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

Before processing the claim, eligibility criteria and claim requirements must 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:

• if 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 Transaction Summary (TS) screen, select Process.

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

• Select messages to view/update the relevant details. An error or warning will show if information has not loaded correctly from the online claim or ACC
• The Task Selector will show 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, go 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)

Check the Proof of Identity Details (POI) screen. If there is no entry with Service Reason Code SHC, open and check the Identity Confirmation Dashboard (dashboard) in Process Direct.

Customers that:

• do not have a Confirmed Identity status, see Identity Confirmation
• cannot confirm their identity must be supported to establish their identity, see Alternative Identity

Claims cannot be processed when the customer has not confirmed or established their identity in the dashboard.

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

Note: if a customer advises they are separating, see Separating safely - protecting personal details to make sure personal information is kept safe.

If the customer has separated in the last 6 months this is a family and domestic violence interaction point, see Family and domestic violence.

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 before 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].

Where a claim for CSHC has been submitted prior to the start date of an already granted claim for Age Pension the claim may incorrectly reject Customer on Precluding Payment (REJ-CPP), This can be despite the customer meeting the basic CSHC qualification prior to the start date of their Age Pension.

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, (including where the claim is incorrectly REJ-CPP), 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 form (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 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 show 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 not be a date after the Date of Receipt (DOR) and should be the date of claim as recorded on the SHA screen.

Where an existing DOV includes the same Reference tax year, a duplicate entry is not required.

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 DOR of the claim determines the reference tax year
  • The reference tax year for Tax Notice of Assessment (TNA) or Not Required to Lodge (NRL), must be within 2 years of the current financial year. Use the year the financial year ended. For example, 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 Notice of Assessment (NOA) using type TNA and the date before the claim DOV, that is, DOV - 1 day

Note: if 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.

If 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 Australian Taxation Office (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: updates to the income declared by the customer are not required if the verification of income documentation provided shows the income:

• is not reasonable, and
• will result in an incorrect claim outcome

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

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 show 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.

The Taxable Income Limit for CSHC increases for each dependent child of the person.

Dependent children should show on the Seniors Health Card income summary (SHIS) screen. The Number of dependents field will confirm the number of dependents be included for the extra income limit.

If an Assessment of Care Arrangements (AOCA) referral has recently been completed, do a SAP Refresh to update the confirmed dependant relationships data into the claim transaction.

Does the customer have dependent children?

• Yes, and the SHIS screen Number of dependents field is showing the:
  • correct number of dependents, go to Step 13
  • incorrect number of dependents, go to Step 12
• No, and the SHIS screen Number of dependents field is showing:
  • dependents, go to Step 12
  • no dependents, go to Step 13

Check the Child Details in the Claim Summary against the information held on the customer's record for each child:

• Check the Child Details in the Claim Summary
• In Process Direct, go to and select each child from the left-hand column, then go to:
  • Shared Care Assessment (SCA) screen
  • Child in Care (CHC) screen

An Assessment of Care Arrangements (FAO) - Dependent child/ren is required if:

• there is no record for child/ren, or
• a change to the children in care is required. For example, the child is no longer in the customers care

• In the claim transaction, go to the Transaction Summary (TS) screen
• Select > Referral
• Select Referral Type: Assessment of Care Arrangements Referral
• Select Next
• Select the appropriate Referral Reason
• Document Lists - A 'Details of your child's care arrangements form (FA012)' is not required for CSHC claims
• In the What is Required? field, add the details below:
  • CSHC claim lodged 'date'. Care determination and Principal Carer determination is required for:
  • Child/ren's Name and DOB:
  • Date of care change: if known, otherwise key the following text: CSHC staff are not suitably skilled to discuss change in care and any further information may need to be requested by staff completing referrals
  • Percentage of Care:
  • Other Carer's Name/CRN:
  • Additional Information:
• Select Finish
• Annotate the Progress of Claim DOC with the referral for a care assessment

See Assessing Commonwealth Seniors Health Card (CSHC) claims.

If the CHC screen is correctly showing dependents in customers care and this is not showing in the SHIS screen, do a SAP Refresh. If the SHIS does not update correctly, see Reporting ICT issues in Process Direct.

When the SHIS screen Number of dependents field is correct, go to Step 13.

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 keying 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 show 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 15

After selecting Assess, the Entitlement (ELD) screen will show . Make sure the claim outcome 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,
  • for claims incorrectly rejecting CPP, go to Step 17
  • for all other claims, go to Step 16

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.

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.

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

A CSHC may incorrectly reject Customer on Precluding Payment (CPP) when the claim Start Day (SHA) is earlier than the Start Day of the customer’s Age Pension entitlement. This may occur when a customer is eligible for CSHC and the start day of their CSHC claim is before the start day of their already granted Age Pension (AGE) claim.

Note, if the customer was in receipt of an ISP on the Start Day of the CSHC claim, reject CPP is the expected result, see Rejecting a claim for Commonwealth Seniors Health Card (CSHC)

• Inhibit SHC advice in the ASC screen
• 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.

Add the following text to dialogue box: Claim for CSHC Granted from (insert SHA date) and cancelled CPP from (insert PNSH date for AGE) under the Social Security Act 1991, Section 1061ZG. LVL2 enquiry made for manual override of concession entitlement for this period.

• Select Finalise to complete the claim assessment
• Escalate to Level 2 Policy Helpdesk
• Once Level 2 escalation is complete, run the Confirm concession entitlement workflow to issue a notice. See Confirming concession card entitlement and issuing an interim voucher (temporary concession card)

All scans associated with the claim must be actioned once the claim is finalised.