DHB Outpatient
Burns & Scar Management
Purchasing
Updated January 2013
Operational Guidelines
This is a living document and will be updated as required
DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Contents
Introduction ...................................................................................................... 1
Useful contact numbers .................................................................................... 1
Section 1: The Burns Purchasing Framework..................................................... 2
Client eligibility for burns management .............................................................. 2
Medical or nursing treatment for burns ............................................................... 2
Occupational therapy or physiotherapy treatment for burns .................................. 3
Burns garments............................................................................................... 4
Burns splinting ................................................................................................ 5
Burns scar management consumables ................................................................ 6
Requesting Burns Treatment Prior Approval ..................................................... 7
Invoicing and Payment - Burns Treatment ........................................................ 7
Manual bulk billing ........................................................................................... 7
e-Invoicing ..................................................................................................... 8
Section 2: Purchasing DHB Scar Management Services for
Clients not Covered by the Burns Framework ................................................. 9
Eligibility criteria.............................................................................................. 9
Scar management purchasing mechanism .......................................................... 9
Requesting Scar Management Prior Approval ................................................... 11
Invoicing and Payment - Scar Management Treatment .................................... 12
Manual bulk billing .......................................................................................... 12
e-Invoicing .................................................................................................... 12
APPENDICES ..................................................................................................... 13
Appendix 1: Frequently asked questions (FAQs) ................................................. 13
Appendix 2: Purchasing DHB outpatient treatment for burns clients ...................... 15
Appendix 3: Purchasing DHB outpatient consumables for burns clients .................. 16
Appendix 4: Suggested format for manual invoicing schedule .............................. 17
Appendix 5: ACC1855 Burns Outpatient Treatment and Consumables –
Prior Approval Request ............................................................................... 18
Appendix 6: ACC1856 Scar Management Treatment & Consumables –
Prior Approval Request. .............................................................................. 21
April 2010
DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Introduction
The following information is designed to help providers interpret the DHB outpatient
burns & scar management purchasing framework, and access it where appropriate. This
is a living document and updated versions will be made available on the ACC provider
website as queries arise.
What’s in this document
Section 1 of this document covers purchasing burns services and related scar
management treatment. Section 2 covers purchasing scar management treatment for
clients who are not covered by a burns claim.
The purchasing framework is used to fund:

medical or nursing treatment

occupational therapy

physiotherapy

pressure garments

scar management consumables and

burns splinting.
Other specialist treatment is provided on an as required basis under DHB held contracts.
ACC supports best practice for the assessment of all clients. To ensure that all providers
are aware of the process for funding assessments, the services are clearly outlined in this
document.
For Quick Reference information see Appendix 2 - Purchasing DHB outpatient treatment
for burns clients and Appendix 3 - Purchasing DHB outpatient consumables for burns
clients. These can be printed off as quick reference guides.
Useful contact numbers
Provider helpline
Ph: 0800 222 070
providerhelp@acc.co.nz
The Provider helpline staff can help answer queries relating to provider numbers, ARTP
updates, and general enquiries.
Health procurement
Ph: 0800 400 503
health.procurement@acc.co.nz
Health Procurement can advise on appropriate vendor IDs
Inquiry service centre (ISC)
Ph 0800 101 996
For general enquiries, ISC will answer your call and refer you for further assistance if
required.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Section 1: The Burns Purchasing Framework
Client eligibility for burns management
A client is eligible for help with their burns when the definition of accidental burn or
exposure to radiation or rays applies to their injury. The injury must come within all of
the following criteria:

A single occurrence at an identifiable time and place.

Not a burn or exposure caused by exposure to the elements.

Considered to be an accident under section 25 of the Accident Compensation Act
2001.1
If the injury was caused by either of the following on a specific occasion, it can be
considered an accident:

Any kind of burn (for example, a burn caused by fire, contact with a hot object,
friction such as a rope burn, burnt retina from welding arc, electrical burns, ice
burn), or

Exposure to radiation or rays of any kind (for example, x-rays, nuclear radiation,
laser beams).
Medical or nursing treatment for burns
Prior approval for medical or nursing treatment is:
Not required
for…
Required
for…

Medical treatment

Nursing treatment under Regulations

Community nursing – short term.

Community nursing – long term.
Service item codes and costs

Medical treatment is purchased using codes BT11, BT12, BT13.

Nursing treatment is purchased using codes MB1, MB2, MB5.

Home-based nursing treatment can be provided via the DHB and purchased using
the service codes from the relevant community home-based nursing contracts.
For costs, see Appendix 2: Purchasing DHB outpatient treatment for burns clients.
Cover for personal injury suffered in New Zealand (except mental injury caused by certain
criminal acts)
1
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Occupational therapy or physiotherapy treatment for burns
Prior approval for occupational therapy or physiotherapy is:
Not required
for…
The first 18 outpatient treatments following the initial burn
injury
Required
for…
Treatment requests after 18 sessions have been provided. Use
the ACC1855 Burns Outpatient Treatment & Consumables –
Prior Approval Request form.

If the client has a known case manager (CM) at a Branch, forward the request to
that CM.

If a CM is not allocated, send the request:
By email to:
By post to:
By fax to:
Scar.mgt@acc.co.nz
Elective Service Centre
Attention: ACC32 Clinical
Advisor Team
Po Box 408
Dunedin 9016
Attention: ACC32
Clinical Advisor Team
0800 471 477

Requests will be reviewed by the ACC32 Clinical Advisory Team.

ACC may approve or decline the request, or seek additional information.

If treatment is agreed then a purchase order is raised using the relevant BT code.
Service item codes and costs

Occupational therapy or physiotherapy treatment is purchased using codes BT20,
BT21, BT22, BT23.
For costs, see Appendix 2: Purchasing DHB outpatient treatment for burns clients.
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Burns garments
Prior approval for burns garments is:
Not required
for…
The first 10 invoices for burns garments.
Required
for…
Garments requests after 10 invoices have been submitted to
ACC. Use the ACC1855 Burns Outpatient Treatment &
Consumables – Prior Approval Request form.
See, Invoicing and Payment - burns treatment.

If the client has a known case manager (CM) at a Branch, forward the request to
that CM.

If a CM is not allocated send the request:
By email to:
By post to:
By fax to:
Scar.mgt@acc.co.nz
Elective Service Centre
Attention: ACC32 Clinical
Advisor Team
Po Box 408
Dunedin 9016
Attention: ACC32
Clinical Advisor Team
0800 471 477

Requests will be reviewed by the Clinical Advisor Team.

ACC may approve or decline the request, or seek additional information.

If garments request is agreed a purchase order is raised using service item code
BT04.
Supplier invoices for burns garments must be held by the DHB should ACC request to
view them.
Service item code

Burns pressure garments are purchased using code BT04.
See also, Appendix 3: Purchasing DHB outpatient consumables for burns clients.
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Burns splinting
Prior approval for burns splinting is:
Not required
for…
The first two invoices for burns splinting.
Required
for…
Splinting requests after 2 invoices have been submitted to
ACC. Use the ACC1855 Burns Outpatient Treatment &
Consumables – Prior Approval Request form.
See, Invoicing and Payment - burns treatment.

If the client has a known case manager (CM) at a Branch, forward the request to
that CM.

If a CM is not allocated send the request:
By email to:
By post to:
By fax to:
Scar.mgt@acc.co.nz
Elective Service Centre
Attention: ACC32 Clinical
Advisor Team
Po Box 408
Dunedin 9016
Attention: ACC32
Clinical Advisor Team
0800 471 477

Requests will be reviewed by the Clinical Advisor Team.

ACC may approve or decline the request, or seek additional information.

If the splinting request is agreed, a purchase order is raised using service item
code BT05.
Service item code

Burns splinting is purchased using code BT05.
See also, Appendix 3: Purchasing DHB outpatient consumables for burns clients.
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Burns scar management consumables
Burns scar management products are purchased using the service item code BT03 for
non-ProPharma products, or using the vendor catalogue code for ProPharma products.
Clinical decision-making will determine which is most appropriate.
Prior approval for non-ProPharma consumables is:
Not required
for
The first 10 invoices for consumable products.
Required for
Consumable requests after 10 invoices have been submitted to
ACC. Use the ACC1855 Burns Outpatient Treatment &
Consumables – Prior Approval Request form.
See, Invoicing and Payment - burns treatment.

If the client has a known case manager (CM) at a Branch, forward the request to
that CM.

If a CM is not allocated, send the request:
By email to:
By post to:
By fax to:
Scar.mgt@acc.co.nz
Elective Service Centre
Attention: ACC32 Clinical
Advisor Team
Po Box 408
Dunedin 9016
Attention: ACC32
Clinical Advisor Team
0800 471 477

Requests will be reviewed by the ACC32 Clinical Advisory Team.

ACC may approve or decline the request, or seek additional information.

If the consumables request is agreed, a purchase order is raised using service
item code BT03.
Process for ProPharma consumables

ProPharma scar management consumables are purchased from the ProPharma
Medical Consumables Catalogue, under “Skin & Wound Care Products” using the
vendor catalogue code. Purchases are submitted to ACC on the ACC178
Consumables Order form.
Service item codes

Non-ProPharma scar management consumables are purchased using code BT03.

ProPharma scar management consumables are purchased using the vendor
catalogue code.
See also, Appendix 3: Purchasing DHB outpatient consumables for burns clients.
Exceptions to cover
ACC does not fund cosmetics for scar coverage, ie microskin or cosmetic products.
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Requesting Burns Treatment Prior Approval
Complete the ACC1855 Burns Outpatient Treatment & Consumables – Prior Approval
Request form. This is shown in Appendix 5.
To help ACC staff understand that additional treatment is necessary and appropriate,
document the following information in prior approval requests:

A summary of the clinical course to date, including outcomes achieved.

An indication of how long the therapy or treatment is required, and why.

A plan for the scar management including frequency of treatment, garments, and
consumables required to support treatment.

Expected outcomes and how will they be measured.

An explanation of why a client is not making progress, and the cause of why
treatment is not progressing as expected.
It is valuable to provide comment from the burns consultant or plastic surgeon
confirming that scar management and treatment continues to be essential.
Incomplete forms will be returned to the clinician for more information. If a section of the
form is not applicable, please record n/a in that section.
Invoicing and Payment – Burns Treatment
Manual bulk billing
The DHB should complete an invoice schedule, preferably in the format suggested in
Appendix 4 and attach a GST invoice for the total amount.
The schedule should be sent to Elective Service Centre, PO Box 408, Dunedin
When bulk-billing manually for garments (BT04), or consumables (BT03):

Ensure the schedule line has the total amount listed against one line rather than
multiple lines for each item.

Do not bulk together requests from more than one treatment session over a
period of weeks. Each schedule line should only reflect garments or consumables
from one visit to the therapist.

Attach a list of individual items being claimed to the schedule.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
e-Invoicing
Bulk invoice schedules for burns treatments can be sent electronically if ACC approves
your software and the layout of your forms. For more information see For Providers >
Set up and work with ACC > Work electronically with ACC.
When e-billing for garments (BT04), or consumables (BT03):

Use only one schedule line with the total value of the individual garments or
consumables being claimed.

Use the comments to quote how many garments are being supplied.

Do not bulk together requests from more than one treatment session over a
period of weeks. Each schedule line should only reflect garments or consumables
from one visit to the therapist.

Ensure that copies of the individual invoices are available should ACC requires
them.
All schedules must be submitted within 12 months of the treatment, garments, or
consumables being provided.
Payment by ACC is usually made 6 days after receiving an electronic invoice, or 12 days
after receiving a manual invoice.
The provider helpline will answer any invoice queries: Free phone 0800 222 070.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Section 2: Purchasing DHB Scar Management Services for
Clients not Covered by the Burns Framework
Eligibility criteria
ACC funds scar management services for clients who do not have a burns injury but due
to treatment injury, car accidents, or other covered injury, still need:

Scar management treatment

Scar management consumables

Pressure garments.
Scar management purchasing mechanism
When providing…
use the…
Outpatient treatment
by a medical specialist
or nurse (outside of
the PHAS period)

Cost of Treatment Regulations.

DHB contract relevant for the client such as Community
Nursing or Clinical Services.
Treatment by
physiotherapists, or
occupational
therapists

Cost of Treatment Regulations to fund the cost of
treatment, and DHBs will elect the hourly rate, or the visit
rate.

DHB contract relevant for the client such as Hand Therapy
or Physiotherapy Services.
Scar management
consumables

Relevant contract such as Community Nursing, if
consumables under $20 are included in the nurse
consultation. Consumables over $20 are paid using the
service item code CN11.

Cost of Treatment regulations.

ProPharma mechanism.

Service item code CONC (Customised Consumable) for
non-contracted consumables - this code requires prior
approval.
Note:
ACC will not pay for postage within NZ to send consumables
to clients as this is considered a normal cost of business to
the DHB.
Continued over…
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
When providing…
use the…
Scar management
pressure garments

Service item code CONC (Customised Consumable) for
non-contracted pressure garments - this code requires
prior approval.
Note:
ACC will pay freight associated with garments coming
from overseas, but will not pay for postage within NZ to
send pressure garments to clients as this is considered a
normal cost of business to the DHB.
Thermoplastic splints
for scar management

DHB held Hand Therapy contract.

Service item code CONC (Customised Consumable) for
non-contracted splinting - this code requires prior
approval.
Process for ProPharma consumables

ProPharma scar management consumables are purchased from the ProPharma
Medical Consumables Catalogue, under “Skin & Wound Care Products” using the
vendor catalogue code. Purchases are submitted to ACC on the ACC178 form.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Requesting Scar Management Prior Approval
Complete the ACC1856 Scar Management Treatment & Consumables – Prior Approval
Request form. This is shown in Appendix 6.
To help ACC staff understand that additional treatment is necessary and appropriate,
document the following information in prior approval requests:

A summary of the clinical course to date, including outcomes achieved.

An indication of how long the therapy or treatment is required, and why.

A plan for the scar management including frequency of treatment, garments, and
consumables required to support treatment.

Expected outcomes and how will they be measured.

An explanation of why a client is not making progress and why treatment is not
progressing as expected.
It is valuable to provide comment from the plastic surgeon confirming that scar
management and treatment continues to be essential.

If the client has a known case manager (CM) at a Branch, forward the request to
that CM.

If a CM is not allocated, send the request:
By email to:
By post to:
By fax to:
Scar.mgt@acc.co.nz
Elective Service Centre
Attention: ACC32 Clinical
Advisor Team
Po Box 408
Dunedin 9016
Attention: ACC32
Clinical Advisor Team
0800 471 477

Requests will be reviewed by the ACC32 Clinical Advisory Team.

ACC may approve or decline the request, or seek additional information.

A purchase order is raised using service item code.
Incomplete forms will be returned to the clinician for more information. If a section of the
form is not applicable, please record n/a in that section.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Invoicing and Payment - Scar Management Treatment
Manual bulk billing
The DHB should complete an invoice schedule, preferably in the format suggested in
Appendix 4 and attach a GST invoice for the total amount. The schedule should be sent
to Elective Service Centre, PO Box 408, Dunedin
When bulk-billing manually for garments, consumables, or splints (CONC):

Ensure the schedule line has the total amount listed against one line rather than
multiple lines for each type of item, ie where garments, and consumables for the
same client are invoiced, one schedule line should be for garments and one for
consumables.

Do not bulk together requests from more than one treatment session over a
period of weeks. Each schedule line should only reflect garments or consumables
from one visit to the therapist.

Include the purchase order approval number.

Attach a list of individual items being claimed to the schedule.
e-Invoicing
Bulk invoice schedules can be sent electronically if ACC approves your software and the
layout of your forms. For more information see For Providers > Set up and work with
ACC > Work electronically with ACC.
When e-billing for garments, consumables, or splints (CONC):

Use only one schedule line with the total value of the individual garments or
consumables being claimed.

Use one schedule line for garments and one for consumables, when garments and
consumables for the same client are invoiced.

Use the comments to quote how many garments are being supplied.

Do not bulk together requests from more than one treatment session over a
period of weeks. Each schedule line should only reflect garments or consumables
from one visit to the therapist.

Include the purchase order approval number.

Ensure that copies of the individual invoices are available should ACC requires
them.
All schedules must be submitted within 12 months of the treatment, garments, or
consumables being provided. Payment by ACC is usually made 6 days after receiving an
electronic invoice, or 12 days after receiving a manual invoice.
The provider helpline will answer any invoice queries: Free phone 0800 222 070.
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
APPENDICES
Appendix 1: - Frequently asked questions (FAQs)
Q1
A.
Q2
A.
Q3
A.
Q4
A.
Q5
A.
Can DHBs still invoice for services through other contracts?
If clinically necessary other treatment may be requested through the appropriate
discipline-specific contracts held by your DHB.
Can we still use the Clinical Services contract assessment codes for burns
clients?
No. The outpatient codes BT11, 12 and 13 replace the Clinical Services contract
codes and must be used for all burns outpatient client assessments and treatment.
Invoices using the Clinical Services codes will be returned and a request will be made
for an invoice with the correct BT codes.
Is there a restriction on the number of additional treatments that can be
requested?
There is no restriction on the number of additional treatment sessions, however
requests will be approved or declined based on the clinical information that is
supplied to the ACC32 Clinical Advisor team.
Can we invoice ACC for indirect patient time (phone calls, documentation)?
No. This is included within the overall treatment price.
If we have concerns that the client may not receive consumables, what can
we do?
This should be communicated to the client service staff member who may agree to
the consumables being delivered to the therapy department in lieu of a personal
address.
Q6
Can a client access more than one discipline per day? How would we invoice
for this?
A.
Yes. For example a client may be seen by the medical specialist, followed by an
appointment with the occupational therapist on the same day. An invoice requesting
payment for both codes, eg BT11 and BT22 should be submitted to ACC.
Q7
A.
If treatment is provided by two therapists in the same session can we
request two payments?
No. Only one treatment can be submitted for payment.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Q8
Can a client’s outpatient treatment be transferred between DHBs?
A.
Yes. If the referring DHB is unable to identify the number of outpatient treatments
provided, contact the provider helpline for this information.
Q9
My client does not have a delegated client service staff member and needs
further help from ACC. Who do I contact?
A.
Q10
A.
Q11
A.
Q12
A.
Q13
A.
Q14
A.
Q15
A.
Contact the Inquiry Service Centre.
Do treatment limits start again after elective surgery?
No. Treatment limits are for the life of the claim. If you are unsure on whether prior
approval will be required, contact the provider helpline.
Do I have to send individual invoices for each consultation?
No. Consultations can be invoiced in bulk, see Appendix 4 for the suggested format.
Can I send my invoices electronically?
It will depend on your software and its compatibility with ACC. For more information
see For Providers > Set up and work with ACC > Work electronically with ACC, or
contact the e-business team 0800 222 994 (option 1) or email
ebusinessinfo@acc.co.nz.
If billing ACC electronically, do I provide a copy of the supplier invoice for
burns garments?
No. Please hold copies of the individual invoices on the clients file and provide a copy
should ACC request them.
What is the burns contract number for all invoices?
The contract code is BURNS1.
If I am unsure of which vendor ID number the DHB should be using for
burns invoices, who can help me?
Please call health procurement and they can advise you on the correct code.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Appendix 2: Purchasing DHB outpatient treatment for burns clients
All fees are per consultation, GST exclusive, and include all non face-to-face contact time
DHB Medical
Specialist
outpatient clinic
Treatment
within 6 weeks
of inpatient
discharge
Treatment post six weeks of discharge
from either acute admission or most recent
ED attendance for that injury
Hospital based
clinic
Funded via PHAS (includes OT, PT, nurse etc if delivered via MDT clinic)
Funded via Regulations, or via Outpatient medical treatment/assessment using service item codes:
● BT11 - $157.35 – Simple assessment (less than 45 minutes)
● BT12 - $241.10 – Complex assessment (over 45 minutes)
● BT13 - $106.59 – Follow up visits
No prior approval required
Funded via Nursing Regulations, or via MB service item codes:
● MB1 - $33.48 – Treatment of burn less than 4cm2
● MB2 - $65.92 – Treatment of burns at single site greater than 4cm2
● MB5 - $96.04 – Treatment of burns at multiple sites (greater than 4cm2) necessary wound cleaning,
preparation, and dressing
No prior approval required
Nurse treatment
Home based
treatment
Occupational therapy or
Physiotherapy treatment
specialising in burns
Funded via Community home-based nursing contract
● Applicable service item code per contract
Funded via Regulations or via Outpatient treatment/rehabilitation using service item codes:
● BT20 – $52.54 – Simple initial assessment (under 45 minutes)
● BT21 – $87.56 – Complex initial assessment (over 45 minutes)
● BT22 - $43.78 – Simple Follow-up visits (under 30 minutes)
● BT23 - $70.05 – Complex Follow-up visits (over 30 minutes)
As per contract arrangements
Prior approval required after
18 treatments.
Use the ACC1855 Burns
Outpatient Treatment &
Consumables – Prior
Approval Request
Discipline-specific contracts held at DHB
Other DHB Specialist
treatment, eg Clinical
Psychologist
Client-specific negotiation with ACC client service staff member
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Appendix 3: Purchasing DHB outpatient consumables for burns clients
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Appendix 4: Suggested format for manual invoicing schedule
Vendor name:
Date of invoice:
Vendor ID number:
Tax invoice number:
Contract number: BURNS1
GST number
Client name
April 2010
DOB
Injury site
Claim number
Service
date
Assessment
type
(service code)
Price
(incl GST)
Purchase
order number
Provider name
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Appendix 5:
ACC
1855
This form can be downloaded from For Providers > Publications > Burns.
Burns Outpatient Treatment & Consumables
- Prior Approval Request
Complete this form to outline the client’s functional status and request prior approval for
ongoing treatment.
1. ACC DETAILS
ACC office:
ACC Client Service staff member:
2. DHB DETAILS
DHB name:
3. CLIENT DETAILS
Vendor number:
PLACE BRADMAR STICKER IF APPLICABLE
Client name:
ACC45 number:
Date of birth:
Ethnicity:
Home address:
Home phone:
Mobile phone:
Work phone:
Email address:
4. INJURY DETAILS
Date of injury:
Date of discharge from inpatient treatment (where applicable):
Original diagnosis:
5. CURRENT STATUS
Current diagnosis.
Describe the client’s current presentation and functional level including treatment outcomes achieved.
If the client is not making progress please explain the cause of this.
Describe any factors not related to the injury that may impact on treatment and/or the client’s return to independence.
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
6. TREATMENT AND REHABILITATION
Date of last medical specialist review confirming this treatment plan:
Please provide treatment options, and the clinical rationale for these, to enable this client to return to independence. Attach any specialist reports or other
medical information that supports your recommendations.
Treatment option / modality: BT22 – Simple follow up (service item code: BT22)
Clinical rationale for recommendation:
Client goal (specific, measurable, achievable):
Number of treatment sessions requesting:
Treatment option / modality: Complex follow up (service item code: BT23)
Clinical rationale for recommendation:
Client goal (specific, measurable, achievable):
Number of treatment sessions requesting:
Treatment option / modality: Scar management consumables (service item code: BT03)
Clinical rationale for recommendation:
Consumable products requesting:
Amount of product and frequency of use:
Indicative cost:
Treatment option / modality: Burns Garments (service item code: BT04)
Clinical rationale for recommendation:
Type of garments:
Number of garments requesting:
Indicative cost (including overseas freight) :
Treatment option / modality: Thermoplastic Splints (service item code: BT05)
Clinical rationale for recommendation:
Number and type of splints requesting:
Indicative cost:
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Treatment option / modality:
Clinical rationale for recommendation:
Client goal (specific, measurable, achievable):
Timeframe or frequency requesting:
Indicative cost (if appropriate):
7. PROVIDER SIGNATURE
I certify that I have personally examined the client and to the best of my knowledge the information given is accurate.
Signature:
Date:
Name:
Professional affiliation:
Phone number:
Email:
Fax:
The information collected on this form will only be used to fulfil the requirements of the Accident Compensation Act 2001. In the collection,
use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy
Code 1994.
April 2010
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
Appendix 6:
ACC
1856
This form can be downloaded from For Providers > Publications > Burns.
Scar Management Treatment & Consumables
- Prior Approval Request
Complete this form to outline the client’s functional status and request prior approval for
ongoing treatment.
1. ACC DETAILS
ACC office:
ACC Client Service staff member:
2. DHB DETAILS
DHB name:
3. CLIENT DETAILS
Vendor number:
PLACE BRADMAR STICKER IF APPLICABLE
Client name:
ACC45 number:
Date of birth:
Ethnicity:
Home address:
Home phone:
Mobile phone:
Work phone:
Email address:
ACC
855
4. INJURY DETAILS
Date of injury:
Date of discharge from inpatient treatment (where applicable):
Original diagnosis:
5. CURRENT STATUS
Current diagnosis.
Describe the client’s current presentation and functional level including treatment outcomes achieved.
If the client is not making progress please explain the cause of this.
Describe any factors not related to the injury that may impact on treatment and/or the client’s return to independence.
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DHB Outpatient Burns and Scar Management Purchasing – Operational Guidelines
6. TREATMENT AND REHABILITATION
Date of last medical specialist review confirming this treatment plan:
Please provide treatment options, and the clinical rationale for these, to enable this client to return to independence. Attach any specialist reports or other
medical information that supports your recommendations.
Treatment option / modality: Scar management consumables (service item code: CONC)
Clinical rationale for recommendation:
Consumable products requesting:
Amount of product and frequency of use:
Indicative cost:
Treatment option / modality: Pressure Garments (service item code: CONC)
Clinical rationale for recommendation:
Type of garments:
Number of garments requesting:
Indicative cost (including overseas freight) :
Treatment option / modality: Thermoplastic Splints (service item code: CONC)
Clinical rationale for recommendation:
Number and type of splints requesting:
Indicative cost:
Treatment option / modality:
Clinical rationale for recommendation:
Client goal (specific, measurable, achievable):
Timeframe or frequency requesting:
Indicative cost (if appropriate):
7. PROVIDER SIGNATURE
I certify that I have personally examined the client and to the best of my knowledge the information given is accurate.
Signature:
Date:
Name:
Professional affiliation:
Phone number:
Email:
Fax:
The information collected on this form will only be used to fulfil the requirements of Accident Compensation Act 2001. In the collection, use
and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy Code
1994.
April 2010
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