NDIS Plan Review Refused

The NDIA can refuse your plan review request for several specific reasons under Section 48 of the NDIS Act 2013. The most common refusal grounds include insufficient evidence of changed circumstances, failure to demonstrate that current supports are no longer meeting your needs, or requesting a review too soon after your last plan approval.

According to recent NDIA data, approximately 22% of plan review requests are initially refused. The NDIA must provide you with a written decision outlining the specific reasons for refusal, referencing how your request failed to meet the criteria under Section 34 (reasonable and necessary supports) or Section 48 (plan review grounds).

Common refusal reasons include: lack of medical evidence supporting changed needs, insufficient demonstration that current funding is inadequate, requesting supports that don't meet reasonable and necessary criteria, or submitting a review request within 12 months of plan approval without demonstrating significant changed circumstances.

Understanding the specific reason for your refusal is crucial because it determines your next steps and the type of evidence you'll need to gather for an internal review or resubmission.

When the NDIA refuses your plan review, you have specific legal rights under the NDIS Act 2013. Most importantly, you have 28 days from the decision date to request an internal review under Section 100 of the Act. This deadline is strict and cannot be extended, so acting quickly is essential.

The internal review process allows a different NDIA delegate to examine your case with fresh eyes. During this process, you can submit additional evidence, clarify misunderstood information, or address specific concerns raised in the original refusal. The internal review is free and typically takes 60-90 days to complete.

Beyond internal review, you also have the right to contact the NDIS Quality and Safeguards Commission if you believe the NDIA failed to follow proper processes, or to seek external advocacy support through organisations like Disability Advocacy Network Australia (DANA).

You can initiate an internal review by calling the NDIA on 1800 800 110 or submitting a written request through the myNDIS portal. Ensure you reference the original decision date and clearly state you're requesting an internal review of the plan review refusal.

A successful internal review requires addressing the specific reasons for the original refusal with compelling new evidence or clarifications. Start by carefully analysing the NDIA's written decision to understand exactly why your request was refused.

For medical evidence deficiencies, obtain detailed reports from treating specialists that specifically address your functional capacity and support needs. These reports should cost around $300-500 but are often covered under Category 15 (Improved Daily Living) as a capacity building expense.

If the refusal cited insufficient demonstration of changed circumstances, gather evidence showing how your condition has deteriorated or how new challenges have emerged since your last plan. This might include therapy notes, carer observations, incident reports, or comparative functional assessments.

Document how your current funding levels are inadequate by tracking expenses, unmet support hours, or situations where you've had to go without necessary supports. PlanMaxx can help analyse your current plan to identify systematically underfunded support categories that strengthen your case.

Different refusal scenarios require targeted response strategies. Here's how to address the most common refusal situations:

If you have Support Coordination funding (Category 7), your coordinator can be invaluable during the internal review process. Support Coordinators can help gather evidence, liaise with providers, and ensure your submission meets NDIA requirements.

Current Support Coordination rates are $77.23 per hour for standard coordination and $123.15 per hour for complex coordination. Many coordinators will prioritise internal review support as it falls within their core responsibilities under the NDIS Practice Standards.

If you don't currently have Support Coordination, consider whether requesting this in your internal review might help. Support Coordination is often approved even when other supports are refused, as it demonstrates your commitment to using NDIS funding effectively.

Your Support Coordinator should help you understand which specific support categories to target in your internal review and can provide market analysis showing typical funding levels for participants with similar needs and goals.

The NDIA evaluates plan review requests against specific criteria outlined in Section 48 of the NDIS Act. Understanding these criteria helps you structure your internal review submission effectively.

Primary criteria include: whether your circumstances have changed significantly since your last plan, if your current supports are no longer meeting your needs, whether new supports would be reasonable and necessary under Section 34, and if the requested supports align with your NDIS goals.

The NDIA also considers cost-effectiveness, whether supports could be provided more appropriately by mainstream services, and if your request represents value for money. Recent pricing schedule updates show the NDIA is particularly focused on cost justification, with Therapist rates capped at $214.41/hour for psychologists and $186.57/hour for occupational therapists.

Your internal review submission should directly address each criterion with specific evidence and clear reasoning. Generic statements about needing 'more support' are unlikely to succeed.

If your internal review is unsuccessful, several alternative pathways remain available. The Administrative Appeals Tribunal (AAT) provides an independent review of NDIA decisions, though this process can take 12-18 months and may involve legal costs.

AAT application fees are currently $1,826 for NDIS matters, though fee waivers are available for pension cardholders. Legal representation costs typically range from $300-600 per hour for disability law specialists, though some work on no-win-no-fee arrangements.

Before proceeding to the AAT, consider whether a fresh plan review request might be more appropriate. If your circumstances have changed further or you've gathered substantially new evidence, a new request might be faster and more cost-effective than AAT proceedings.

The Commonwealth Ombudsman can also investigate complaints about NDIA processes, though they cannot overturn decisions. Contact them on 1300 362 072 if you believe the NDIA failed to follow proper procedures.