Processing Low Income Health Care Card (LIC) claims 101-18042300

Customers in vulnerable circumstances who have a genuine difficulty providing documents with the claim can lodge a claim and provide the documents later.

The actual claim date will be the lodgement date and the deemed claim date (under sections 13 and 14 of the Social Security (Administration) Act 1999) will be the contact date, where applicable.

Examples of vulnerable circumstances include (but are not limited to), where the customer is:

• in a crisis situation and is unable to fully complete a claim due to being homeless
• affected by a major disaster
• impacted by family and domestic violence
• a recent humanitarian entrant
• recently released from prison or psychiatric confinement
• a young person who is unable to live at home (ongoing situation)

Some customers may have STP employer details pre-fill when claiming a LIC. A customer will be presented with:

• the employer's name, and
• Australian Business Number (ABN)/Withholding Payer Number (WPN)

Where STP data does not indicate employment has ceased, customers are asked if they work for the employer. They are shown other trading names associated with the STP employer's ABN/WPN to help them recognise the employer's details. The customer must review and advise Yes or No to confirm or reject the STP employer. These details are available on the STP Employer Update (EMCF) screen.

Where the customer advises Yes to confirm the employer, the STP employer's details can be linked with an existing employer from their record or a new employer entry is created.

If the customer advises No, they do not work for the employer, this will show in the claim slider.

When the STP employer is confirmed, the customer must manually enter details in the online claim of their:

• gross pay
• date paid

Note: STP income data does not pre-fill in an online claim or ACC for the customer to review.

The system will also request a customer to update income if the assessment period changes due to a delay in claim submission. This occurs if the customer starts the claim but does not finish it on the same day.

If a customer has not requested an explanation or applied for a formal review of a decision, service officers should consider any new information being supplied to determine if the rejected claim can be reassessed, see Request to reassess a rejected claim.

If a customer indicates they do not agree with a decision, check if they want an explanation or a formal review. See First contact about a decision and the internal review process.

To cover medical, pharmaceutical or other related expenses already incurred, the start date of a LIC may be backdated, to a particular date of the medical service or treatment.

The customer must provide evidence of the medical service or treatment to support the request for backdating the start date.

Claims may only be backdated for a medical service or treatment if the customer has remained eligible for the entire period between the date of medical service or treatment and the date of claim.

This means that the customer must be able to verify that:

• the income in the 8 weeks ending on the date of medical service or treatment was below the allowable income limit applicable to the customer and/or partner, and
• their relevant income remained below the LIC threshold for the entire past period ending on the date the claim was lodged, and
• the customer continued to satisfy the LIC residency requirements for the entire period

The start date field on the LIC Start Date (LSD) screen defaults to the Date of Receipt (DOR). The LSD screen may be changed during a new claim activity. If a request has been made to backdate the claim for longer than 13 weeks due to medical service or treatment, escalate to the Level 2 Policy Helpdesk.

Service Officers must check the identity status in the Identity Confirmation Dashboard (dashboard) in Process Direct.

A claim can only be processed when the:

• Customer has a confirmed identity status or has established their identity via Alternative Identity provisions
• Partner has a confirmed or no linkage identity status, if not, and the partner is an Income Support Pension (ISP), Department of Veterans Affairs (DVA), Low Income Health Care Card (LIC) or Commonwealth Senior Health Card (CSHC) recipient, the Alternative Identity process was followed and an Identity Review is applied for the partner

Note: Service Officers must not code the Proof of Identity (POI) screen.