beneficial (regarding good practice)
5. Consider informal supports
6. Be most appropriately funded by the NDIS

Challenging NDIA Funding Decisions:

If a funding request is denied, it may be due to the support not being assessed as ‘Reasonable and Necessary.’
Participants can challenge decisions through Internal Reviews and External Reviews via the Administrative Appeals Tribunal (AAT).

Tips for Internal Review Application:

• Submit your application in writing using the form from the NDIS website.
• Include relevant reports demonstrating why the support is ‘Reasonable and Necessary.’
• Pull out key points from reports to make the application clear for reviewers.
• Avoid using the Internal Review process for complaints, as it is done by a separate reviewer at the NDIA.

External Review Process:
External Reviews through the AAT can be facilitated by public advocacy bodies, Legal Aid, or law firms specializing in NDIS decisions.

Frequently Asked Questions (FAQ)

• Q: Why would a funding request be denied?
  A: A funding request can be denied if the support is not considered ‘Reasonable and Necessary’ according to NDIS criteria.

• Q: How can participants challenge an NDIA decision?
  A: Participants can apply for an Internal Review within 3 months of receiving a decision. If unsuccessful, they can proceed with an External Review through the AAT.

• Q: What should participants expect after making an application to the AAT?
  A: Participants can expect the AAT to review their case and provide a decision based on the evidence presented.

A guide to challenging NDIA funding decisions for Support Coordinators

Introduction

It can be incredibly hard for a participant and their family when their NDIS plan doesn’tcontain enough funding to properly meet their support needs. As a Support Coordinator, how can you help?

• Understanding the options available for challenging an NDIA decision on funding is a start.
• Most Support Coordinators will be familiar with the Internal Review process. If an Internal
• Review isn’t successful then participants can choose to apply for an External Review.
• This guide will explain the different options and provide tips that you can share with any participants who are unhappy with the funding they’ve received.

Read on to learn about:

• Why funding requests can be denied (‘Reasonable & Necessary’)
• The difference between Internal and External Reviews
• How to make an application to the Administrative Appeals Tribunal (AAT)
• What to expect from the AAT review process

Why would a funding request be denied?

A funding request will be denied if the NDIA has not assessed the support to be ‘Reasonable and Necessary.’

What is ‘Reasonable and Necessary’?
The NDIS will fund a support if it meets all the below criteria.

A support must:

• Assist in pursuing goals, objectives and aspirations
• Be effective and beneficial (regarding good practice)
• Assist with social and economic participation
• Consider informal supports
• Represent value for money
• Be most appropriately funded by the NDIS

Why participants should feel empowered to challenge decisions about their funding

• What is considered ‘Reasonable and Necessary’ will look different for everyone. Sometimes, decisions made as part of the Operating Guidelines might unintentionally contradict the NDIS Act. This means people’s individual needs may not be fully accounted for.
• It’s also not just “needs” that are important. The NDIS is a goal-based scheme and the right for a participant to use NDIS funding to pursue their goals is written into thelaw. This means that personal aspirations are a completely valid reason to challenge a decision by the NDIA.

What is considered ‘Reasonable and Necessary’ will look different for everyone

What are the options for challenging an NDIA decision?

• If a participant receives an NDIS plan they are unhappy with, the first thing they have to do is apply for an Internal Review.
• If the Internal Review is unsuccessful, the next step is to apply for an External Review. External Reviews are handled through the Administrative Appeals Tribunal (AAT).

Internal reviews

• An Internal Review (also known as a Review of a Reviewable Decision, shortened to RoRD) is an internal process within the NDIA. Internal Reviews are not just for funding decisions.
• Applications for Internal Reviews must be submitted within 3 months of receiving a decision.
• In this instance, the ‘decision’ refers to a participant’s latest NDIS plan. This can be a first plan or a new plan. The decision date is the same as the plan date.

If the Internal Review is unsuccessful, the next step is to apply for an External Review.

External Reviews through the Administrative Appeals Tribunal (AAT)

• The AAT is an independent government department that reviews all government decisions, not just NDIA decisions.
• If an Internal Review is unsuccessful in achieving more funding, participants can make an application to the AAT.
• An application to the AAT must be made within 28 days after receiving the result from the Internal Review. However, in urgent circumstances, applications can be fast-tracked orgiven an extension.
• Applications for an AAT review can be made via email, post, in-person or online. More information and the form to fill out can be found on the Administrative Appeals website.
• Participants are allowed to represent themselves throughout the AAT process but it can be difficult and lengthy (commonly lasting from 6 – 12 months).
• Public advocacy bodies, your state’s Legal Aid or law firms that specialize in NDIS decisions can be extremely helpful for participants and their families. Keep in mind that there may be fees associated with using a law firm.

Public advocacy bodies, your state’s Legal Aid or law firms that specialise in NDIS decisions can be extremely helpful.

Tips and recommendations for applying for an internal review

• DO Submit your application in writing by using the form found on the NDIS website.
• DO Write the ‘Date of the Decision’ as the date of the plan.
• DO Include relevant reports that show why the support is
• DO ‘Reasonable and Necessary’.
• DO Pull out the most important points from your reports, to make it easy and clear for the person reviewing the application.
• DON’T Use the Internal Review process for complaints. The original decision-maker or planner won’t see what you write. Internal Reviews are done by a separate reviewer at the NDIA.

What can participants expect once they’ve made an application to the AAT?

Application Assessed
Their application will be assigned a case number. The NDIA will also send them Tribunal Documents, known as “T Documents.” The “T Documents” will be any documents that the NDIA referenced that helped them make their decision.

Tip for participants:
Reading the “T Documents” will help you understand how the NDIA landed on the original decision that you’re now challenging. This will give you a basis for your own argument.

A date for the case conference is set

• A case conference is a meeting between the applicant (and their representative if they have one), a Registrar from the AAT, a lawyer representing the NDIA and often also a person from the NDIA.
• A case conference is when everyone discusses and agrees on the issue being raised. If more evidence is needed, it will be identified in this meeting.
• The result of the meeting will be a decision about whether the case proceeds to a conciliation conference or a hearing.
• Sometimes, an agreement is reached at this stage and so no further steps are required.

Tip for participants:
The majority of cases do not require a hearing. Out of the 7,600 AAT cases closed as of 30 June 2022, only 221 went to a hearing according to the latest NDIS Quarterly Report.

A conciliation conference is held to reach an agreement

• Usually, a case conference is followed by a conciliation conference.
• Throughout the conciliation conference, a conciliator from the AAT may make suggestions and actively encourage all parties to reach an agreement.
• Outcomes from a conciliation conference are confidential.

If no agreement is reached, a hearing will be held

• Sometimes, no agreement is reached at a conciliation conference. If this happens, the next step will be a hearing.
• An AAT hearing is not as formal as a typical court hearing. It is heard by a Member of the Tribunal who specializes in NDIS cases. Evidence from the applicant, carers, witnesses, and experts can be given here.
• The Tribunal will decide within 60 days after the hearing. The decision will take into account the evidence of the case and be aligned with the NDIS Act 2013, NDIS rules, and relevant case law.
• If a participant is unsatisfied with the Tribunal’s decision, they have the right to appeal to the Federal Court.

Tip for participants:
You can withdraw at any point throughout the AAT process.

Important to note: AAT cases are not precedent-setting
This means that just because an outcome is reached in one AAT case, there is no guarantee that the same outcome will be reached in another case.
Each case is reviewed completely individually and independently from all other cases. Decisions are based on evidence from within that case only.

Conclusion

This doesn’t mean looking at AAT cases isn’t useful
Being familiar with past AAT cases and their outcomes can help you understand how the criteria for ‘Reasonable and Necessary’ work in action. Understanding the logic that the NDIA uses can help you think creatively and empower your participants to advocate for themselves.

At Provider Choice, we understand how much you care about your participants. We do too. That’s why we’re Personal Plan Managers. We’re not a call center. Every participant with Provider Choice gets support and expertise from a single, dedicated member of our team allocated to them.
To learn more about what we do, get in touch with our friendly team today or visit www.providerchoice.com.au

Get in touch

hello@providerchoice.com.au
1300 776 246
www.providerchoice.com.au

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