Rejecting a claim for Commonwealth Seniors Health Card (CSHC) 065-06030040

A customer who has lodged a claim for CSHC will not be eligible for a CSHC if they do not meet the basic qualification or means test provisions for CSHC or if they may have failed to comply with a customer obligation. In these circumstances, claims must be rejected.

Note: Online claims submitted prior to 13 October 2018 and all paper claims are not subject to Circumstance Change Monitor (CCM) rules.

Some rejection reasons can be coded manually and others will be automatic. Automatic rejections will occur when all of the customer's information is updated on the correct screens and the new claim is processed.

Customers are required to provide documentation to support the information declared in a CSHC claim. Online claims provide the customer details of outstanding tasks and documentation requirements for the claim.

Additional documentation is sometimes requested after the claim has been submitted. Customers are required to provide information/documentation in the allowable timeframe as requested in writing.

Reject claims 'Failed to Supply Documents (FSD)' or ‘Failed to Reply to Correspondence (FRC)’ if:

• documentation is not provided by the due date, or
• if the delegate determines the customer has provided inappropriate or irrelevant documentation

See Request to reassess a rejected claim.

All new CSHC claimants and their partners are required to provide a Tax File Number (TFN), or be granted a TFN exemption. If no TFN or exemption is provided then the CSHC claim will be rejected.

Customers who have provided an estimate of income for the current financial year, which is not an acceptable condition are to be rejected using reason ESR-Estimate Rejected.

Customers who are rejected due to an estimate of current year income being over the income limits cannot lodge another claim using Adjusted Taxable Income (ATI) from a previous financial year. Customer must provide a revised estimate for the current financial year and details of why their estimate has changed. Service Officers are not obliged to accept a revised estimate if reasons and amount of reduction do not seem reasonable.

When coding a claim for CSHC the correct relationship status must be coded for customers so that any future entitlements of quarterly supplement will be paid at the correct rate (partnered or single).

When an unfavourable decision is to be made, such as a rejection, a Decision Maker (DM) must provide the customer with an explanation of the decision and an opportunity to provide more details or evidence relevant to the decision. The DM must also advise the customer of their review and appeal rights.

If a DM is not speaking with a customer at the time of making a decision, they are required to make 2 attempts to contact the customer prior to finalising an unfavourable decision. The contact attempts can be made at different times on the same day, where possible. A pre call SMS should be sent before making the contact attempt, where possible.