Escalation process for Medicare Eligibility 011-44015000

• Enrolment work received from a customer when attending a service centre
• An urgent request to enrol a newborn using the Newborn Child Declaration (FA081) form
• A request to process the following enrolments where the customer is vulnerable or in hardship:
• Customers enrolling in Medicare for the first time
• A returning resident enrolment
• Reciprocal Health Care Agreement (RHCA) enrolment
• Extending Medicare eligibility
• A Child Dental Benefits Schedule (CDBS) enquiry

If a face to face Service Officer does not have Access to VEVO (Visa Entitlement Verification Online) program, they must submit a request to get access.

In the interim:

• call a Medicare and Aged Care - Local Peer Support (LPS), and
• ask for a copy of the customer's VEVO details

The Medicare Eligibility and Enrolments (MEE) LPS will email details.

Do not escalate an enrolment application because of no VEVO access.

If a face to face Service Officer does not have access to Document Verification Service (DVS), they must:

• complete the DVS training package, and
• submit a request to get access

See a Team leader.

In the interim, Service Officers should:

• call Medicare and Aged Care - Local Peer Support (LPS), and
• ask for a customer's DVS check to be completed

The Medicare and Aged Care- LPS will email details to the Service Officer.

Do not escalate an enrolment application because of no DVS access.

• Australian citizens, New Zealand citizens and permanent residents
• Applicants for permanent residency
• Indigenous enrolments (MS018)
• Ministerial Orders including parent visa categories
• Newborn Child enrolments (FA081 or MS004 Part C)
• Child Protection Agency (DCP) requests
• Medicare card requests for incarcerated customers
• A Child Dental Benefits Schedule (CDBS) enquiry
• Copy or transfer requests (MS011)
• Diplomat enrolments
• Public Trustee/POAs
• Digital Medicare enrolment (DME) applications. See Digital Medicare enrolments (DME) and the MEE Portal

Note: if a Service Officer cannot resolve the enquiry using all available resources, including Operational Blueprint, Communications, and Network News Updates (NNU), they must seek help from LPS. See Tier 0 technical support - self-sufficiency.

If escalation is required Service Officers must:

• leave appropriate escalation notes in PaNDA
• include snips of failed DVS results
• attach VEVO results
• make sure the work status is open before escalating
• escalate to MEE LPS for assessment, and
• not escalate directly to National Office folders in PaNDA, they must seek help from LPS

LPS may receive complex eligibility and enrolments work escalated in PaNDA or Workload Management (WLM):

• third Medicare card requests
• complex Child Protection Agency (DCP) requests
• applications to transfer a child under 15 years of age (unrelated to family and domestic violence (FDV)) where both parents or guardians cannot give consent
• escalated DME work received via WLM
• Document Verification Service (DVS) N and D results see Identity verification for Medicare enrolments and re-enrolments in the Medicare Document Verification Service (DVS) Portal

If LPS reassign a work item to a Service Officer for processing they must also recategorise the work item from the Escalations folders to the appropriate work type in PaNDA.

LPS will confirm if escalated work items are for a Medicare Consumers Program Support work type. If escalation is required, LPS must see Table 3.

Service Officers must escalate requests to remove children under 15 years of age from a Medicare card (unrelated to FDV) using work type Medicare eligibility and enrolment, Nat. Office Escalations DCP (ME_NO_ESCALATION_DCP).

Note: LPS must not pend work items as ‘future release date’ in the Escalations folders.

The work types can include:

• 410 visa holders:
• issued or applied for before 1 December 1998, and
• who have never had a Medicare card
• PALM 403 visa holders
• Ministerial Interventions
• removal of Pending Bridging 070 visa holders
• Complex enrolments that need to be escalated to the Department of Home Affairs or the Department of Health and Aged Care
• Victims of People Trafficking programme
• Request to remove children under 15 from a family Medicare card where FDV is not involved
• Fourth Medicare card requests
• Postcode locality update
• Process Record Amendment (PRA) requests
• Surrogacy arrangement where documentation provided does not meet standard requirements
• Complex Child Protection Agency enquiries that require further assessment before rejecting
• MSN out of pocket expenses (OOPS) CDMS adjustments only
• MSN PRA - incorrect family created, or family circumstances change
• Escalated unresolved DVS D results

Note: Service Officers and LPS must not action or recategorise work items in the ME_NO_ESCALATION or ME_NO_ESCALATION_DCP folder in PaNDA.

A face to face Service Officer must first try to resolve the customer enquiry by using:

• Operational Blueprint
• staff messages, such as Daily Comms
• comments in the Consumer Directory Maintenance System (CDMS)
• a Visa Entitlement Verification Online (VEVO) system check

The face to face Service Officer must:

• Call Medicare and Aged Care - Local Peer Support (LPS) if they cannot resolve the customer's enquiry, and
• If the enquiry is deemed not urgent, scan all enrolment documents to PaNDA via the Multi-Function Device (MFD)

This work will be finalised by a Medicare Eligibility and Enrolment trained Service Officer or LPS.

If the enquiry is urgent, the face to face Service Officer must escalate to LPS. To do this they must:

• Scan all enrolment documents, and
• Contact Medicare Eligibility and Enrolments (MEE) LPS to escalate the work item

This work will be finalised by a Medicare Eligibility and Enrolment trained Service Officer (SO4/LPS).

Service centre staff not currently serving the customer must:

• escalate to LPS using the online form Tier 1 - LPS Request for Assistance - Health
• for technical support see Technical Support Model Tier 0 technical support - self-sufficiency

Service Officers not trained in MEE must contact MEE LPS using the online request form. See Medicare and Aged Care – LPS. LPS takes ownership of the request and will contact the Service Officer if they need more details.

For customer enquiries or processing, all Service Officers trained in Medicare Eligibility and Enrolments must complete the work if they have all the:

• training/skills
• required delegation
• necessary details and documents

If Services Australia gets an application and all relevant documents:

• assess the customer's eligibility, and
• process the enrolment regardless of the date of lodgement

If the customer indicates they are experiencing hardship or are vulnerable, and all documentation has not been provided, see Table 5.

Must:

• follow Tier 0 technical support - self-sufficiency, and research:
• Operational Blueprint
• Communications, and
• Network News Updates (NNU)
• search CDMS and PaNDA to locate:
• customer records
• application and supporting documents
• authenticate the customer from CDMS or the Medicare Enrolment form (MS004)
• complete a basic assessment of the application and check:
• all customer and contact information is complete and all pages have been received
• the declaration is complete
• all requested documents have been provided

If the customer has provided all documents and the application form is complete:

• tell them a skilled Service Officer will process the application
• complete a Local Peer Support (LPS) Referral Form to refer the application to a trained Service Officer

If the customer indicates they are experiencing hardship or are vulnerable, Service Officers not trained in MEE must see Table 5.

If more documents or details are needed to complete an activity:

• For inbound calls - tell the customer what details and/or documentation is needed and that they can:
• email documents to MES@servicesaustralia.gov.au. They must include the PaNDA work ID (WID) in the subject line of the email or write it on the application form
• lodge documents in person at a service centre if they are not able to send an email
• For processing - Service Officers must:
• attempt to contact the customer by phone to tell them what documents are needed before sending a request for information (RFI) letter
• not access positional mailboxes or contact LPS to access documents emailed during the contact with the customer

Service Officers must follow the process in Digital Medicare enrolments (DME) and the MEE Portal.

All Service Officers trained in DME must review document/s provided and check if any other documents or details are needed. If the:

• customer has provided relevant documents, assess eligibility and process the enrolment regardless of the date of lodgement
• agency needs more documents, request more documentation through the Medicare Eligibility and Enrolments (MEE) Portal

If the customer indicates they are experiencing hardship or are vulnerable, Service Officers not trained in DME must see Table 5.

Before escalating any work type to the Medicare Consumers Program Support Team, make sure all resources have been used to resolve the query. See Tier 1 technical support - Local Peer Support (LPS).

If LPS cannot resolve the enquiry for PaNDA work items, LPS will:

• leave appropriate escalation notes in PaNDA, and
• make sure the work status is open before escalating
• escalate the enquiry via PaNDA using work type Nat.Office Escalation (ME_NO_ESCALATION), or
• email Medicare Consumers Program Support team, go to Step 2

If LPS cannot resolve the enquiry for Digital Medicare Enrolments (DME) applications, LPS will:

• leave notes in the activity log in the MEE Portal explaining the reason for escalation
• update the status in the MEE Portal to On hold - Escalated to - National Office or DVS Operations
• tell the processing Service Officer to:
• return to the work item in Work Optimiser - Medicare
• unassign and recategorise the work item to the relevant DME MEE escalation work type: National Office ME_DME_NO_ESC

If a Service Officer escalated the DME application work item through an LPS referral form, LPS must escalate the application by email to Medicare Consumers Program Support team, and include the:

• DME application number, and
• reason for the escalation

The Medicare Consumers Program Support team will send a response within 10 business days.

For escalations about DVS, see Table 3 in Identity verification for Medicare enrolments and re-enrolments in the Medicare Document Verification Service (DVS) Portal.

Urgent PaNDA requests

Service Officers must escalate urgent applications escalated via PaNDA, using work type Medicare Eligibility and enrolment, Nat. Office Escalations DCP (ME_NO_ESCALATION_DCP).

Email requests

For urgent enquiries not related to an existing PaNDA work item, MEE LPS can email Medicare Consumers Program Support, who will respond to urgent email requests within 2 business days. The team assess urgent requests and responds to them in order of priority.

Note: the response time may be longer if the case needs external stakeholder advice.

• Work items that have been incorrectly escalated to Medicare Consumer Program Support will be returned to the referring Service Officer
• Medicare Consumer Program Support will submit feedback via the Staff Feedback Tool

Customers:

• experiencing financial hardship or vulnerability may ask for urgent processing of their Medicare enrolment
• vulnerability can occur because of various risk factors including:
• Financial hardship
• Safety concerns
• Health concerns
• Housing
• Crisis or trauma
• Visa circumstances

If a customer says they are experiencing hardship or are vulnerable, Service Officers:

• not trained in Medicare Eligibility and Enrolments must:
• complete Tier 1 - Request for Local Peer Support (LPS) Assistance - Health online form, and
• warm transfer the customer call to LPS
• not trained in MEE working outside of LPS contact hours must:
• tell customers a skilled Service Officer will process the application
• complete a LPS Referral Form to refer the application to a trained Service Officer
• in face to face see Table 2

LPS:

• take ownership of the request
• take over the customer call, and
• review the application to check if more details are needed

If:

• no more documentation is needed, LPS complete the enrolment
• more documentation is needed, LPS tell customers to:
• email documents to MES@servicesaustralia.gov.au, and
• include the PaNDA work ID (WID) in the subject line of the email or write it on the application form

LPS will:

• include comments in PaNDA and pend the work item (using validate information) to themselves for a period of 48 hours, and
• review the MES mailbox for details

Once LPS gets the details, they will process the enrolment and contact the customer to tell them the outcome.

If the customer does not provide the documentation in 48 hours, LPS must make one genuine contact attempt.

If contact is:

• successful:
• tell the customer the agency does not have the documentation needed. They can call back once they have lodged all the required documentation
• record comments in PaNDA, and
• return the work item to the queue
• unsuccessful:
• record comments in PaNDA advising of unsuccessful contact attempt, and
• return the work item to the queue

All 'Application to copy or transfer from one Medicare card to another forms (MS011)' received for a child under 15 years of age, involving family and domestic violence (FDV), must only be assessed by a Service Officer skilled tagged in FDV.

Service Officers not skill tagged in FDV must recategorise all applications received to copy or transfer a child under 15 years of age due to FDV.

Service Officers must never:

• tell the customer that a child will be copied or transferred
• provide a timeframe as these cases are sensitive and can be complex in nature

Note: Service Officers and Local Peer Support (LPS) must not contact customers by phone or send letters if required documentation is not submitted with the application. Service Officers skill tagged in FDV will make all follow up calls.

Face to face Service Officers must:

• check the Medicare Safety Net registration with the applicant and make any required updates
• apply a FDV sensitive indicator to the customer's record (if one is not already applied)
• scan applications directly to Dept of Child Protection (ME_DCP_ESCALATIONS in PaNDA) via the Multi-Function Device (MFD)
• LPS will recategorise the work item to ME_FDV

Service Officers must apply a FDV sensitive indicator to the customer's record before recategorising (if one is not already applied).

Service Officers and LPS must check:

• work items received in PaNDA and identified as FDV are recategorised to work type ME_FDV
• the work status is in Open before recategorising, to ensure timely processing of work items

Note: Service Officers and LPS must not action or recategorise work items in the ME_FDV folder in PaNDA unless they are skill tagged in FDV.

• If the customer has concerns about their immediate wellbeing or safety, Service Officers must contact Local Peer Support (LPS)
• If LPS decide immediate attention is needed, they must email Health Service Delivery Division for advice

If a complaints Service Office (APS4) needs help with a complaint related to applications to copy or transfer a child under 15 years due to FDV they must email Health Service Delivery Division > Health Service Delivery Division for advice.

Face to face Service Officers must:

• escalate the query to a Medicare and Aged Care - Local Peer Support (LPS)
• scan all the documents and forms to PaNDA (if processing is required)

The DCP or a non-government organisation may make a verbal request for a child’s Medicare card details. Do not give out these details. The DCP or non-government organisation must call a Medicare Eligibility trained Service Officer and give their agency ID and password.

Any request from a non-government body must not be actioned, for example, Anglicare or Wesley Mission. Call the Medicare Eligibility LPS Team for help.

If an application from a Child Protection Agency needs escalation, Service Officers must contact Medicare and Aged Care - Local Peer Support (LPS) for help.

Examples of applications that need escalation, include:

• third card requests
• the Child Protection Agency has provided a letter on agency letterhead advising they cannot provide an acceptable proof of birth document
• the name on the provided court order does not match the child's legal name on the provided birth certificate or CDMS
• if Service Officers are unsure of the intent of a provided court order or its validity

If LPS asks the Service Officer to escalate the enquiry, the Service Officer must:

• leave appropriate notes in PaNDA to explain the reason for the escalation
• escalate the application in PaNDA using work type Medicare Eligibility DCP Escalations (ME_DCP_Escalations)

If escalation to National Office by LPS is needed, LPS recategorise in PaNDA to work type Medicare Eligibility Nat.Office Escalations DCP (ME_NO_ESCALATION_DCP).

The Medicare Consumers Program Support Team will respond to the LPS. An LPS or a Service Officer will complete the enrolment.

Face to face or Service Officers must escalate all third card requests to the MEE LPS Team via PaNDA. MEE LPS do not decide and grant third card approvals verbally.

Service Officers must check the applicant has provided a completed application and all relevant documentation.

Service Officers will escalate to a MEE LPS via PaNDA under the work type:

• DCP 3rd card request to DCP Escalations (ME_DCP_ESCALATIONS)
• Other 3rd card requests to Escalations (ME_ESCALATIONS)

The LPS will:

• assess and confirm that the request is valid
• include approval/rejection in PaNDA work item notes
• re-assign the third card request back to the processing queue for the next Medicare Eligibility trained Service Officer to complete

All 4th card (or more) requests must be escalated to Medicare Consumers Program Support. The LPS must send the request via PaNDA using work type Nat.Office Escalations DCP (ME_NO_ESCALATION_DCP).

A face to face Service Officer must try to resolve the customer enquiry. See Patient eligibility for Child Dental Benefits Schedule (CDBS) in Medicare.

If the face to face Service Officer cannot resolve the enquiry, they must, contact a Medicare and Aged Care - Local Peer Support (LPS):

• complete the CDBS Eligibility Enquiry Form
• scan it using a Multi-Function Device (MFD)
• email to MPS Eligibility

The Service Officer must try to resolve the enquiry.

If they cannot resolve the enquiry they must:

• ensure consent from the parent/guardian to access Centrelink and check eligibility has been obtained
• contact a Medicare and Aged Care - Local Peer Support (LPS)
• if LPS is not available, Service Officers must complete a CDBS Eligibility Enquiry Form including mandatory consent from the parent/guardian fields, and email the to MPS Eligibility. Note: consent to access Centrelink to check eligibility is a mandatory requirement on the form

If LPS cannot resolve, they must:

• ensure consent has been obtained from the parent/guardian
• complete a:
• CDBS Eligibility Enquiry Form, and
• CDBS National Office Escalation Form
• email both to CDBS Medicare Branch National Office

In some cases, it is acceptable for an applicant to complete a statutory declaration in support of an application to enrol or re-enrol in Medicare if the necessary residency documents cannot be provided.

The statutory declaration must be signed by an approved witness and include comprehensive details about why the applicant cannot provide 2 acceptable residency documents. The statutory declaration must also include:

• the applicant’s previous country of residence
• steps taken to cease residing overseas
• confirmation the applicant has returned to reside in Australia
• any other steps taken to establish residency in Australia

A statutory declaration cannot be used in lieu of:

• 2 residency documents within the first 6 months of arrival for migrants and eligible New Zealand citizens
• specific documents required for visitors to Australia requesting enrolment under a Reciprocal Heath Care Agreement (RHCA) (except Italian citizens)

See Document types for Medicare eligibility and enrolment.

Where an Australian citizen has been residing overseas for 5 years or more and has returned to reside in Australia, they must provide 2 documents to confirm residency. If they cannot provide residency documents after 6 months they can submit a Commonwealth statutory declaration.

Service Officers can accept statutory declarations provided after 6 months as they do not need escalation.

In some cases, a statutory declaration can be made available to an Australian citizen within 6 months from their arrival date.

Service Officers must:

• leave appropriate escalation notes in PaNDA
• make sure the work status is open before escalating, and
• escalate to MEE LPS for assessment and approval

LPS must:

• assess the statutory declaration and leave appropriate approval comments in PaNDA
• recategorise the work to ME_Enrolments for the next available Service Officer to action

When an applicant cannot provide 2 residency documents after being in Australia for 6 months or more, they can submit a Commonwealth statutory declaration along with any documents they have.

Statutory declarations provided after 6 months do not require escalation and can be accepted by a Service Officer.

When an applicant cannot provide 2 residency documents after being in Australia for 6 months or more, they can submit a Commonwealth statutory declaration together with any documents they have.

Statutory declarations provided after 6 months do not require escalation and can be accepted by a Service Officer.

If the Italian citizen cannot provide evidence of a valid EHIC or a valid Italian Health Insurance Card, it is acceptable for them to complete a statutory declaration.

Service Officers can accept statutory declarations provided by Italian citizens under RHCA as they do not need escalation. The declaration must state they are eligible for medical and hospital services under the national health legislation of Italy. It is not necessary for them to state the validity date.