Assessing Disability Support Pension (DSP) claims 008-03030000

For information about how to help customers or their correspondence nominees claim Disability Support Pension and what to do upon receipt of a paper claim or documentation, see Claiming Disability Support Pension.

When an online or Assisted Customer Claim (ACC) is submitted, a Disability Support Pension claim Work Item is created in Process Direct that contains the claim information. The claim is reviewed and processed in Process Direct.

When a paper claim is scanned to the customer's record, a SOA shell Work Item is created in Process Direct. Claim information is entered manually in Process Direct before the claim is processed.

At the lodgement of a DSP new claim customers may identify or provide evidence of having a potential terminal illness (life expectancy is less than 2 years). If so, the claim must be prioritised for a Medical Assessment (MAt). To escalate, see Prioritising Disability Support Pension (DSP) claims for terminally ill customers.

The Verification of Terminal Illness form (SA495) form may be supplied. This can be completed by the customer's treating doctor where the customer does not have medical evidence showing the diagnosis and prognosis of their condition. This form:

• is automatically issued with a Claim for Disability Support Pension for a Terminal Illness form (SA494), or
• can be accessed by the treating doctor through the Services Australia website

The Resources page has a link to forms.

The medical evidence required to support a DSP claim depends on the customer's circumstances. New claimants are required to supply medical records such as clinical notes, test results and specialist reports to support their claim. The Medical Evidence Requirements (SA473) form is available to assist customers to determine suitable medical evidence. The Resources page has a link to the form.

If the customer does not submit any medical evidence their claim may be rejected. See Streaming a new claim for DSP.

When accepting medical evidence from customers, check if the medical evidence suggests they may meet DSP manifest eligibility.

Scanning of medical documentation can occur at a Service Centre or as part of an Assessment Services appointment. See Scanning Centrelink medical/sensitive documents using an MFD.

See also, What is medical evidence for DSP?

Assessors from Assessment Services are responsible for checking and assessing all medical evidence and providing a DSP Medical Eligibility Assessment Recommendation (SA479) for Disability Processing Service Officers.

The Assessor will make attempts to obtain medical evidence if the claim is submitted without evidence and they consider the customer is likely manifestly medically eligible or vulnerable.

Contributing Assessors may be used to provide discipline specific input to the assessment.

An assessment of Continuing Inability to Work (CITW) is completed in the DSP Medical Eligibility Assessment Recommendation (SA479) if manifest medical eligibility or medical eligibility within a current and valid JCA is recommended.

Once the Assessor has submitted the MAt recommendation, the DSP claim comes off hold and is assessed through a streaming process. The streaming process determines if the claim can be manifestly granted, manifestly rejected, or requires a referral for a Job Capacity Assessment (JCA). It also identifies if there is any outstanding information required to process the claim. See Streaming a new claim for DSP.

A JCA is an important step in the medical assessment process. It is generally not required when it is clear from available evidence the customer is manifestly eligible or ineligible for DSP.

A claim may be manifestly:

• rejected on non-medical grounds, such as where the customer does not meet age, residence or income/assets criteria
• rejected on medical grounds, such as where medical evidence shows the customer's condition is clearly temporary
• granted where the customer meets the non-medical eligibility criteria and the MAt recommends the customer meets specific manifest medical eligibility criteria, such as having a terminal illness, or requiring nursing home level care

In these cases, the claim is determined without a JCA or Disability Medical Assessment (DMA).

The MAt may recommend a JCA is required to assess the claimant's medical conditions under the Impairment Tables, and to determine if they have a Continuing Inability to Work (CITW).

If a JCA is required, a referral request is sent to the Assessment Services Branch (ASB). ASB are then responsible for contacting the customer and advising of the JCA details including appointment time, location and format.

If a JCA report recommends likely medical eligibility for DSP, and the customer has met the non-medical eligibility criteria, the customer will be referred to a Government-contracted doctor (GCD) for a DMA before their claim is determined. See DMA referrals.

How the claim is assessed once the Job Capacity Assessment (JCA) report is submitted, depends on whether the JCA report indicates:

• medical ineligibility
• manifest grant or reject recommendation
• potential medical eligibility

If medical ineligibility is determined, the claim is finalised and DSP is rejected.

If manifest grant/rejection recommendation is determined, the claim is finalised as DSP is manifestly granted or rejected.

If potential eligibility is indicated, and the customer has met the non-medical eligibility criteria, they are referred to a GCD for a DMA to confirm medical eligibility.

The possible outcomes from a Disability Medical Assessment (DMA) report are:

• Manifestly eligible, for example, requires nursing home level care
• Eligible under the Impairment Tables with:
• the same outcome as the JCA report
• minor changes to medical condition/s and impairment rating/s, when compared with the JCA report
• major changes to medical condition/s and the impairment rating/s, when compared with the JCA report. For claims, this may need more assessment of Program of Support (POS), and/or work capacity
• Not eligible under the Impairment Tables, or
• Considered not eligible because the customer either:
• could not be contacted
• did not attend the DMA appointment, or
• failed to participate in the DMA

For more information, see Assessing a new claim for DSP after a DMA.

When the DSP claim is finalised the customer is contacted by phone and/or letter and advised of the claim outcome.