Assessing Commonwealth Seniors Health Card (CSHC) claims 065-06030000

For claims, request or search for the claim work item via Inbox.

Select the work item to view the Customer and Activity Information table on the Transaction Summary (TS) screen.

For new claims, Service Officers must stream the claim on the day allocated and a progress of claim note must be created and/or updated, if the claim cannot be immediately finalised.

Has the claim been previously streamed (see Progress DOC for details)?

• Yes, see Processing Commonwealth Seniors Health Card (CSHC) claims
• No, go to Step 2

The claim status must be In Process before it can be processed.

Is the claim status In Process?

• Yes, go to Step 3
• No, for claim status definitions and action to take, see Process Direct navigation, common screens and functions

To reassess a previously rejected claim:

• If rejected FSD, FRC or POI, see Request to reassess a rejected claim
• To re-index the claim, refer to directions for SAP online claims in Indexing, re-indexing and cancelling claim activities

Note: the claim should not be re-opened until the customer provides all requested information.

Check the customer's benefit status line.

If the customer's benefit status is SHC/CUR indicating that the claim assessment has already been completed, update the claim status to Not Required via the Status icon. Procedure ends here.

To review the information provided by the customer in the online claim or ACC:

Select and to view the Claim Summary in a new window. If it is blank, press [F5] to refresh the page

To view paper claims and scanned supporting documents:

• select links at the bottom of the expanded Claim Summary, or
• select Documents from the Icon Menu

Check the date the document was scanned. There may also be older documents not related to the claim.

Check customer tasks, DOCs and Notes by selecting the relevant icons.

Check the type of CSHC claim that has been allocated

CSHC online/ACC claim

• When an online claim or ACC is submitted, an CSHC claim work item is created in Process Direct containing the claim information
• If 2 separate individual claims are received for a partnered couple these should be processed as individual claims. If the partner’s claim has not been allocated for processing, locate the partner’s claim via WLM and assess the claim as appropriate
• Due to a known issue, the Date Submitted will default to the original Date of Receipt (DOR) entered, where:
• the claim was started through ACC, and
• submitted on a later date

Service Officers must check the date of submission and if necessary, correct the Date of Receipt (DOR). See Step 11 in the Run Assisted Customer Claim (ACC) workflow table for required action.

Combined partner online claim

• Combined claims (sometimes referred to as 'dual claims') are allocated as a single work item
• Do not process an CSHC combined partner online claim as 2 separate individual claims as the data for the partner claim may be lost
• To identify a CSHC combined partner online claim:
• A specific message will display in the claim header in Process Direct 'This claim is Customer Partner Combined claim'
• Check for a keyword of DUALCLM
• View the claim note or SHC OLC Claim Progress DOC, where the words 'Awaiting partner review' will display within the text

Paper claim (SA296 or SA443 or SA296a)

• When SA296 or SA443 or SA296a is scanned to the customer's record, a SOA shell work item is generated. SOA shell contains no claim information apart from the CRN, personal details and receipt date. Add the claim information into the SOA shell using the scanned claim and documentation
• If both the customer and partner have claimed on the same claim form, the single SOA shell should be transformed to a combined customer-partner claim by using > Combined claim switch > select Switch to combined claim. This is to make sure correct assessment of the claim and any items that impact both parties. This action can be reversed to return the claim to an individual claim if 'switched' in error
• If the same paper claim is scanned to both customer and partner records, 2 SOA shells are created. Once one of the SOA shells has been switched to a combined claim, the other SOA needs to be set to 'Not required'. If the partner's claim has not been allocated for processing, locate the partner's claim via WLM and assess the claim as appropriate

Note: if CSHC claimant is partnered but the partner has not also claimed CSHC (including as part of a combined partner claim online or paper), their partner may also be eligible for CSHC or another service.

• Attempt to contact the partner by phone to clarify their intentions
• If the partner is able to be contacted, invite the partner to complete a claim for CSHC and DOC the outcome
• If the partner is unable to be contacted, issue the CSHC claim – invite partner to claim Q999 and DOC the record with the contact attempts and that the suggestion has been made for the partner to complete a claim for CSHC

When a paper claim is scanned to the customer's record, a SOA shell work item is generated on the customer's record. This contains no claim information apart from the:

• Customer Reference Number (CRN)
• Claim ID
• Claim dates and
• personal details

The claim information is added into the work item using the scanned claim and documentation.

If the customer and partner have claimed on the same paper claim form, the single SOA shell should be transformed to a combined customer-partner claim using the Combined claim switch more options button.

If the customer has indicated in the claim they are in a crisis this can be confirmed by:

• Checking the Keyword icon for vulnerable (URGVULN) or in financial hardship (URGFINH)
• Checking the claim and customer record to see if there is evidence of a crisis situation. See Identifying customer vulnerability and risk issues

Pre-Claim Vulnerable Circumstance (PRECLM) screen:

Where the customer has pre-claim vulnerable circumstances recorded within the eight weeks before their intent to claim contact date the system will automatically calculate the start date. See Intent to claim and vulnerable customers for background and processing information.

Services Officers must check the claim details to make sure the existing customer details are correct.

If the customer has died, see Processing a claim after the death of a customer.

If changes to the customer's contact details are required, see Updating address details.

Access and Display on Access (DOA) alerts for specific warnings or messages on the customer's record.

This includes:

• if the customer is income managed. See Identifying and assisting income managed customers for assistance
• the Customer Incident Management System (CIMS), and
• the Managed Service Plan (MSP). See Customer aggression - Managed Service Plan (MSP) for more information

These details must be reviewed/updated before processing the claim.

On the TS screen:

• Link Summary (LS) table shows linked records, such as partner, nominees and any Relationship Qualifier Code.
• Marital Status (MS) table shows the customer's relationship details
• If the customers relationship status needs to be updated, and manual coding on the claim has already been started, select and regenerate the claim. This will reset the claim to only contain the information provided by the customer in their claim
• If the customer's partner has used the TAC to confirm the relationship through the Partner Confirmation Logon service on the Services Australia website, this will display as a Digital Partner Confirmation (DMODP) tile and can be viewed under scanned documents. Note: this does not apply where an CSHC combined partner claim has been lodged
• Before linking to a partner, ensure the partner's record is in the same Environment. For help with coding environment transfers and relationships, see the Environment transfers and relationships table
• Assess if the customer is a member of an illness separated couple
• A change in marital status from partnered to single must be actioned outside the claim transaction within Process Direct using Customer Summary. Once completed perform a SAP Refresh to update the confirmed data within the claim transaction. For help with coding, see relationships table
• If a customer advises the death of their partner and the records are linked, complete the death action. See Initial notification of death

On the day the claim was lodged was the customer Age Pension age? See the Resources page for a link to the Age Pension age rules.

• Yes, go to Step 10
• No, the customer is not qualified. Reject the claim. Go to Processing Commonwealth Seniors Health Card (CSHC) claims. Procedure ends here

Note: early claim provisions do not apply to the CSHC. If the person is not qualified for CSHC on the date of claim lodgement the claim must be rejected. A request for information should not be issued if the claim will be rejected, unless it is going to change the outcome of the claim.

On the day the claim was lodged, does the customer satisfy the residence requirements? See Residence assessment for customers claiming Commonwealth Seniors Health Card (CSHC).

• Yes, go to Step 11
• No, the customer is not qualified. Reject the claim. See Processing Commonwealth Seniors Health Card (CSHC) claims. Procedure ends here

Check if the customer was physically present in Australia on the date they lodged their claim, by checking the customer's travel movements (if available) using the Travel Outside Australia Summary (TOAS) and Immigration Movements (RSIM) screens.

On the day the claim was lodged, is there evidence that the customer was not in Australia?

• Yes, the customer is not qualified. Reject the claim. See Processing Commonwealth Seniors Health Card (CSHC) claims. Procedure ends here
• No, go to Step 12

On the day the claim was lodged, was the customer in receipt either of a Social Security pension/benefit (see Resources page for a link to the Services Australia website for Income Support payments)?

• Yes, the customer is not qualified. Reject the claim. Go to Processing Commonwealth Seniors Health Card (CSHC) claims. Procedure ends here
• No, go to Step 13

On the day the claim was lodged, was the customer in receipt any of:

• Department of Veterans' Affairs (DVA) Service pension,
• DVA Age Pension,
• Veteran Payment
• Income Support Supplement (ISS)
• DVA CSHC

See Payments from the Department of Veterans' Affairs (DVA) and referrals to the DVA Clearance Team for more information.

• Yes, the customer is not qualified. Reject the claim. See Processing Commonwealth Seniors Health Card (CSHC) claims. Procedure ends here
• No, go to Step 14

The claimant must meet the Identity Confirmation requirements. Identity Confirmation for a partner is only needed if the partner is also applying for CSHC.

Check the customer's Identity Status under the Snapshot icon in Process Direct.

Has the customer met the Identity Confirmation requirements?

• Yes, go to Step 15
• No, consider the following options:
• identity is provided, see Coding identity documents
• customer cannot provide identity documents, see Alternative Identity
• customer cannot attend in person to confirm identity, see Alternative Identity
• customer cannot provide proof of age, see Verifying the date of birth or age of a customer or child

Where the identification requirements cannot be met, the claim will be rejected. See Processing Commonwealth Seniors Health Card (CSHC) claims. Procedure ends here.

Has the customer provided their (and their partner's) Tax File Number (TFN) (unless an exemption is granted)?

See Tax File Number (TFN) for Commonwealth Seniors Health Card (CSHC) for more information.

• Yes, go to Step 16
• No, a request for information is required, take note of the required information, go to Step 16

Has the customer declared Adjusted Taxable Income (ATI) for the reference year less than the Commonwealth Seniors Health Card (CSHC) - Taxable Income Limit?

Note: this should include any deemed income from account based income streams.

• Yes, go to Step 17
• No, reject the claim due to income. See Processing Commonwealth Seniors Health Card (CSHC) claims. Procedure ends here

Has the customer provided the required evidence of income?

See Lodgement of the Notice of Assessment (NOA) and other evidence of income for Commonwealth Seniors Health Card (CSHC) for more information.

• Yes, go to Step 19
• No, take note of the required information
• For online claims, go to Step 18
• For paper /SOA claims, go to Step 19

Has the customer submitted an online claim with all the required information?

• Yes, go to Step 20
• No, make sure the customer and/or nominee contact details are recorded correctly before making a request for information. See Updating address details
• For online claims submitted under a claim submission exception and/or where there is evidence the customer may be in a crisis or need special help, see Calling a customer or returning a customer's call and where applicable, send a pre-call SMS. Make 2 attempts to contact, at different times on the same day where possible to explain the claim requirements and DOC the outcome. Check if the customer needs more time to meet the requirements due to their circumstances. Request the information verbally or in writing and allow extra time for mail delivery to respond. See also, Documents required for Centrelink new claims
• For online claims where the customer has intentionally provided non-claim related documentation to allow their claim to be submitted, the claim must be rejected
• For online claims, where more information is needed to assess the claim and there is no existing request, see Calling a customer or returning a customer's call and where applicable, send a pre-call SMS. Make 2 attempts to contact, at different times on the same day where possible to explain the claim requirements and DOC the outcome. Check if the customer needs more time to meet the requirements due to their circumstances. Request the information verbally or in writing and allow extra time for mail delivery to respond. See also, Documents required for Centrelink new claims

Update the Progress of claim Note/DOC or where a progress of claim DOC is required, create a Fast Note - select Auto Text, use Older Australians > Claims > Progress of AGE/SHC/PDB claim. (Edit to remove the AGE/PDB)

Check the claim status and if required manually change to On Hold – Customer to Provide Information via the Status icon with a due date after the allowed time.

Note: When assessing a combined partner online claim or a joint paper claim where a request for information is required then it should be issued to both customer and partner

Procedure ends here until customer responds or the allowed time has lapsed.

Has the customer provided a completed claim with all the required information?

• Yes, go to Step 20
• No, make sure the customer and/or nominee contact details are recorded correctly before making a request for information. See Updating address details
• For incomplete paper claims, see Calling a customer or returning a customer's call and where applicable, send a pre-call SMS. Make 2 attempts to contact at different times on the same day where possible to explain the claim requirements and DOC the outcome. Request the information verbally or in writing and allow extra time for mail delivery to respond. See also, Claims received that are incomplete or incorrect

Update the Progress of claim Note/DOC or where a progress of claim DOC is required, create a Fast Note - select Auto Text, use Older Australians > Claims > Progress of AGE/SHC/PDB claim (Edit to remove the AGE/PDB).

Check the claim status and if required manually change to On Hold – Customer to Provide Information via the Status icon with a due date after the allowed time.

Note: when assessing a combined partner online claim or a joint paper claim where a request for information is required then it should be issued to both customer and partner.

Procedure ends here until customer responds or the allowed time has lapsed.

Is a specialist referral required?

• Yes, select More Options > Referral. From the Select Referral Type drop down list select:
• International Services (CIS) - Residence Assessment, if the data transfer from the Department of Home Affairs was not successful
• Assessment of Care Arrangements (FAO) - Dependent child/ren, if there is a change in care of a child. This could be a change in shared care arrangements or a dependant entering or leaving care
• Hold claim pending outcome of specialist assessment
  In the text, note the care assessment is required for a CSHC claim. FAO processing see Family Tax Benefit (FTB) and income support payment new claim processing interactions
• No, see Processing Commonwealth Seniors Health Card (CSHC) claims