Approval Process

When a worker is injured in New South Wales, medical treatment, rehabilitation, and support services are often needed to help them recover and return to work. Under the State Insurance Regulatory Authority (SIRA) framework, not every treatment is automatically approved. Instead, many services must go through an approval process before they can be funded by the insurer.

For injured workers and their treating doctors, understanding this process can reduce stress, avoid delays, and ensure the right care is delivered at the right time.

Why Is Approval Needed?

The WorkCover system is designed to make sure treatments are:

• Reasonable and necessary for the injury.

• Evidence-based and supported by clinical guidelines.

• Cost-effective and appropriate for recovery and return-to-work goals.

Approval ensures the system remains fair—providing injured workers with the care they need while avoiding unnecessary or ineffective interventions.

What Needs Pre-Approval?

Not all services require prior approval. In fact, many common treatments (like GP visits, initial physiotherapy, or basic imaging) can be billed directly without waiting. However, approval is generally required for:

• Surgery or invasive procedures.

• Extended rehabilitation services (beyond the standard early sessions).

• Specialist referrals outside the usual scope of injury management.

• High-cost medical equipment or home modifications.

• Psychological treatment beyond initial sessions.

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The Approval Process: Step by Step

1. Request from the Treating Doctor or Allied Health Professional: The treating provider submits a request, usually in writing, outlining the treatment, rationale, and expected outcomes. This often uses a SIRA-approved form.

2. Submission to the Insurer: The request is sent to the workers compensation insurer managing the claim.

3. Insurer Review: The insurer assesses whether the request meets the “reasonable and necessary” test, considering SIRA’s guidelines and the worker’s injury management plan.

4. Independent Input (if needed)If there is uncertainty, the insurer may seek an Independent Medical Examination (IME) or specialist opinion.

5. Decision

   • Approved: The service can proceed, and costs are covered.

   • Partially approved: Only some aspects are funded.

   • Declined: The worker and provider are notified with reasons.

     
     

What If a Request Is Denied?

If treatment is not approved, the worker has rights:

• Review or appeal the insurer’s decision.

• Seek support from their doctor or rehabilitation provider to provide further evidence.

• Contact the Workers Compensation Independent Review Office (WIRO) for free legal advice and assistance.

  
  

Tips for Smoother Approvals

• Be specific: Providers should give detailed clinical reasoning.

• Use SIRA guidelines: Align requests with recommended treatment pathways.

• Communicate early: Workers should talk openly with their doctors about what may require approval.

• Keep records: Maintain copies of all correspondence with insurers.

  
  

Conclusion

For injured workers, waiting for treatment approval can feel frustrating. But the SIRA approval process exists to ensure that care is safe, effective, and focused on recovery at work. By understanding how it works—and knowing your rights if a request is denied—you can navigate the system with more confidence and get the care you need without unnecessary delays.