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

This document explains when to reject a claim for Commonwealth Seniors Health Card (CSHC).

Reject CSHC claim

Table 1

Step	Action
1	Rejection reasons + Read more ... Is the rejection reason for the Commonwealth Seniors Health Card (CSHC) any of the following? departure/absence overseas permanently departure/absence overseas temporary (more than 13 weeks) does not meet the age requirements estimate income too high excess income has not yet served the newly arrived resident's waiting period (NARWP) not residentially qualified Identity Confirmation not provided for customer whereabouts unknown CSHC current already customer has not supplied their Tax File Number (TFN) customer has not supplied their partner's TFN customer has not supplied both their and their partner's TFN customer in receipt of a Social Security pension or benefit, Department of Veterans' Affairs (DVA) Service Pension, DVA Age Pension, Veteran Payment, Income Support Supplement (ISS) or a DVA CSHC Note: early claim provisions do not apply to the CSHC. If the person is not qualified for CSHC from the date of claim lodgement the claim must be rejected. Under no circumstances should the start date on the SHC Assessment (SHA) screen be manually altered to a date after the determined start date. Yes, the claim will automatically reject for the correct reason when the CSHC claim is coded end to end. Before finalising the rejection action, contact the customer to explain the adverse decision: 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. Go to Step 7 No, the claim will require manual rejection via the Benefit Action (BA) screen Note: if the claim is a combined claim, the BA screen may need to be coded for both customer and partner claims. Combined claims may have a different eligibility outcome, as one may be granted and the other rejected Go to Step 2
2	Streamline Rejections - explained + Read more ... Where the customer has not provided the required documents at the time submitted their claim, it can be rejected Fail to Provide Documents (FSD) using the Streamline Rejection function. Where the customer has intentionally provided inappropriate documentation to allow their claim to be submitted under Circumstance Change Monitor (CCM). For example, non-claim related documents or images, reject the claim FSD with no request for information or documentation requests to be issued. It is important to note that when a Streamline rejection is processed, the system will remove all provisional data applied within the claim, before the streamline rejection option was selected. Streamline Rejection allows the user to bypass errors for faster processing of rejected claims (e.g. FSD) To undo a streamline rejection, the claim must be regenerated from the TS screen Does the claim meet requirement for streamline rejection? Yes, go to Step 3 No, go to Step 4
3	Streamline Rejection - Process + Read more ... To complete a Streamline Rejection: From the Transaction Summary Page (TS) Select Process Go to the Benefit Action screen by typing 'BA' in the Super Key field Select Add New The Create Benefit Action popup screen is presented Enter: Benefit Type: SHC Benefit Action: REJ - Reject Reason: FSD Date of Effect: only change if the pre-populated date is incorrect Streamline Rejection - Tick the Indicator box Select Save Update the region office code, residence information, personal and contact details in the claim activity. Note: these updates must be actioned after selecting Streamline Rejection on the Benefit Action (BA) screen Use the Super Key to go back to the Errors (SWE) screen Check the SWE screen for any errors or warnings due to coding updates. Go to the appropriate screens and resolve the errors and warnings Select Assess The Entitlement (ELD) screen shows Check the correct rejection reason shows Go to Step 7.
4	Manual rejection + Read more ... To complete a Manual Rejection: Make all necessary updates required within the claim Before finalising the claim, delete all provisional data that requires verification so the data is not applied to the customer record From the Transaction Summary Page (TS) go to the Benefit Action screen by typing 'BA' in the Super Key Select Add New The Create Benefit Action popup screen presents Enter Benefit Type: SHC Benefit Action: REJ – Reject Reason: select appropriate reason, for example FRC. See Cancellation and rejection codes for Commonwealth Seniors Health Card (CSHC) Date of Effect: in most cases this is deemed date of claim or date of receipt, only change if the pre-populated date is incorrect Streamline Rejection: do not tick the indicator box Select Save Use the Super Key to go back to the Errors (SWE) screen Check the SWE screen for any errors or warnings due to coding updates. Go to the appropriate screens and resolve the errors and warnings Update region office code, residence information, personal and contact details within the claim activity where required. This ensures the notice of rejection issues to the correct address Select Assess The Entitlement (ELD) screen displays Check the outcome is correct Note: for rejection reason 'Failure to Reply to Correspondence (FRC)' no further customer contact is required. For all other rejection reasons, before finalising the rejection action contact the customer to explain the adverse decision: 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
5	Handover function + Read more ... Sometimes a claim activity may need to be processed in Customer First/Customer Record and the Handover to CF/CR function may be required. This is to apply an approved workaround for a known issue/error or gaps in Process Direct. Prior to utilising the Handover function, staff must refer to the Using Digital Assistance Roxy in Process Direct and the Handover function table for required actions. Is a handover to Customer First or Customer Record required? Yes, to commence a handover, see the Handover function table. Once completed, go to Step 6 No, go to Step 7
6	Manual rejections in Customer First/Customer Record + Read more ... A claim is manually rejected as follows: Make all necessary updates required within the claim Code fields on the Benefit Action (BA) screen: Svc Rsn: use 'SHC' for Senior Health Card Action: use 'REJ' for rejection Reason: use the appropriate reason code. See Cancellation and rejection codes for Commonwealth Seniors Health Card (CSHC) Effect Date: in most cases this is the deemed date of claim or date of receipt. Only change if the pre-populated date is incorrect Press [Enter] Update region office code, residence information, personal and contact details within the claim activity where required. This ensures the notice of rejection issues to the correct address Go to the Assessment Results (AR) screen Check the outcome is correct Note: for rejection reasons 'Failure to Supply Documents (FSD)' or 'Failure to Reply to Correspondence (FRC)' no further customer contact is required. For all other rejection reasons, before finalising the rejection action contact the customer to explain the adverse decision: 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
7	Rejection DOC and follow-up action + Read more ... For claims rejected in Process Direct: Select Finish to finalise claim A finalisation DOC template displays with claim outcome Record information appropriate to the decision If the rejection reason is 'FSD/FRC' ensure DOC lists all documents not provided at the time of rejection Select Finalise For claims processed in Customer First/Customer Record: Finalise the activity Select the Fast Note. Select Auto Text option > Concession Cards > Claims > Commonwealth Senior Card (CSHC) NCL Grant/Reject (select the appropriate outcome only) Record information appropriate to the decision. Remove unnecessary wording If the rejection reason is: 'FSD/FRC' annotate the rejection DOC with all documents not provided at the time of rejection Follow-up actions in Process Direct for claims finalised in Customer Record and Customer First: Check claim status in Process Direct If claim status has not automatically set to Complete upon finalisation of the claim: select the claim transaction and raise an Incident through Roxy choose option ‘No, the issue is blocking me’ so that claim is placed On Hold for System Investigation/Issue retain the work item by using the Hold to User function in Work Optimiser Claim status will be set to Complete by ICT
8	Send a manual letter + Read more ... If the customer is deceased, manual letter (Q999) must be issued to the: ‘Executor of the Estate’ (if known) address, or ‘Estate of the Late [customer’s name]’ at the deceased customer’s last known address The Resources page contains an example of suitable text for these letters. For other cases where no auto-reject letter is generated, issue manual letter Q134 (select the ‘undetermined’ option) to the customer, giving the reason(s) for rejecting the claim and advising their review and appeal rights.