Assessing a recognised disability for Carer Allowance (CA) (child) 009-03040020

This process does not apply to carers claiming Carer Payment (CP) only. For CP only claims, see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Did the carer lodge the Services Australia medical report that was requested when they submitted their claim?

• Yes, see Table 2
• No, go to Step 2

If the carer:

• previously lodged a claim for Carer Allowance (CA) only, with a non-Services Australia medical report which was not accepted, and:
• the agency sent a Request for Information (RFI) asking them to provide a Services Australia medical report, and
• the carer did not provide the Services Australia medical report , reject the CA claim. See Rejecting a Carer Allowance (CA) claim
• procedure ends here
• previously lodged a claim for CP and CA, with a non-Services Australia medical report, which was not accepted, and
• sent an RFI asking them to provide a Services Australia medical report to assess CP and CA, and
• the carer did not provide Services Australia medical report, reject the CP and CA claim. See Rejecting a Carer Allowance (CA) claim and Rejecting a Carer Payment (CP) claim
• procedure ends here
• previously lodged a claim for CP and CA, with a non-Services Australia medical report, and
• the agency accepted the non-Services Australia report for CA, and
• sent an RFI asking the carer to provide a Services Australia medical report to assess CP, and
• the carer did not provide the Services Australia medical report, go to Step 9
• lodged a non-Services Australia medical report, go to Step 3
• did not lodge any medical reports:
• see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA)
• procedure ends here

The non-Services Australia medical report can only be used instead of a Services Australia medical report if:

• the report clearly states the child care receiver has a formal diagnosis of ASD, and
• the formal diagnosis was made using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and
• the formal diagnosis was made by:
• a psychiatrist
• a registered psychologist, or
• a paediatrician

Note: terms such as ‘autistic traits’ and ‘likely to have autism’ indicate ASD has not been formally diagnosed.

Does the non-Services Australia medical report meet all the above conditions?

• Yes, go to Step 5
• No, go to Step 4

The non-Services Australia medical report cannot be accepted. The carer must provide a Services Australia medical report.

• Send a Request for Information asking the carer to provide a Carer Payment and Carer Allowance Medical Report (SA431)
• Place the claim on hold using the Hold to User function
• Procedure ends here until the Services Australia medical report is lodged or the claim comes off hold

The non-Services Australia medical report:

• can be used to assess CA
• cannot be used to assess CP. A Services Australia medical report is required to assess CP

If the carer is claiming:

• combined CP and CA, go to Step 6
• CA only, go to Step 9

Record all the available information for the CP/CA claim.

Is CP and/or CA rejecting for a ‘non-medical’ reason (for example, income)?

• Yes, go to Step 7
• No, go to Step 8

Both CP and CA are rejecting for non-medical reasons:

• Reject the payments. In the rejection DOC, record the following (in addition to any other information required to reassess the claim): ‘If the carer wants to appeal the decision, a Carer Payment and Carer Allowance Medical Report (SA431) is required to medically assess CP.’
• To reject the payments see:
• Rejecting a Carer Payment (CP) claim
• Rejecting a Carer Allowance (CA) claim
• Procedure ends here

If CP only is rejecting for a non-medical reason (CA is not rejecting):

• Reject the CP claim, see Rejecting a Carer Payment (CP) claim
• Continue with the CA claim, go to Step 9

To assess the carer’s combined CP/CA claim, take the following action:

• Do not finalise the CA claim
• Send a Request for Information asking the carer to provide a Carer Payment and Carer Allowance Medical Report (SA431)
• Place the claim on hold, using the Hold to User function
• Procedure ends here until:
• the Services Australia medical report is lodged, or
• the claim comes off hold

The non-Services Australia medical report can be used to assess the CA claim because:

• the child medically qualifies for CA (child)
• an assessment under the Disability Care Load Assessment (DCLAD) (2020) is not required

Note: if the carer did not return the Services Australia medical report to assess CP, when the combined CP/CA claim is assessed CP will reject due to no Treating Health Professional (THP) score.

To determine the period of the condition, go to Table 3.

Did the agency previously write to the carer or Treating Health Professional (THP) asking them to provide details that were incorrect or missing from their Services Australia medical report?

• Yes:
• If the carer or THP has responded to this request, go to Step 2
• If the claim has come off hold and there is no response from the carer/THP, reject the claim. See Rejecting a Carer Allowance (CA) claim. Procedure ends here
• No, go to Step 2

To determine if the child care receiver has been diagnosed with a recognised disability or a recognised medical condition, review the THP’s responses to Questions 7, 8 and 9:

• Question 7 and/or Question 8, the THP does not indicate the child has a recognised disability and/or a recognised medical condition, and at:
• Question 9, they answered ‘No’, go to Step 9
• Question 9, they answered ‘Yes’, go to Step 4
• Question 7 and/or Question 8, the THP indicates the child does have a recognised disability and/or a recognised medical condition, and at:
• Question 9, they answered ‘Yes’, ‘No’ or left the answer blank, go to Step 3

Eligibility for CA requires the medical condition to be present for at least 12 months, unless the condition is terminal.

If the THP marked Questions 3, 4 and 5 to indicate the disability or medical condition is:

• permanent, or temporary and expected to be present for at least 12 months, go to Step 10
• temporary, and expected to be present for less than 12 months:
• contact the THP
• ask them why they consider the disability or medical condition is temporary

Was contact with the THP successful?

• Yes, go to Step 7
• No, go to Step 6

Eligibility for CA requires the medical condition to be present for at least 12 months, unless the condition is terminal.

If the THP marked Questions 3, 4 and 5 to indicate the disability or medical condition is:

• permanent, or temporary and expected to be present for at least 12 months, go to Step 10
• temporary, and expected to be present for less than 12 months, go to Step 5

Contact the THP. Ask them:

• Why they consider the disability, or medical condition to be present for less than 12 months
• If the child care receiver has a disability and/or medical condition listed in Question 7 and/or Question 8

Was contact with the THP successful?

• Yes, go to Step 7
• No, go to Step 6

Send a request in writing to the carer or THP. Ask them to provide the incomplete/incorrect details in the medical report. To do this, follow the process as per Table 1 > Step 5 in Claims received that are incomplete or incorrect.

Place the claim on hold using the Hold to User function.

Procedure ends here until the carer/THP responds to the above request or the claim comes off hold.

In a DOC, record all verbal information given by the THP. To record this, follow the process as per Table 1 > Step 4 in Claims received that are incomplete or incorrect.

If the THP confirms:

• the child does not have a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of the condition is permanent, or temporary and expected to be present for at least 12 months, go to Step 9
• the child has a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of the condition is permanent, or temporary and expected to be present for at least 12 months, go to Step 10
• the child does not have a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of condition is temporary and expected to be present for less than 12 months:
• The care receiver does not medically qualify for CA, see Rejecting a Carer Allowance (CA) claim
• Procedure ends here
• the child is over 3 years old and has a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of condition is temporary and expected to be present for less than 12 months:
• The care receiver does not medically qualify for CA, see Rejecting a Carer Allowance (CA) claim
• Procedure ends here
• the child has a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the THP has indicated they are uncertain if period of condition is temporary and expected to be present for less than 12 months and/or the child is under 3 years
• Place the claim on hold, using the Hold to User function
• Go to Step 8

Refer the case to the Level 2 Policy Helpdesk for advice and include the following information:

• carer’s CRN
• claim ID
• medical condition/disability the child has been diagnosed with, listed in Question 7 and /or Question 8, and
• any relevant details of the discussion with the THP

If they advise the condition is:

• permanent or temporary for at least 12 months:
• Record a DOC with confirmation information
• The Level 2 Policy Helpdesk will also advise if CA must be manually reviewed in the future
• Go to Step 10
• less than 12 months:
• Record a DOC with this information. To record this, follow the process as per Table 1 > Step 4 in Claims received that are incomplete or incorrect
• The carer does not medically qualify for CA, see Rejecting a Carer Allowance (CA) claim
• Procedure ends here

The carer of a child who does not have a recognised disability or recognised medical condition may qualify for CA (child) if the child receives a rating of ‘intense’ under the Disability Care Load Assessment (DCLAD) (2020).

Assessing a recognised disability process ends here. Follow the process in Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Procedure ends here.

A child with a recognised disability:

• medically qualifies for CA (child), and
• is not required to provide:
• a Care Needs Assessment
• an assessment under the Disability Care Load Assessment (DCLAD) (2020)

The process for assessing a recognised disability process ends here.

To finalise the CP and/or CA claim, see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Has the carer lodged a non-Services Australia medical report which was accepted for a Carer Allowance claim or medical review?

• Yes, go to Step 2
• No, go to Table 2

Consider the following factors:

• The condition. Some conditions are clearly permanent whilst other conditions are clearly temporary
• Previous medical reports
• Other medical evidence
• If practical, google the condition. See Medical conditions, codes and terminology

If the Service Officer determines the condition is:

• Permanent, go to Step 3
• Temporary, go to Step 4
• Not sure, refer the case to the Level 2 Policy Helpdesk. Once clarified, proceed to either Step 3 or Step 4

Unless the condition is unlikely to improve, code the condition as PIM. Otherwise, code the condition as PNI. There is no need to clarify this with the Treating Health Professional (THP).

Process the claim, see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Is the Service Officer satisfied the condition will be present for at least 12 months?

• Yes, go to Step 5
• No, go to Step 6
• Not sure, refer the case to the Level 2 Policy Helpdesk. Once clarified, proceed to either Step 5 or Step 6

Code the period of condition as G12.

Process the claim, see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Code the period of condition as L12.

The care does not medically quality for CA. An automatic rejection is not generated when a Period of Condition (POC) of less than 12 months is coded.

The carer may quality for CA (auto) if they receive CP in respect of the care receiver.

Process the claim, see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).