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Processing Low Income Health Care Card (LIC) claims 101-18042300

Low Income Claims (LIC) claims should be processed in Process Direct, select the Process Direct tab. Only process in Customer First, in limited circumstances, when directed.

Process Direct

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Pre-claim processing

Assessment of Care Arrangements referral

Processing LIC claims

Pre-claim processing

Table 1

Step	Action
1	Customer contacts or work item allocated If the customer's query is about: LIC eligibility and claiming, see Low Income Health Care Card (LIC) a submitted LIC claim, go to Step 2 an allocated work item, go to Step 2 a reassessment of their rejected claim, go to Step 2 a LIC renewal, see Low Income Health Care Card (LIC) renewals being unable to claim or renew LIC online as their expired LIC is incorrectly displaying as current, go to Process page > Customer First tab > Table 5 Note: when Service Officers get error E082CU - This service reason currently exists for this record when trying to run (ACC) for the customer to claim or renew LIC, go to Process page > Customer First tab > Table 5
2	Locate claim Locate the work item in Process Direct. Select the work item to go to the Customer and Claim Information table on the Transaction Summary (TS) screen, to review and process the customer's claim. Paper claims When a Claim for a Health Care card (SS050) is scanned to the customer's record, a Social Application (SOA) shell work item is generated on the customer's record. If the customer has indicated on the paper claim that their partner will require a Health Care Card (HCC) of their own, create a Social Application (SOA) shell on the record by scanning the paper claim to both records. For further information, see Table 3 > Step 2 in Indexing, reindexing and cancelling claim activities. This has no claim information apart from: the Customer Reference Number (CRN) personal detail, and receipt date Claim information will need to be manually added into the SOA claim, using details from the scanned claim and documents. Note: children in the care of Approved Care Organisations may qualify for a LIC in their own right, as long as no individual is being paid Family Tax Benefit (FTB) for the care of the child. The Claim for a Health Care Card (SS050) must be completed in the name of the child and not in the name of the organisation, or a worker from that organisation. For information on how to access claims for processing, see Process Direct navigation, common screens and functions. Is the claim for a child in the care of an Approved Care Organisation? Yes, and the child: has a person (PER) CRN. Go to Step 3 does not have a CRN. See Adding a customer to the system, then complete actions to move the digital image to the correct CRN. Go to Step 3 has an existing child (CHI) CRN. Convert the CHI record to a person (PER) record, then complete actions to move the digital image to correct CRN. Go to Step 3 No, go to Step 3
3	Claim status The claim status must be In Process before it can be processed. If this claim has been submitted within 13 weeks of a previously rejected claim, see Request to reassess a rejected claim. If the previously rejected claim was able to be reassessed, the subsequent claim status should be updated to 'Not Required'. Is the new or reindexed claim status In Process? Yes, go to Step 4 No, for claim status definitions and actions to take, see Process Direct navigation, common screens and functions
4	Review Claim Summary To review the Claim Summary: select to view the Claim Summary select to expand the Claim Summary review the Claim Summary in a new window if needed. Key details, include: relationship status Australian residence Identity requirements for the customer and partner income details select Documents to view the documents provided by the customer (uploaded online or scanned to their record)
5	Identity Confirmation On the Transaction Summary (TS) screen, check the customer’s and if relevant partner’s identity status. Is the identity status confirmed? Yes, go to Step 6 No: select the Not Confirmed link, to open a Customer Summary window Select Identity Confirmation > Identity Confirmation Dashboard from the Task Selector For the customer: See Identity Confirmation If the customer cannot confirm their identity, code any available identity documents, complete an Alternative Identity assessment For the partner: If the partner: is confirmed or has a no linkage identity status: identity requirements have been met for partner no documents are required go to Step 6 is receiving an Income Support Pension (ISP), Department of Veterans Affairs (DVA), Low Income Health Care Card (LIC) or Commonwealth Seniors Health Care Card (CSHC): no documents are required Service Officers must apply an identity review on the partner’s record. The review will auto complete when the linked claim is processed. For the process when the partner is an ISP, DVA, LIC or CSHC recipient, see Alternative Identity is none of the above: the partner is required to establish their identity by providing 3 approved documents to achieve a no linkage identity status on the dashboard, Service Officers are required to select NP - No Linkage required. See Coding identity documents New LIC claims can only be finalised when Identity Confirmation or Alternative Identity is competed in the Identity Confirmation Dashboard. Do not update Proof of Identity (POI) screens. Note: if identity requirements have been met, and the claim presents a POI error, the claim must be regenerated and processed. This is a new claim mapping issue and not related to identity. If the POI error E257CU presents when processing a claim, see details for the error in the Roxy Digital Assistant.
6	Relationship details These details must be reviewed/updated before selecting Process. Relationship details are viewed on the Transaction Summary (TS). The: Link Summary (LS) table shows all known relationships to the customer, for example: Partner and any Relationship Qualifier Code Children Nominees Marital Status (MS) table shows the marital status of the customer Compare relationship details provided in the claim with the details already recorded in the Marital Status (MS) table. Has the customer advised within their claim that they are: separated/single, go to Step 7 partnered, go to Step 9
7	Separated/single customer Is the customer already current on a payment or benefit? Yes, go to Step 8 No, the customer is claiming LIC only, go to Step 10
8	Current on payment or benefit Is the customer advising of a change in relationship status within their new claim? Yes, the relationship will need to be assessed based on the customer's current payment or benefit, prior to assessing the LIC new claim: see Change in relationship status from partnered to single go to Step 10 No, the relationship details within the new claim and on the Marital Status (MS) screen are the same, go to Step 10
9	Partnered customer Note: a Member of a couple (MoC) assessment is not required for a customer and sharer/other person who are claiming or have a current LIC only. Is the customer and/or partner current on a payment or benefit, and the current partner is the same as already recorded? Yes, the relationship details within the new claim on the MS screen are the same, go to Step 10 No, the customer has lodged a: paper claim form and the partner has: signed the form, go to Step 10 not signed the form, see Confirming a partnered relationship to assess the relationship. Once confirmed, go to Step 10 claim online advising they are partnered: LIC claims do not issue a MOD P or a Temporary Access Code (TAC) see Table 1 > Step 5 in Confirming a partnered relationship to assess the relationship once confirmed, go to Step 10
10	Eligibility for LIC Check if the customer has met the basic eligibility for LIC Does the customer qualify for a LIC? Yes, go to Step 11 No, go to Step 12
11	Documents Check the claim to make sure all required documents have been provided. Have all relevant supporting documents been provided? Yes, go to Step 14 No, go to Step 12
12	Check for Vulnerable Indicator A customer identified as vulnerable as part of the LIC claim can submit their claim before completing all required tasks. Does the claim have the keyword 'URGVULN' on the Keyword screen? Yes, and: only additional documents are now required, go to Step 13 it has been less than the time allowed to respond since the claim lodgement, hold the claim for the appropriate timeframe from the Claim Submission Date on the Status screen. On the Notes screen, add or update the Claim Progress note for action taken. Procedure ends here it has been more than the time allowed to respond since claim lodgement, go to Step 14 No: if additional documents are required, go to Step 13 if documents have been requested at the time of claim or after, and not returned, go to Step 14
13	Request more documents or information If more details or clarification of the claim or submitted documents are needed to determine the customer's eligibility, make genuine attempts to contact the customer by phone. If the contact was successful, record the details of the conversation in the Progress of Claim Note. If the customer: has provided required information to assess the claim verbally, or the customer can immediately upload the information, go to Step 14 cannot immediately upload the information and it is still required, request the information. Procedure ends here contact was unsuccessful, or it is not appropriate for the customer to provide the information or evidence verbally, request the information. Procedure ends here
14	Rejecting the claim Is the claim to be rejected? Yes, see Rejecting a claim for Low Income Health Care Card (LIC). Procedure ends here No, go to Step 15
15	Further action required Are further actions required? Yes: a referral is required, go to Step 16 actioning a completed Assessment of Care Arrangement referral is required, see Table 2 > Step 4 No, there are no outstanding referrals, see Table 3 > Step 1
16	Referral If more than one referral is required, make sure that all referrals are completed. When a specialist assessment is required: select > Referral complete the referral details when a referral is made, the claim remains on hold until the assessment has been completed. Annotate the Progress of Claim Note with details of the request when the referral(s) are completed, continue processing the LIC claim Complex Assessment Officer (CAO) Unless it is clear the claim must be rejected because basic eligibility criteria has not been met, claims needing a CAO referral should not be finalised until the assessment has been completed. If the customer’s financial circumstances are complex, for example, they include a trust or company, a CAO referral is needed to make sure the income and assets tests are met. For referral instructions, see Identifying and making suitable referrals to the Complex Assessment Officer (CAO). Note: only refer to CAO if all documents for the new claim are received. Compensation Clearance request See Coding Compensation and damages (MOD C) to request a clearance for referral instructions. Centrelink International Services Officer (CIS) A non-government payment, or a payment made by a private organisation is not a foreign pension and should not be referred to CIS for coding. If necessary, make sure all foreign pension documents are scanned to the customer record 'S 'INT'OG' ensuring that no work item is created (scan to store). Translation of foreign pension documents is not needed before referring to CIS. For referral instructions, see Foreign pension coding. Assessment of Care Arrangement referral A completed FA012 form must be lodged as part of a LIC claim, where either of the following is advised: a change to care arrangements for an existing child, or a new child has entered the customer's care An Assessment of Care Arrangements referral must be created when a Details of your child’s care arrangements (FA012) form has been requested and returned as part of a LIC claim. The Resources page has a link to the form. If an Assessment of Care Arrangement FA012 form been returned and referral is required, see Table 2 > Step 1.

Assessment of Care Arrangements referral

Table 2

Step	Action
1	Check for a completed Assessment of Care Arrangements Go to Document List (DL). Check the Notes screen, to confirm if a care assessment has been completed. One of the below titles may display (this is not an exhaustive list): Change in Care Status Changes in Child - No Decision Shared Care Decision Add child coming into care Care Decision Care details update per Child Support Agency (CSA), or Care assessment not required Has a care assessment been completed? Yes, go to Step 4 No, go to Step 2
2	Check for existing referral On the Notes screen, does a Note with the title 'Care Assessment referral' display with a date after the claim submission? Yes: the care assessment is in progress hold the claim and annotate the Progress of claim Note with 'Claim held for 14 days pending Assessment of Care Arrangements' procedure ends here No, go to Step 3
3	Create an Assessment of Care Arrangements referral Select > Referral. On the Referral screen: Referral Type: select Assessment of Care Arrangements Referral > Next Referral Reason: select the appropriate referral reason Document Lists: select Details of your Child's Care Arrangements (FA012) in the What is required? field, add, 'LIC claim lodged DD/MM/YYYY. Care determination and Principal Carer determination is required for: Child/ren's Name and date of birth New Child advised within LIC claim, care assessment required. FA012 scanned to record' in the Have all necessary documents been provided? field, select Yes select Finish Select the Status icon. The Status screen shows the claim has been placed on hold for 14 days. Select the Notes icon. Annotate the LIC Claim Progress Note with, 'Claim held for 14 days pending Assessment of Care Arrangements'. Procedure ends here.
4	Care assessment finalised Review the Notes for key information to determine the assessment for child/ren in the LIC claim. This includes child/ren name, date of birth (DOB) and care percentage details. If the assessment outcome is: a change to or confirmation of care arrangements for a child already in care, or no change to existing care arrangements: select to complete a SAP refresh see Table 3 > Step 1 a new child has entered the customer's care, go to Step 5 the child is not in the customer's care, go to Step 6 Note: use the steps above to apply different circumstances to each child where there is more than one child listed within the LIC claim, depending on the care assessment results.
5	New child in customer's care If a new child is in the customer's care: select > Regenerate Claim once the claim has been regenerated, the child should be listed under the Known Relationships select > Child check the Child in Care (CHC) screen has been coded see Table 3 > Step 1
6	Child not in customer's care If the child is not in the customer's care: select > Regenerate Claim go to Known Relationships check the child is showing under the Claim Relationships table, change the status to 'Not Required' see Table 3 > Step 1

Processing LIC Claims

Table 3

Step	Action
1	Process the claim Before selecting Process, make sure all outstanding referrals are completed. If not, place the claim back on Hold for a further 14 days and annotate the Progress of Claim Note. If the relationships details are updated after processing has been started, the claim will need to be regenerated by selecting > Regenerate claim. Do not start coding before selecting Process as this will result in errors. Select Process to view the Errors (SWE) screen. Before coding any screens: select Assess when the Entitlement (ELD) screen displays, select Back or key 'SWE' in Super Key to return to the SWE screen complete the claim coding Message Log This section displays any errors with existing coding. These must be fixed before the claim can be assessed. For help, see Using Digital Assistant Roxy in Process Direct. Task Selectors These list common screens. Task selectors that have mandatory screens are pre-selected. Task selectors may not list all screens that must be checked or coded. Check screens to compare historical details with the claim details. A flag will display against all screens that have provisional claim data. These may not need to be accessed to process the claim: select the screens to be checked or updated. There is an option to select all screens select Next or press [Enter] to go through the selected screens Use Super Key to go to screens. Key 'Screens' to view a full list.
2	Error Message The following system errors display when a LIC NCL is more than 10 months old at date of processing: E244ZZ - Cannot backdate DOR of a LIC NCL for more than 10 months in the past E051LI - LIC NCL cannot be completed for this date of commencement E0031 - This date may not be more than one year in the past Have any of these error messages presented? Yes, see Table 4 > Step 1 on the Customer First tab No, continue assessing the claim, go to Step 3
3	Assess and code the LIC claim Check information provided in the claim (provisional data) is accurate and in line with any evidence that has been provided. See income and financial investments. LIC start date LIC start date defaults to the date of claim lodgement. In some circumstances, based on the information supplied by the customer, Services Officers may need to make a decision on the LIC start date. LIC income LIC entitlement is based on the customer's last 8 weeks of income from the LIC start date. If a decision is made to change the defaulted start date, the income assessment period will need to be reassessed and evidence supplied. See Low Income Health Care Card (LIC) income test. Residency The customer's residence qualification will be automatically assessed based on the residence information recorded. See Residence assessment for adult customer claiming a Low Income Health Care Card (LIC), Foster Child Health Care Card (FST HCC) or Ex-Carer Allowance (child) Health Care Card (EHC). Note: residence information must still be recorded if the claim will be rejected for any reason. If residence details are not recorded, the system will override any other rejection reason, and the claim will reject for a residence related reason. Select all relevant Task Selectors and select Next: Key/update required information for each relevant screen Check information provided in the claim (provisional data) is accurate and in line with any evidence that has been provided. Update where necessary Check nominee information has not been incorrectly ended, for example, Public Trust nominees. See Adding or rejecting a nominee request Check there is no historical coding of continuous income that needs to be ended, see Recording and correcting employment income details If an STP employer has been presented to the customer (question 'Do you work for (employer) ABN XXXX') within the claim, any provisional income needs to be confirmed. STP income is not presented to the customer within the claim. Service Officers must check evidence supplied, and manually update the Employment Income Paid Details (EAPP) screen with income from the claim and evidence supplied by the customer If the POI error E257CU presents when processing a claim, see details for the error in the Roxy Digital Assistant. Do not manually code the Proof of Identity (POI) screen. Has the customer provided all required information? Yes: and the customer has asked for the start date of the LIC card to be backdated, go to Step 4 otherwise, go to Step 7 No: streamline reject the claim Fail to Supply Documents - FSD see Rejecting a claim for Low Income Health Care Card (LIC) procedure ends here
4	Determining a new LIC start date (backdating) To cover medical, pharmaceutical, or other related expenses already incurred, the start date of a LIC may be backdated to a particular date of the customer’s or their dependant’s medical service or treatment. The customer must provide evidence to: support the request for backdating the start date satisfy the income test in the 8 week assessment period ending on the date (service or treatment) and remain eligible throughout the period up to the claim date See Determining a backdated LIC start date. The start date field on the LIC Start Date (LSD) screen defaults to the DOR. Has the customer provided evidence and requested the start date to be backdated? Yes, and the claim is to be backdated: 13 weeks or less from the processing date, go to Step 6 more than 13 weeks from processing date, go to Step 5 No, the claim cannot be backdated, go to Step 7
5	Referral required If backdating more than 13 weeks from the processing date, a referral will be required. Refer to the Level 2 Policy Help Desk - Concessions. The following information must be included within the referral Enquiry Description: backdating start date to be applied proof of medical service or treatment reason why the customer did not claim from the earlier date if known determination that the customer has satisfied the income test for the new relevant 8 week assessment period, prior to the medical service or treatment and throughout the backdated period up to the claim date. DOC the customer record to advise a referral has been requested Once response from Level 2 Policy has been provided, go to Step 7.
6	Coding the new LIC claim start date Go to the LIC Start Date (LSD) screen and select Add. Complete all required fields: Start date: key the backdated date Reason for backdating: key a valid reason code: MED - Medical services or treatment DEL - Delayed processing of claim ARO - ARO review of decisions (applies to the outcome of a review officer decision made either by a Subject Matter Expert or an Authorised Review Officer) select Assess when the Entitlement (ELD) screen displays, manually navigate to relevant screens to make sure all Event Date field entries align with the correct 8 week assessment period and the backdated start date recorded on the LSD screen select Save Go to Step 7.
7	Dependent children coding Does the customer have a dependent child/ren in their care? Yes, go to Step 8 No, go to Step 9
8	Update information on the Child Override/Claim (CHOC) screen The CHOC screen must be recorded for each child individually, otherwise the child will not be included in the assessment. Go to the CHOC screen, via the Super Key: if the dependent child/ren do not display Service Reason LIC, select Add update Start Date: for a new claim, the date will default based on the date of receipt of the claim and the child's birth date. For the LIC Income test to be applied correctly, it may be necessary to change the date to the child’s date of birth if the birth occurred in the 8 week assessment period. Future dates are not permitted for a reassessment, code the date of the event Child Name: select each relevant child separately Service Reason: Low Income Health Care Card Reason: claim select Save
9	Claim outcome After coding the claim: select Assess the Errors (SWE) screen will list any validation errors to address once the Message Log is clear, select Assess the Entitlement (ELD) screen displays the outcome make sure the claim outcome is correct for the customer (and partner if applicable) Is the claim to be rejected? Yes, see Rejecting a claim for Low Income Health Care Card (LIC). Procedure ends here No, the customer is eligible for LIC: select Finish review the Claim Outcome Note, following Online Document Recording (ODR) if backdating include: the backdated grant date and the reason continuous eligibility was met from the revised grant date select Finalise select Finish. A box will confirm the claim has been successfully completed procedure ends here