What is a Continuing Healthcare Retrospective Review?
If you have been paying for your care but have not been assessed for NHS Continuing Healthcare (CHC) eligibility, it may be possible to request a retrospective review of these ‘previously unassessed periods of care’ (PUPoC). This can apply to both current patients and people who are deceased.
A request for a retrospective review can only be made for periods of unassessed care.
The period that can be considered is after 1 April 2012, as the opportunity to claim for period before that date has now passed.
Requests for a retrospective (PUPoC) review should be made to;
or contact the team on tel: 0151 433 6987 then select option 3
The Retrospective Review Process
If it is agreed that a retrospective review should proceed you will be asked to complete a questionnaire and provide documentation concerning your authority to act.
Once this has been returned, evidence will be obtained from all parties involved in the individual’s care for the claim period. Someone can represent you if you wish – legal representation is not required however if you choose to employ someone to represent your case the NHS will not reimburse you this cost.
The evidence will be reviewed by a clinical assessor who will complete a Care Needs Portrayal (CNP) detailing the individual’s health needs throughout the review. Once completed the CNP will be shared with you and you will be asked to review and confirm the details presented and provide any further comments you may have.
An NHS Continuing Healthcare Checklist will be completed. If the outcome of the checklist is negative, we will inform you of this and provide copies of the checklists, your case will be closed and you will be informed how you can challenge this decision.
If the outcome of the checklist is positive the retrospective review will proceed. It is possible that only part of the period may result in a positive checklist, and this will form the claim period.
A Multi-disciplinary team (MDT) will use the CNP and any comments or evidence you have provided to produce the retrospective Decision Support Tool(s) [DST]. The DST(s) will contain a recommendation on the individual’s eligibility for NHS Continuing Healthcare funding for the review period. That recommendation will be submitted to your Integrated Care Board for them to make the final decision on Continuing Healthcare Eligibility.
You will be sent a letter detailing the retrospective review’s outcome. The outcome will be one of the following:
- The individual was eligible for Continuing Healthcare Funding Care throughout the Retrospective Review.
- The individual was eligible for Continuing Healthcare Funding/ for part of the period of the Retrospective Review
- The individual was not eligible for Continuing Healthcare Funding for any part of the period of the Retrospective Review
If the individual was eligible for Continuing Care Funding for all or part of the period under consideration, reimbursement arrangements will be made.
If you are unhappy with the outcome of the Retrospective Review, you can notify the Retrospective Team within 6 months of the date of the outcome letter that you wish to appeal the decision.
Why would a request to complete a retrospective review be declined?
When we have checked an application, it is not always be possible to go ahead with a retrospective review, for reasons such as:
- The period of care requested may have been previously assessed for CHC eligibility.
- We cannot get all the care records we need; this may be because they have been destroyed by the record holder. There is guidance about retention of records needed to be held by NHS organisations, but these do not apply to private companies such as Nursing Homes who will have their own guidance.
- The individual may be registered under a different ICB and therefore MLCSU would not be able to review this but can direct your information to the correct ICB.
We will always explain to you the reason for not going ahead with a retrospective review.
What information will we collect as part of the process?
We will collect and process data from a number of sources to ensure individuals reviews can be processed. As mentioned above, this will include requesting records from various places such as Care Homes, GP’s, Local Authorities, Hospitals, District Nurses and Mental Health teams. If they cannot provide records, we will let you know.
These records may include:
- Physical or mental health details
- Racial and ethnic origin
- Sexual orientation
- Details of care
- Religious or similar beliefs
- Sensitive information with regards to physical and mental health conditions
- Information pertaining to the referral, assessment, and care plans of the patient
- Financial information such as, Bank statements and Department of Work and Pensions (DWP) documents
- Family and relationship details
How will my information be used and shared?
Under the UK General Data Protection Regulation (UK GDPR) consent is not required for the processing of personal and healthcare data in the context of NHS Continuing Healthcare (CHC).
Information will be shared with relevant health professionals who are involved in the CHC appeals process in order to determine whether any retrospective claim should be upheld.
All professionals involved in the process must maintain strict confidentiality regarding any information that is shared as part of any review process. Information may be shared at several points during the retrospective review process.
Information will not be shared with friends, family or other individuals not involved in the process without prior consent from the patient or appointed patient representative. Individuals have the right to withdraw consent to share information with friends/family/representatives at any time. A health professional will be able to advise you how withdrawal of consent may impact any review.
For further information regarding how your information is processed and how it is used within the NHS, please see MLCSU’s Privacy Policy:
https://www.midlandsandlancashirecsu.nhs.uk/privacy-policy/
How will my information be used and shared?
Should you wish a copy of any of your information then please initially speak to a member of the retrospective reviews team who can advise. If they are unable to provide it easily, they will re-direct you to the appropriate department so you can make a ‘Subject Access Request’ or an ‘Access to Health Records Request’.
