Assessing a recognised disability for Carer Allowance (CA) (child) 009-03040020

This process does not apply to customers claiming Carer Payment (CP) only. For CP only claims, see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Did the customer lodge the Services Australia medical report that was requested when they submitted their claim?

• Yes, see Table 2
• No, go to Step 2

If the customer:

• previously lodged a non-Services Australia medical report which was not accepted, and the agency asked them to provide either an SA426 or SA431 form, and the customer did not provide the SA426 or SA431 form, reject the claim. See:
• Rejecting a Carer Payment (CP) claim
• Rejecting a Carer Allowance (CA) claim
• previously lodged a non-Services Australia medical report and the agency asked them to provide an SA427 form, and the customer did not provide the SA427 form, go to Step 9
• lodged a non-Services Australia medical report, go to Step 3
• did not lodge any medical reports:
• See Processing claims for Carer Payment (CP) and/or Carer Allowance (CA)
• Procedure ends here

The non-Services Australia medical report can only be used instead of a Services Australia medical report if:

• the report clearly states the child care receiver has a formal diagnosis of ASD. Note: terms such as ‘autistic traits’ and ‘likely to have autism’ indicate ASD has not been formally diagnosed, and
• the formal diagnosis was made using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and
• the formal diagnosis was made by:
• a psychiatrist
• a registered psychologist, or
• a developmental paediatrician. If a paediatrician completed the report, make sure they are a developmental paediatrician. For help, see Identifying a developmental paediatrician on the Resources page

Does the non-Services Australia medical report meet all the above conditions?

• Yes, go to Step 5
• No, go to Step 4

The non-Services Australia medical report cannot be accepted. The customer must provide a Services Australia medical report.

Send a Request for Information. If the customer lodged a claim for:

• CP and CA, request an SA431 form
• CA only, request an SA426 form

Place the claim on hold. Use the Hold to User function.

Procedure ends here until the Services Australia medical report is lodged or the claim comes off hold.

The non-Services Australia medical report:

• can be used to assess CA
• cannot be used to assess CP. A Services Australia medical report is required to assess CP

If the customer is claiming:

• combined CP and CA, go to Step 6
• CA only, go to Step 9

Record all the available information for the CP/CA claim.

Is CP and/or CA rejecting for a ‘non-medical’ reason (e.g. income)?

• Yes, go to Step 7
• No, go to Step 8

Both CP and CA are rejecting for non-medical reasons:

• Reject the payments. In the rejection DOC, record the following:
  ‘If the customer wants to appeal the decision, a Carer Payment - Medical Report including functional assessment for a child under 16 years (SA427) is required to medically assess CP.’
• To reject the payments. See:
• Rejecting a Carer Payment (CP) claim
• Rejecting a Carer Allowance (CA) claim
• Procedure ends here

If CP only is rejecting for a non-medical reason (CA is not rejecting):

• Reject the CP claim, see Rejecting a Carer Payment (CP) claim
• Continue with the CA claim, go to Step 9

To assess the customer’s combined CP/CA claim, take the following action:

• do not finalise the CA claim
• send a Request for Information asking the customer to return a completed Carer Payment - Medical Report including functional assessment for a child under 16 years (SA427)
• place the claim on hold. Use the Hold to User function

Procedure ends here until the Services Australia medical report is lodged or the claim comes off hold.

The non-Services Australia medical report can be used to assess the CA claim because:

• the child medically qualifies for CA (child)
• an assessment under the Disability Care Load Assessment (DCLAD) (2020) is not required

The process for assessing a recognised disability ends here.

Continue assessing the CA claim. To do this, see Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Procedure ends here.

Did the agency previously write to the customer or Treating Health Professional (THP) asking them to provide details that were incorrect or missing from their Services Australia medical report?

• Yes:
• If the customer or THP is responding to this request, go to Step 2
• If the claim has come off hold and there is no response from the customer/THP, reject the claim. See Rejecting a Carer Allowance (CA) claim. Procedure ends here
• No, go to Step 2

To determine if the child care receiver has been diagnosed with a recognised disability or a recognised medical condition, review the THP’s responses to Questions 7, 8 and 9:

• Question 7 and/or Question 8, the THP does not indicate the child has a recognised disability and/or a recognised medical condition, and at:
• Question 9, they answered ‘No’, go to Step 9
• Question 9, they answered ‘Yes’, go to Step 4
• Question 7 and/or Question 8, the THP indicates the child does have a recognised disability and/or a recognised medical condition, and at:
• Question 9, they answered ‘Yes’, ‘No’ or left the answer blank, go to Step 3

Eligibility for CA requires the medical condition to be present for at least 12 months, unless the condition is terminal.

If the THP marked Questions 3, 4 and 5 to indicate the disability or medical condition is:

• permanent, or temporary and expected to be present for at least 12 months, go to Step 10
• temporary, and expected to be present for less than 12 months:
• contact the THP
• ask them why they consider the disability or medical condition is temporary

Was contact with the THP successful?

• Yes, go to Step 7
• No, go to Step 6

Eligibility for CA requires the medical condition to be present for at least 12 months, unless the condition is terminal.

If the THP marked Questions 3, 4 and 5 to indicate the disability or medical condition is:

• permanent, or temporary and expected to be present for at least 12 months, go to Step 10
• temporary, and expected to be present for less than 12 months, go to Step 5

Contact the THP. Ask them:

• why they consider the disability, or medical condition to be present for less than 12 months
• if the child care receiver has a disability and/or medical condition listed in Question 7 and/or Question 8

Was contact with the THP successful?

• Yes, go to Step 7
• No, go to Step 6

Send a request in writing to the customer or THP. Ask them to provide the incomplete/incorrect details in the medical report. To do this, follow the process in Step 5 (Request information in writing) in the Processing an incomplete or incorrect claim table.

Place the claim on hold. Use the Hold to User function.

Procedure ends here until the customer/THP responds to the above request or the claim comes off hold.

In a DOC, record all verbal information given by the THP. To record this, follow the process in Step 4 (Verbal information) in the Processing an incomplete or incorrect claim table.

If the THP confirms:

• the child does not have a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of the condition is permanent, or temporary and expected to be present for at least 12 months, go to Step 9
• the child has a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of the condition is permanent, or temporary and expected to be present for at least 12 months, go to Step 10
• the child does not have a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of condition is temporary and expected to be present for less than 12 months:
• The care receiver does not medically qualify for CA, see Rejecting a Carer Allowance (CA) claim
• Procedure ends here
• the child is over 3 years old and has a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the period of condition is temporary and expected to be present for less than 12 months:
• The care receiver does not medically qualify for CA, see Rejecting a Carer Allowance (CA) claim
• Procedure ends here
• the child has a recognised disability and/or recognised medical condition listed in Question 7 and/or Question 8 and the THP has indicated they are uncertain if period of condition is temporary and expected to be present for less than 12 months and/or the child is under 3 years
• Place the claim on hold. Use the Hold to User function
• Go to Step 8

Refer the case to the Level 2 Policy Helpdesk for advice and include the following information:

• carer’s CRN
• claim ID
• medical condition/disability the child has been diagnosed with, listed in Question 7 and /or Question 8, and
• any relevant details of the discussion with the THP

If they advise the condition is:

• permanent or temporary for at least 12 months:
• record a DOC with confirmation information
• the Level 2 Policy Helpdesk will also advise if CA must be manually reviewed in the future
• go to Step 10
• less than 12 months:
• record a DOC with this information. To record this, follow the process in Step 4 (Verbal information) in the Processing an incomplete or incorrect claim table
• the carer does not medically qualify for CA, see Rejecting a Carer Allowance (CA) claim
• procedure ends here

The carer of a child who does not have a recognised disability or recognised medical condition may qualify for CA (child) if the child receives a rating of ‘intense’ under the Disability Care Load Assessment (DCLAD) (2020).

Assessing a recognised disability process ends here. Follow the process in Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).

Procedure ends here.

A child with a recognised disability:

• medically qualifies for CA (child), and
• is not required to provide:
• a Care Needs Assessment
• an assessment under the Disability Care Load Assessment (DCLAD) (2020)

Assessing a recognised disability process ends here. Follow the process in Processing claims for Carer Payment (CP) and/or Carer Allowance (CA).