Rejecting a Carer Allowance (CA) claim 009-03040120

Where the carer is claiming CA, can the care receiver be identified?

• Yes, go to Step 2
• No, make extensive efforts to identify the care receiver (including phone calls, Q164 letter to the carer and system searches). If the care receiver still cannot be identified:
• set new claim to 'Not Required'
• complete a DOC stating that it has been determined that the claim is rejected 'FRC' and as the care receiver cannot be identified the claim cannot be finalised so has been cancelled
• send a Q134 manual letter to the carer advising of the claim rejection
• procedure ends here

To reject the carer's claim, all information provided by the carer must be recorded to allow the system to assess and auto-reject the claim. Only if the system cannot auto-reject the new claim, is a manual rejection to be coded.

FRC

If it is clear a claim will be rejected, it is not necessary to request more information, before rejecting a claim. Before manually rejecting a claim with manual reason FRC, record all information provided with the claim, including care needs/THP, to assess if the claim will auto-reject for a qualification reason.

If a claim is submitted under a Special Case Exemption, it cannot be rejected until 22 days has been reached. If the claim presents via WLM and 22 days has not been reached, it must be held until day 22 before it is rejected.

Once the 22 day timeframe is reached, a claim can be rejected at any time when:

• documents lodged are inappropriate or not relevant to the claim
• the claim has not been lodged under an exception category
• the carer has failed to respond to a request for information

Medical information

If the carer is already receiving CP for the same care receiver, see the scenario ‘Carer claiming CA received for the adult’ in the Carer claiming CA receives CP for the adult table in Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

If the carer is not already receiving CP for the same care receiver and has lodged the carer questionnaire but not a medical report, and re-use provisions do not apply, record the carer questionnaire. The claim will automatically reject because there is no THP score.

See Processing claims for Carer Payment and or Carer Allowance.

Check residence information is recorded

The carer's residence qualification is automatically assessed as long as the residence information is correctly recorded.

Note: residence information must still be recorded if the rejection is for any other reason. If residence details are not recorded, the system will override any other rejection and the claim will reject for a residence related reason.

Go to Step 3.

After all information is coded into the claim, processing Service Officers should have made their own determination of whether they expect the claim to reject.

Use the Super Key to go to the Errors and Warnings (SWE) screen, and then onto the Entitlement (ELD) screen.

If coding the claim:

• does not result in an outcome the Service Officer is expecting, and not going to auto-reject, go to Step 4
• results in an auto reject, check:
• the carer does not meet qualification and/or payability provisions for CA, and
• the decision to reject the claim is correct
• if there are multiple rejection reasons
• A Service Office Interview (SOI) is required for all rejections, go to Step 5

Service Officers are to re-check the coding of the claim to make sure it is correct. See Eligibility for Carer Allowance (CA).

If it appears that all coding is correct and the claim will still not auto-reject correctly, Service Officers should seek help from Local Peer Support (LPS) or Service Support Officer (SSO) to investigate the record further.

Note: if CA is rejecting at the carer level, the Care Receiver Assessment Result (CJAR) screen will display the rejection reason as OTH (other). This is because the claim was rejected due to the carer, not the care receiver.

Following this investigation, if the outcome is still not an auto-reject of the claim, LPS or SSO may advise that a manual rejection of the claim via the Benefit Action (BA) screen is appropriate.

Manual rejection of a claim is a last-resort option and should only be done under the advice of LPS or SSO.

Manual rejection

If the rejection relates to care receiver:

• In the carer's record, use the Super Key to go to Care Receiver Benefit Action (CJBA) screen
• Action field - key 'REJ'
• Reason field - key the relevant reason code
• HCC Only field - key 'Y' or 'N' (as appropriate) if the claim relates to a child care receiver
• Effect Date field - key relevant date
• Enter and navigate to the SWE, then ELD screen

If the rejection relates to carer (for example, failed to supply requested information (FRC)):

• In the carer’s record, use the Super Key to navigate to the Benefit Action (BA) screen
• Svc Rsn field - key 'CDA'
• Action field - key 'REJ'
• Reason field - key a relevant reason code
• Enter and navigate to the SWE, then ELD screen

If rejection code 'OTH' is used, an MFU for the rejection will be created, and a manual letter must be issued to the customer.

Note: E007AS - Current CDA benefit status inconsistent with REJ assess action may display on the Assessment and Warning Error (AWE) screen. This occurs when the carer is already receiving CA for 1 or more care receivers, but has claimed for another care receiver and the additional claim is being rejected. In this case, do not use the BA screen to reject the claim. Instead, code the rejection on the CJBA screen.

The claim will appear ready to finalise. Do not finalise.

Before finalising a rejection for CA, the Service Offer Interview (SOI) must be completed. Go to Step 5.

Staff must make genuine contact attempts to contact the carer, before finalising a claim which results in:

• rejection of CA claim, or
• the carer not being eligible for payment CA but is eligible for CA HCC only

This is to allow the carer an opportunity to provide any updated information which may change the outcome of their claim. See Advising verbally of an unfavourable decision.

Note: this includes claims finalised during overtime. Consider local time zone differences. See Calling a customer or returning a customer’s call.

Successful contact

Service Officers must follow:

• Calling a customer or returning a customer's call
• Authenticating a Centrelink customer

When identification/authorisation of the person on the phone has been established, explain:

• (if the contact is during overtime), the claim is being actioned outside normal business hours
• the reason for the call
• the reason for rejection
• the claim may be able to be reassessed if they provide additional information, such as medical evidence within 13 weeks
• their review and appeal rights

Tell the carer of possible alternative entitlement and give them any relevant publications for payments and concessions. See Initial contact by a carer

If identification/ authorisation is established, but the carer/nominee say it is not a convenient time, tell them:

• the claim will be finalised and a written advice issued, and
• to contact the agency if they need details about the decision after receiving the letter

Record any new information or details provided by the carer in the SOI and rejection DOCs on the carer’s record, including if they will be lodging more information to support a reassessment.

If information provided changes the outcome of the CA claim see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

National Support Services

If a carer discloses they may be at risk of harm see Family and Domestic Violence.

If the carer is in immediate danger, a delegate must call 000.

Unsuccessful contact attempt

Follow Calling a customer or returning a customer's call if the number called has an answering machine or voicemail.

Recording the SOI

A SOI Fast Note must be completed in Customer First to record successful and unsuccessful contact attempts with the carer.

• Complete the Fast Note header details and make sure Document Completion has Yes selected (this will create DOC and not a hand-off).
• Select Auto Text > use Carers > Claims > Service Offer Interview on the carer's record
• SOI text is prepopulated > select Confirm
• In the free text section record the following information:
• Date, phone number/s and time call attempts were made and if contact was successful, or unsuccessful,
• Reason for rejection
• Information/documents required from the customer to have their claim reassessed
• Select Continue

SOI exemptions

For CA new claims actioned (weeknights and weekends), Service Officers must review the carer's record and determine if an SOI exemption may apply.

Examples of when it may not be appropriate to attempt the SOI outside business hours include:

• adversely impact the carer's wellbeing
• bereavement cases
• clearly documented CRU complaints
• likely to result in political or media attention
• if it is clear from the carer's record, they require an interpreter for Services Australia interactions

In these exception cases:

• clearly detail why an SOI was not attempted (in Progress Note or DOC)
• follow Hold to User procedures. Hold the claim and any related Work Items to self until the next available day, adding keyword SOI to the claim activity

The claim will present the next business day for an SOI attempt.

SOI and quality checking

SOI calls should be attempted before finalising a claim. If a claim goes to QMA, the QMO must check the:

• rejection outcome of the claim is correct
• SOI DOC is complete on the carer’s record

If the QMO's decision is significantly different (for example, grant rather than reject), the QMO must make and document contact attempts to tell the customer the change in decision.

If the activity is correct, but QMO identifies the SOI process was not followed, the QMO must complete the SOI steps. That is, genuine contact attempts and the SOI Fast Note before releasing the claim. The QMO is not to include SOI feedback in QMA tool but complete national feedback to the processing Service Officer using the Staff Feedback Tool.

Use the Finalise button to generate a rejection DOC.

• Amend the DOC to record the rejection reason/s
• Record all information used to make the claim decision, for example any verbal details provided by the carer or referral outcomes
• For a rejection due to not meeting the qualification for caring for a disabled adult in a private home not shared by the carer and care receiver, the DOC must contain certain information. See the Resources page for details

The decision Note and DOC must include:

• information given by the carer, before the claim is rejected
• a list all documents not provided at the time of the rejection which may be required for a reassessment. This can include:
• Medical Reports
• Care Needs forms
• information that may then require a referral (CSAT, CIS)

Note: if a referral is required as part of the reassessment, make sure to include this in your notes to avoid delay in processing.

Has the claim been rejected manually?

• Yes, go to Step 7
• No, procedure ends here

A rejection outcome may require a manual letter. If required, a Manual Follow-up (MFU) activity will be created on the carer’s AL screen after the rejection activity is finalised.

However, the MFU may not generate straight away and may take overnight to generate.

Processing staff must add the rejected carer’s CRN to their ARM in Workload Management. This is to make sure any Manual Follow Up (MFU) created as a result of the activity is allocated the following business day. See Work Optimiser for staff

Next business day

Workload Management will issue Service Officer with MFUs created in CRNs attached to a Service Officer’s ARM.

Access the CRN in Customer First to check AL for the CRNs in their ARM.

Has an MFU, requiring a manual letter to be sent to the carer, been allocated or generated on AL in the carer’s record?

• Yes, go to Step 8
• No, the carer will get an auto-letter. Service Officer is to remove the CRN from their ARM. Procedure ends here

'S'elect the MFU activity from the AL screen.

• Create a Q134 letter
• Complete relevant details, give reasons for the rejection
• Include review and appeal rights

When the letter has been sent, remove the CRN from ARM.