Rejecting a claim for Low Income Health Care Card (LIC), Foster Child Health Care Card (FST) or Ex-Carer Allowance (child) Health Care Card (EHC) 101-06040060

To determine the correct reason for the rejection, see Cancellation and rejection codes.

Before starting the rejection action, consider discussing the decision with the customer.

Does the claim require manual rejection via the Benefit Action (BA) screen?

• Yes, go to Step 2
• No, go to Step 4

For claim rejections processed via:

• Process Direct:
• streamline rejection, go to Step 3
• manual rejection, go to Step 5
• Handover to Customer First. Note: only use the Handover to CF/CR function when directed. Go to Step 6

If a claim is streamline rejected, full claim coding is not required. After the streamline rejection is completed, check contact details to make sure the notice of rejection is issued to the correct address. Update any other changes that may impact a customer’s and/or partner’s current payment or service.

In Process Direct, undertake a streamline rejection. Go to the Transaction summary (TS) screen:

• select Process
• in the Super Key field, key BA to go to the Benefit Action (BA) screen
• select Add New to create a new entry and choose the relevant option from the dropdown menu:
• Benefit Type Code, select LIC, FST or EHC
• Benefit Action, select REJ-Reject
• Streamline Rejection, check the box
• Reason for rejection, select the appropriate reason code from the drop down menu. See Cancellation and rejection codes for Low Income Health Care Card (LIC), Foster Child Health Care Card (FST) or Ex-Carer Allowance (child) Health Care Card (EHC)
• Date of Effect will automatically default to the claim submission date
• select Save to display a new line on the BA screen
• in the Super Key field, key SWE to go to the Errors (SWE) screen
• select Assess
• once all errors, if any, have been addressed, select:
• Assess to go to the Entitlement (ELD) screen. Check the correct rejection reason is displaying for the customer and/or partner
• Finish. When the finalisation DOC shows, if more details are needed, add this to the DOC and list the specific documents that were not supplied
• Finalise

Note: contact is not needed for some streamline reject decisions where the customer is not vulnerable or at risk.

Procedure ends here.

Record all information provided on the claim by selecting the Task Selectors and updating the fields. In most cases, the system will automatically reject the claim:

• select Finish. When the finalisation DOC shows, if more details are needed, add this to the DOC
• do not finalise the activity. Advise the customer of the decision, go to Step 7

Code the claim with all information that has been supplied before rejecting the claim.

Once claim is ready to be manually rejected, go to the Transaction summary (TS) screen:

• select Process
• in the Super Key field, key BA to go to the Benefit Action (BA) screen
• select Add New to create a new entry and choose the relevant option from the dropdown menu:
• Benefit Type Code, select LIC, FST or EHC
• Benefit Action, select REJ-Reject
• Reason for rejection, select the appropriate reason code from the drop down menu. See Cancellation and rejection codes for Low Income Health Care Card (LIC), Foster Child Health Care Card (FST) or Ex-Carer Allowance (child) Health Care Card (EHC)
• Date of Effect will automatically default to the claim submission date
• select Save to display a new line on the BA screen
• in the Super Key field, key SWE to go to the Errors (SWE) screen
• select Assess
• once all errors, if any, have been addressed, select:
• Assess to go to the Entitlement (ELD) screen. Check the correct rejection reason is displaying for the customer and/or partner
• Finish. The finalisation DOC will show. If more details are needed, add this to the DOC
• do not finalise the activity. Advise the customer of the decision, go to Step 7

Sometimes a claim activity may need to be processed in Customer First/Customer Record and the Handover to CF/CR function may be required. Generally, this is to apply an approved workaround for a known issue/error or gap/s in Process Direct.

Note: before utilising the Handover to CF/CR function, staff must refer to Table 5 in Using Digital Assistance Roxy in Process Direct for required actions.

For EHC only, in Customer First, select ISS from the System field, key SVEHC in the Next field and press [Enter].

To manually reject a claim:

• make all necessary updates required within the claim
• code fields on the Benefit Action (BA) screen:
• Svc Rsn, select LIC, FST or EHC
• Action, select REJ
• Reason for rejection, select the appropriate reason code from the drop down menu. See Cancellation and rejection codes for Low Income Health Care Card (LIC), Foster Child Health Care Card (FST) or Ex-Carer Allowance (child) Health Care Card (EHC)
• Effect Date, this usually defaults to Date of Commencement and may not need to be coded

For a manual rejection, all customer verified personal details must be coded to ensure the notice of rejection is issued to the correct address. If the customer and/or partner are not currently on an income support payment, income and asset coding is not required if rejecting FSD or FRC.

Do not finalise the activity. Advise the customer of the decision, go to Step 7.

When an unfavourable decision is made, the Decision Maker (DM) must provide the customer with:

• an explanation of the decision and an opportunity to provide more information or evidence relevant to the decision
• their review and appeal rights, see Initial contact about a decision and the review of decision process

Note: this includes unfavourable decisions made by Service Officers in a smart centre.

If the DM is not speaking with the customer at the time of making an unfavourable decision, the DM needs to make genuine attempts to contact the customer before finalising the activity.

Select Finalise to complete the claim.

Procedure ends here.