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

Is the rejection reason for the Commonwealth Seniors Health Card (CSHC) any of the following?

• departure/absence overseas permanently
• departure/absence overseas temporary (more than 13 weeks)
• does not meet the age requirements
• estimate income too high
• excess income
• has not yet served the newly arrived resident's waiting period (NARWP)
• not residentially qualified
• Identity Confirmation not provided for customer
• whereabouts unknown
• CSHC current already
• customer has not supplied their Tax File Number (TFN)
• customer has not supplied their partner's TFN
• customer has not supplied both their and their partner's TFN
• customer in receipt of a Social Security pension or benefit, Department of Veterans' Affairs (DVA) Service Pension, DVA Age Pension, Veteran Payment, Income Support Supplement (ISS) or a DVA CSHC

Note: early claim provisions do not apply to the CSHC. If the person is not qualified for CSHC from the date of claim lodgement the claim must be rejected. Under no circumstances should the start date on the SHC Assessment (SHA) screen be manually altered to a date after the determined start date.

• Yes, the claim will automatically reject for the correct reason when the CSHC claim is coded end to end. Before finalising the rejection action, contact the customer to explain the decision:
• See Calling a customer or returning a customer's call and where applicable, send a pre-call SMS
• make 2 attempts to contact, at different times on the same day where possible. Go to Step 7
• No, the claim will require manual rejection via the Benefit Action (BA) screen
  Note: if the claim is a combined claim, the BA screen may need to be coded for both customer and partner claims. Combined claims may have a different eligibility outcome, as one may be granted and the other rejected.
• to streamline reject, go to Step 2
• to manually reject, go to Step 4

Where the customer has not provided all requested documents their claim can be rejected Fail to Provide Documents (FSD)  using the Streamline Rejection function. Other rejections must be completed using the manual rejection process in Step 4.

Where the customer has intentionally provided inappropriate documentation to allow their claim to be submitted under Circumstance Change Monitor (CCM). For example, non-claim related documents or images, reject the claim FSD with no request for information or documentation requests to be issued.

Under Circumstance Change Monitor (CCM), where it is clear the customer has not provided the Required Documents requested, the claim should be rejected FSD.

It is important to note that when a Streamline rejection is processed, NO updates are made to the customers' record (i.e. income, assets, residency, etc.).

• Streamline Rejection allows the user to bypass errors for faster processing of rejected claims (e.g. FSD)
• In order to undo a streamline rejection the claim must be regenerated from the TS screen
• No data is uploaded into ISIS for streamline rejects

Go to Step 3.

To complete a Streamline Rejection:

• From the  Transaction Summary Page (TS)
• Select Process  
• Go to the  Benefit Action  screen by typing 'BA' in the  Super Key  field
• Select  Add New
• The  Create Benefit Action  popup screen is presented
• Enter:
• Benefit Type:  SHC
• Benefit Action:  REJ - Reject
• Reason:  FSD
• Date of Effect: only change if the pre-populated date is incorrect
• Streamline Rejection -  Tick the Indicator box
• Select  Save
• Update the region office code, residence information, personal and contact details in the claim activity.  Note:  these updates must be actioned after selecting Streamline Rejection on the Benefit Action (BA) screen
• Use the  Super Key  to go back to the Errors (SWE) screen
• Check the  SWE  screen for any errors or warnings due to coding updates. Go to the appropriate screens and resolve the errors and warnings
• Select  Assess
• The Entitlement (ELD) screen displays
• Check the outcome is correct

Go to Step 7.

To complete a Manual Rejection:

• Make all necessary updates required within the claim
• Before finalising the claim, delete all provisional data that requires verification so the data is not applied to the customer record
• From the  Transaction Summary Page (TS)  go to the  Benefit Action  screen by typing 'BA' in the  Super Key
• Select  Add New
• The  Create Benefit Action  popup screen presents
• Enter
• Benefit Type:  SHC
• Benefit Action:  REJ – Reject
• Reason: select appropriate reason.  See  Cancellation and rejection codes for Commonwealth Seniors Health Card (CSHC)
• Date of Effect: in most cases this is deemed date of claim or date of receipt, only change if the pre-populated date is incorrect
• Streamline Rejection: do not tick the indicator box
• Select  Save
• Use the  Super Key  to go back to the  Errors  (SWE) screen
• Check the  SWE  screen for any errors or warnings due to coding updates. Go to the appropriate screens and resolve the errors and warnings
• Select  Assess
• The Entitlement (ELD) screen displays
• Check the outcome is correct

Note:  for manual rejections, check region office code, residence information, personal and contact details in the claim activity are correct. This ensures the notice of rejection issues to the correct address. For rejection reasons 'Failure to Supply Documents (FSD)' or 'Failure to Reply to Correspondence (FRC)' no further customer contact is required. For all other rejection reasons, before finalising the rejection action contact the customer to explain the decision:

• see  Calling a customer or returning a customer's call  and where applicable, send a pre-call SMS
• make 2 attempts to contact, at different times on the same day where possible

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 gaps in Process Direct.

Prior  to utilising the Handover function, staff  must  refer to the  Using Digital Assistance Roxy in Process Direct  and the  Handover function  table for required actions.

Is a handover to Customer First or Customer Record required?

• Yes, to commence a handover, see the  Handover function  table. Once completed,  go to Step 6
• No,  go to Step 7

A claim is manually rejected as follows:

• Make all necessary updates required within the claim
• Code fields on the Benefit Action (BA) screen:
• Svc Rsn:  use 'SHC' for Senior Health Card
• Action:  use 'REJ' for rejection
• Reason:  use the appropriate reason code.  See  Cancellation and rejection codes for Commonwealth Seniors Health Card (CSHC)
• Effect Date:  in most cases this is the deemed date of claim or date of receipt. Only change if the pre-populated date is incorrect
• Press [Enter]
• Go to the Assessment Results (AR) screen
• Check the outcome is correct.

Note:  for manual rejections, check region office code, residence information, personal and contact details on the claim activity are correct. This ensures the notice of rejection issues to the correct address. For rejection reasons 'Failure to Supply Documents (FSD)' or 'Failure to Reply to Correspondence (FRC)' no further customer contact is required.

For all other rejection reasons, before finalising the rejection action contact the customer to explain the decision:

• See  Calling a customer or returning a customer's call  and where applicable, send a pre-call SMS
• Make 2 attempts to contact, at different times on the same day where possible

For claims rejected in Process Direct:

• Select  Finish  to finalise claim
• A finalisation  DOC  template displays with claim outcome
• Record information appropriate to the decision
• If the rejection reason is 'FSD/FRC' ensure  DOC  lists all documents not provided at the time of rejection
• Select Finalise

For claims processed in Customer First/Customer Record:

• Finalise the activity
• Select the  Fast Note. Select  Auto Text  option >  Concession Cards > Claims > Commonwealth Senior Card (CSHC) NCL Grant/Reject
• Record information appropriate to the decision
• If the rejection reason is: 'FSD/FRC' ensure  DOC  lists all documents not provided at the time of rejection

Follow-up actions in Process Direct for claims finalised in Customer Record and Customer First:

• Check claim status in Process Direct
• If claim status has not automatically set to Complete  upon finalisation of the claim:
• select the claim transaction and raise an Incident through Roxy
• choose option ‘No, the issue is blocking me’ so that claim is placed On Hold  for System Investigation/Issue
• retain the work item by using the Hold to User function in Work Optimiser
• Claim status will be set to Complete by ICT

If the customer is deceased, manual letter (Q999) must be issued to the:

• ‘Executor of the Estate’ (if known) address, or
• ‘Estate of the Late [customer’s name]’ at the deceased customer’s last known address

The  Resources  page contains an example of suitable text for these letters.

For other cases where no auto-reject letter is generated, issue manual letter Q134 (select the ‘undetermined’ option) to the customer, giving the reason(s) for rejecting the claim and advising their review and appeal rights.