Processing Commonwealth Seniors Health Card (CSHC) claims 065-18102915

Before processing the claim, eligibility criteria and claim requirements are to be checked.

Has the claim been streamed previously by another Service Officer (see Progress DOC for details)?

• Yes, go to Step 2
• No:
• See Assessing Commonwealth Seniors Health Card (CSHC) claims
• Procedure ends here

Re-indexing a rejected claim may be necessary where a claim is to be reassessed as the customer has provided additional information after the claim was rejected or after a review of decision. 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-indexed until the customer provides all requested information.

From the TS screen, select Process.

The Errors (SWE) screen will display a Message Log and Task Selector:

• Select messages to view/update the relevant details. An error or warning will display if information has not loaded correctly from the online claim or ACC
• The Task Selector will display a flag against screens that contain provisional data (data uploaded from the online claim or ACC or updated by staff)
• Select the screens to be checked/ updated
• Select Next to proceed through the selected screens

The Task Selector does not list all screens that may contain provisional or confirmed data. Check the Claim Overview to see if other information has been provided that may need to be updated. To check confirmed data, navigate to the individual screens.

For paper claims (SOA shells), select the screens to manually code details from the claim.

Check/update customer (and if applicable partner) personal details by selecting:

• Customer Personal Details (CPDS)
• Address (AD)
• Telephone Details (TDS)
• Other Contact Details (OCD)
• Tax File Number Authorisation (TFN)
• Office Code (OC)
• Proof of Identity Details (POI)

To update partner/linked records, select to view the Relations menu. Select the person to access the record. Ensure the correct person's name is displayed before updating. Check/update details from the SWE screen. For help, see Process Direct navigation, common screens and functions.

The Digital Assistant (Roxy) can be used to help address issues or errors within Process Direct, see Using Digital Assistant Roxy in Process Direct.

Residence information must be recorded if the claim is to be rejected for a reason other than residence, otherwise the system will override any other rejection reason and the claim will incorrectly reject for a residence relate reason.

For coding help, see Residence and Portability screens.

The customer must generally be in Australia when the claim is made, or meet an exception to the lodgement inside Australia rule.

The SHA is a compulsory screen where the start date will default to the Date of Receipt. Do not manually change the start date on the SHC Assessment (SHA) screen.

The SHA date should not be changed to a date after the determined start date.

Early claim provisions do not apply to the CSHC. Any CSHC claims lodged prior to the customer being eligible, must be rejected.

The CSHC date of claim will be automatically taken as the immigration advised date of return if:

• the customer lodges a CSHC re-claim within 14 days of the date of return to Australia, and
• the date of return is less than 26 weeks since their CSHC cancellation date

This can apply to CSHC online claims, customised claims, paper claims and verbal re-claims. Customers whose CSHC has been cancelled for more than 26 weeks will need to complete a full new claim.

Press [Next].

Is the claim to be rejected automatically, as the customer does not meet basic CSHC qualification, or via streamline reject or manually on the Benefit Action (BA) screen?

• Yes, for information on how to reject a claim for CSHC, go to Rejecting a claim for CSHC. Procedure ends here
• No, go to Step 7

Does the customer (or partner) have any account-based income streams?

• Yes, see Adding or updating an account-based income stream for coding instructions to update an existing account an existing account-based income stream or add a new account-based income stream
  Note:
• For new income streams it is a requirement to provide a full Centrelink/DVA schedule or Details of Income Stream product (SA330)
• For existing income streams where a product is already recorded and has been updated automatically with Channel Type ISP (Income Stream Provider) within the last 12 months, a Centrelink Schedule is not required
• For all other income streams, a full Centrelink/DVA Schedule or Details of Income Stream product (SA330) is still required
• Go to Step 8
• No, go to Step 8

Income Details

Income Details; records the customer (and partner):

• Date of event
• Reference tax year
• Income type
• Adjusted Taxable Income (ATI)

The deemed income amount will not display until after adding or updating an account-based income stream, navigating to the Entitlement (ELD) screen and then returning to the SHIS/SHID screen.

Date of Event (DOV)

For new claims, the DOV must be the same as the Date of receipt (DOR). The DOV cannot be a date after the DOR and should be the date of claim as recorded on the SHA screen.

Note: the DOV may need to be manually adjusted to match the SHA if:

• the customer lodges a CSHC re-claim within 14 days of the date of return to Australia, and
• the date of return is less than 26 weeks since their CSHC cancellation date

Reference tax year

• The reference tax year is the financial year the customer has declared their income and the date of receipt (DOR) of the claim determines the reference tax year
• The reference tax year for TNA or NRL, must be within 2 years of the current financial year. Use the year the financial year ended, e.g. for 2020/21, code 2021
• Members of a couple need to provide information relating to the same financial year
• The reference tax year for an estimate (EST) is the current financial year. Record the year that the current financial year is to end, for example, for 2021/22 code 2022
• After the estimate (EST) and income details have been recorded, a second entry is required for the reference year of the NOA using type TNA and the date before the claim DOV, that is, DOV - 1 day

Note: where an online claim is started before 1 July but submitted on or after 1 July, the reference year selected by the customer may no longer be valid. Request the relevant reference year information from the customer (and/or partner) to assess the claim.

Where a paper claim is signed on or before 1 July but submitted on or after 1 July, the reference year declared may no longer be valid. Request the relevant reference year information from the customer (and/or partner) to assess the claim.

Income Type:

• TNA for a NOA and for customers who have been granted an ATO lodgement extension
• NRL when a customer does not have a NOA because they are not required to lodge, for example their income was below the tax free threshold or as a result of an ATO tax offset. NRL must not be used when the customer is required to lodge. For example, the customer has income above the tax lodgement threshold, or had tax withheld from any income in that financial year
• EST – Estimate customer (or partner) declared due to an acceptable condition, they are providing an estimate of income for the current financial year. EST can only be coded once a verified line has been coded

Note: when a customer provides an estimate, a superannuation withdrawal under the First Home Super Saver (FHSS) Scheme is not counted towards their taxable income.

Adjusted Taxable Income (ATI) details declared by the customer (and partner) should pre-populate for online claims.

Taxable Income

Taxable income details are mandatory and where coding is required code one of the following:

• The amount on the NOA
• The current year estimate, or
• The income declared by the customer in their claim if they are not required to lodge

Note: if a customer is not required to lodge or are providing an estimate, record or accept income details as declared by the customer in their claim. Updates to the income declared are required if the verification of income documentation shows the income is not reasonable or will result in an incorrect claim outcome.

When a customer provides an estimate, a superannuation withdrawal under the First Home Super Saver (FHSS) Scheme is not counted towards their taxable income.

Adjusted Taxable Income (ATI) additional components

These fields are optional and must only be completed if they are relevant to the customer's claim: See Commonwealth Seniors Health Card (CSHC) income test and reference tax year for coding requirements.

The deemed income amount will not display until after adding or updating an account-based income stream, navigating to the Entitlement (ELD) screen and then returning to the SHIS/SHID screen.

Once all information is updated select Next.

Check bank account details provided in the claim have updated the Payment Destination Details (PAD) screen for Benefit System SHC – Seniors Health Card.

If the customer has dependent children they should appear on in the Seniors Health Card income summary (SHIS) screen in the Number of dependents field.

Does the customer have dependent children or students?

• Yes, the SHIS screen Number of dependents field will confirm the number of dependents be included for the extra income limit
• If there is no record for child/ren, an Assessment of Care Arrangements (FAO) - Dependent child/ren is required. See Assessing Commonwealth Seniors Health Card (CSHC) claims
• If a referral has been completed, perform a SAP Refresh to update the confirmed dependant relationships data into the claim transaction
• Select Next or go back to the TS screen
• No, go to Step 12

After saving updates, return to the SWE screen to view errors, warnings, and messages in the Message Log. These messages inform of the items that need to be addressed to prepare to finalise the claim.

Select to launch the Digital Assistant. This will populate details of any error presented on the screen it is launched from.

For help, see Using Digital Assistance Roxy in Process Direct.

Once all errors have been addressed, select Assess.

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.

Note: handover should only be completed after raising an incident in Roxy and ICT have responded with Claim is to be completed in ISIS.

Once selected the claim can no longer be accessed in Process Direct unless the claim is handed back from Customer First/Customer Record to Process Direct by cancelling the activity and entering the reason Process in PD (PPD).

Is a handover is required?

• Yes,
• Select > Handover to CF/CR
• Select a reason for requesting handover on the Change Status screen
• Once Handover is completed a warning will display advising the claim has been handed over to Customer First/Customer Record for processing
• The status of the claim will change to On Hold - Handover to Customer First/Customer Record
• A new claim activity will be created in ISIS
• See Table 2, procedure ends here
• No, go to Step 14

After selecting Assess, the Entitlement (ELD) screen displays. Ensure the claim outcome is correct. Remember to return to the SHIS screen, to view refreshed deemed income, and number of dependents is correct.

Is the claim to be rejected, as the customer is not eligible for CSHC?

• Yes, for information on how to reject a claim for CSHC, see Rejecting a claim for CSHC. Procedure ends here
• No, go to Step 15

If a customer has died before their claim was finalised, extra coding is needed to end Electronic Messaging (EM) subscription.

• Select Finish
• A dialogue box will give the Service Officer an opportunity to add additional comments/information about the claim outcome. For combined claims select the partner tab at the top of the dialogue box and add the relevant comments/claim outcome for partner as well
• Select Finalise to complete the claim assessment

Note: all scans associated with the claim must be actioned once the claim is finalised.

When a CSHC claim is finalised using Process Direct, an automatic Note is created on the customer's record to reflect the outcome.

Service Officers will need to check that the Note meets:

• Getting it Right (GIR)
• Online Document Recording (ODR)

If a customer already holds a Low Income Health Care Card (LIC) the CSHC will not be automatically issued as the LIC is a higher priority card than the CSHC. If the customer wants the CSHC issued this can be done by manually issuing a non-priority concession card. For more information, see Preferences for concession cards.

Go to the activity list (AL) screen.

'S'elect the claim activity and immediately place on hold for one day.

Re-select the held claim activity and resume processing.

Note: when a claim is handed over, it creates a new work item for Workload Management (WLM) allocation. By placing the claim on hold, it prevents the new work item allocating to another Service Officer.

The customer's residence qualification is assessed automatically if the residence information is correctly recorded. See Residence assessment for customers claiming Commonwealth Seniors Health Card (CSHC).

Note: record residence information even if rejecting the claim. If residence details are not recorded, the system will always reject for a residence-related reason.

The CDTS screen will auto select the compulsory personal details screens for updating the CSHC claims.

Select any other screen(s) needing updates, for example, Marital Status, Tax File Number Summary (TFS) or customer may have a nominee

Press [Enter] and complete all personal details.

The SHTS screen displays a summary of automatically selected screens to update the CSHC claim. For example, SHA Assessment (SHA), Child Selection (CHS), SHC Income Details (SHID), Grandfathering Summary (GFS) and Assessment Results (AR).

The SHA is a compulsory screen where the start date will default to the Date of Receipt. Do not manually change the start date on the SHC Assessment (SHA) screen.

The SHA date should not be changed to a date after the determined start date, for example, the date of claim lodgement or the date the customer contacted the Services Australia in relation to a claim for a concession card.

Early claim provisions do not apply to the CSHC. Any CSHC claims lodged prior to the customer being eligible, must be rejected.

The CSHC date of claim will be automatically taken as the immigration advised date of return if:

• the customer lodges a CSHC re-claim within 14 days of the date of return to Australia, and
• the date of return is less than 26 weeks since their CSHC cancellation date

This can apply to CSHC online claims, customised claims, paper claims and verbal re-claims. Customers whose CSHC has been cancelled for more than 26 weeks will need to complete a full new claim.

Press [Enter] to exit the screen.

Is the claim to be rejected automatically, as the customer does not meet basic CSHC qualification, or via streamline reject or manually on the Benefit Action (BA) screen?

• Yes, for information on how to reject a claim for CSHC, see Rejecting a claim for CSHC. Procedure ends here
• No, go to Step 7

Does the customer (or partner) have any account-based income streams?

• Yes, see Adding or updating an account-based income stream for coding instructions to update an existing account an existing account-based income stream or add a new account-based income stream. Go to Step 8
• No, go to Step 8

Income Details; records the customer (and partner):

• Date of event
• Reference tax year
• Income type
• Adjusted Taxable Income (ATI)

The deemed income amount will not display until after  adding or updating an account-based income stream, navigating to the Activity Result (AR) screen and then returning to the  SHIS/SHID  screen.

Date of Event (DOV)

For new claims, the DOV must be the same as the Date of receipt (DOR). The DOV cannot be a date after the DOR and should be the date of claim as recorded on the  SHA  screen.

Note: the DOV may need to be manually adjusted to match the SHA if:

• the customer lodges a CSHC re-claim within 14 days of the date of return to Australia, and
• the date of return is less than 26 weeks since their CSHC cancellation date

Reference tax year

• The reference tax year is the financial year the customer has declared their income and the date of receipt (DOR) of the claim determines the reference tax year
• The reference tax year for TNA or NRL, must be within 2 years of the current financial year. Use the year the financial year ended, e.g. for 2020/21, code 2021
• Members of a couple need to provide information relating to the same financial year
• The reference tax year for an estimate (EST) is the current financial year. Record the year that the current financial year is to end, for example, for 2021/22 code 2022
• After the estimate (EST) and income details have been recorded, a second entry is required for the reference year of the NOA using type TNA and the date before the claim DOV, that is, DOV - 1 day

Note: where an online claim is started before 1 July but submitted on or after 1 July, the reference year selected by the customer may no longer be valid. Request the relevant reference year information from the customer (and/or partner) to assess the claim.

Where a paper claim is signed on or before 1 July but submitted on or after 1 July, the reference year declared may no longer be valid. Request the relevant reference year information from the customer (and/or partner) to assess the claim.

Income Type:

• TNA  for an NOA and for customers who have been granted an ATO lodgement extension
• NRL  when a customer does not have a NOA because they are not required to lodge, for example their income was below the  tax free threshold  or as a result of an  ATO tax offset.  NRL  must  not  be used when the  customer is required to lodge. For example, the customer has income above the tax lodgement threshold, or had tax withheld from any income in that financial year
• EST – Estimate  customer (or partner) declared due to an  acceptable condition, they are providing an estimate of income  for the  current  financial year.  EST  can  only  be coded once a verified line has been coded

Note:  when a customer provides an estimate, a superannuation withdrawal under the  First Home Super Saver (FHSS) Scheme  is not counted towards their taxable income.

Adjusted Taxable Income (ATI) details declared by the customer (and partner) should pre-populate for online claims.

Taxable Income

Taxable income details are mandatory and where coding is required code one of the following:

• The amount on the NOA
• The current year estimate, or
• The income declared by the customer in their claim if they are not required to lodge

Note:  if a customer is not required to lodge or are providing an estimate, record or accept income details as declared by the customer in their claim. Updates to the income declared are required if the  verification of income documentation  shows the income is not reasonable or will result in an incorrect claim outcome.

When a customer provides an estimate, a superannuation withdrawal under the  First Home Super Saver (FHSS) Scheme  is not counted towards their taxable income.

Adjusted Taxable Income (ATI) additional components

These fields are optional and must only be completed if they are relevant to the customer's claim: See  Commonwealth Seniors Health Card (CSHC) income test and reference tax year for coding requirements.

The deemed income amount will not display until after  adding or updating an account-based income stream, navigating to the Assessment Results (AR) screen and then return to the SHID  screen to view the updated Deemed Income Amount.

Once all information is updated press Enter.

Check bank account details provided in the claim have updated the Payment Destination (PAD) screen (SHC) and display on the Payment Destination Summary (PAS) screen.

This screen is only updated if the customer has dependent children.

Does the customer have dependent children or students?

• Yes, this screen lists the names and number of children of the customer. 'S'elect child/ren listed who are dependants of customer. Update child details if needed
• If there is no record for child/ren, an Assessment of Care Arrangements (FAO) - Dependent child/ren is required. See Assessing Commonwealth Seniors Health Card (CSHC) claims
• Assessment of care referrals are completed within Customer First and should be finalised before handover from Process Direct Check and/or update all children details as needed. This will allow the extra income limits for each dependent child
• Select Enter
• No, go to Step 11

When all information has been updated go to the  AR  screen by entering AR in Next. Ensure the claim outcome is correct. Remember to return to the SHIS screen to view refreshed deemed income and number of dependents is correct.

Is the claim to be rejected, as the customer is not eligible for CSHC?

• Yes, for information on how to reject a claim for CSHC, see Rejecting a claim for CSHC. Procedure ends here
• No, go to Step 13

• If a customer has died before their claim was finalised, extra coding is needed to end Electronic Messaging (EM) subscription
• Finalise activity

Create a Fast Note. Select Auto Text > Concessions Cards > Claims > Commonwealth Senior Card (CSHC) NCL Grant/Reject.

Note:

• for combined claims, remember to add same Fast Note to partner record
• if a customer already holds a Low Income Health Care Card (LIC) the CSHC will not be automatically issued as the LIC is a higher priority card than the CSHC. If the customer wants the CSHC issued this can be done by placing an 'R' next to the CSHC line on the AR screen. For more information, see Preferences for concession cards

Follow-up actions in Process Direct for claims finalised in Customer Record and Customer First:

Check claim status in Process Direct:

• if claim status does not automatically set to Complete:
• select the claim transaction then raise an Incident through Roxy
• choose 'No, the issue is blocking me' to place claim On Hold for System Investigation/Issue
• retain work item using 'hold to user' function in Work Optimiser
• the claim status will be set to Complete by ICT