Rejecting a claim for Commonwealth Seniors Health Card (CSHC) 065-06030040

A customer who has lodged a claim for CSHC will not be eligible for a CSHC if they do not meet the basic qualification or means test provisions for CSHC or if they may have failed to comply with a customer obligation. In these circumstances, claims must be rejected.

Note: Online claims submitted prior to 13 October 2018 and all paper claims are not subject to Circumstance Change Monitor (CCM) rules.

Some rejection reasons can be coded manually and others will be automatic. Automatic rejections will occur when all of the customer's information is updated on the correct screens and the new claim is processed.

Customers are required to provide documentation to support the information declared in a CSHC claim. Online claims provide the customer details of outstanding tasks and documentation requirements for the claim.

Additional documentation is sometimes requested after the claim has been submitted. Customers are required to provide information/documentation in the allowable timeframe as requested in writing.

Reject claims:

• 'Failed to Supply Documents (FSD)' if the customer has provided inappropriate or irrelevant documentation to allow the submission of their online claim and no additional request for information, written or verbal has been made

• ‘Failed to Reply to Correspondence (FRC)’ if the customer has been sent a request for information and failed to provide all the documents (including supporting documents requested in a form) within the time allowed to respond

See Request to reassess a rejected claim.

All new CSHC claimants and their partners are required to provide a Tax File Number (TFN), or be granted a TFN exemption. If no TFN or exemption is provided then the CSHC

claim will be rejected.

Customers who have provided an estimate of income for the current financial year, which is not an acceptable condition are to be rejected using reason ESR-Estimate Rejected.

Customers who are rejected due to an estimate of current year income being over the income limits cannot lodge another claim using Adjusted Taxable Income (ATI) from a previous financial year. Customer must provide a revised estimate for the current financial year and details of why their estimate has changed. Service Officers are not obliged to accept a revised estimate if reasons and amount of reduction do not seem reasonable.

When making an unfavourable decision, the Decision Maker (DM) must:

• fully explain the decision to the customer and any affected party (for example, partner or carer). Give them the chance to provide more information that may change the outcome. This lets the customer:
• clear up any misunderstandings
• provide new information
• have errors corrected
• tell the customer and any affected party their review and appeal rights

The DM must make 2 attempts to contact the customer at different times on the same day where possible, before finalising the decision (unless they are speaking with the customer when making the decision).