Provider location details for health professionals in Medicare 012-42010020

Provider location details include:

• full provider number for the health professional at a specific location
• physical address and contact details at the location
  Note: If the locality exceeds 24 characters (including spaces), HPOS applications will show an error to the health professional. See Staff scripting in the Resources section to troubleshoot this.
• start and end dates (if applicable) of the location or the health professional's eligibility to access Medicare benefits for services rendered at the practice location
• location type (if applicable)
• location specific specialty codes (if applicable)
• provider service rules (if applicable)
• employment details
• organisation details
• bank account details

Note: health professionals using home locations may contact and request to use a PO Box as the location address. For information on requests to use alternative location addresses, see Provider number for health professionals in Medicare.

A health professional must have a provider number for each practice location. If the health professional moves to a new practice location, they must apply for a new provider number at that location.

Over-keying an address on an existing practice location is not permitted unless:

• the correct Australia Post address has been identified for that practice location
• there is or has been a keying error
• the location was issued in error and the provider number at the location has never been released or used
• the practice is relocating within the same physical address, that is, change of suites / rooms

3GA placements and 19AB exemptions are issued for a specific location and any changes to an address will have a flow-on impact. Also, some incentive payments are made based on the area or the address of a health professional’s provider number.

The following areas and programs depend on accurate address information in the Provider Directory System (PDS):

• practices registered under the Practice Incentive Program (PIP)
• 3GA placement approvals which are time and location specific
• 19AB exemptions which are time and location specific
• IBIS (data warehouse) team and Department of Health and Aged Care using PDS for statistical analysis. Note: this information is used in determining Distribution Priority Areas or Districts of Workforce numbers when issuing 19AB exemptions etc.
• old Medicare claims lodged for payment may be rejected where address details do not match
• pharmaceutical benefit claims may be rejected where the health professional's name and practice location do not match provider number details in the PDS

If there is no change to the physical location, for example, the council changes the suburb name, a new provider number is not issued and the address is updated in PDS.

Documentary evidence such as a council notice must be provided. If no evidence is supplied, or if uncertain about validity of request, escalate to Medicare and Aged Care - Local Peer Support (LPS) for a determination.

Note: if there is a current 3GA placement and/or 19AB exemption issued at the location, or if the provider number is an Urgent Care Clinic (UCC) or General Practitioner Respiratory Clinic (GPRC), escalate the request to a Programme Officer (PO) via Medicare and Aged Care - Local Peer Support (LPS) for a determination.

Important changes resulting from the Health Legislation Amendment (Improved Medicare Compliance and Other Measures) Act 2018 (the Act) took effect 1 July 2018. The Act amends the Health Insurance Act 1973. The amendment to legislation introduces the requirement for capturing organisation and banking details on the application for a provider number when the health professional intends to claim a Medicare benefit.

Shared Debt Recovery Scheme

The Act also introduced the Shared Debt Recovery Scheme (SDRS) on 1 July 2019. The Scheme allows the Commonwealth to hold both a practitioner (primary debtor) and another party (secondary debtor) responsible for repayment of compliance debts, arising as a result of incorrectly claiming Medicare benefits, through the making of a shared debt determination.

The Scheme was introduced because Medicare billing is often:

• delegated to non-practitioners
• administered through centralised billing areas, and
• can be influenced by organisational processes and policies

In some instances this has led to incorrect billing practices.

A provider number can only be closed at the request of the health professional through the following channels:

• HPOS
• A telephone call with the health professional
• An email from the health professional’s email address, as indicated on the health professional’s stem
• A signed written request
• An application form for a provider number for their health profession

Note: a delegate may close a provider number through HPOS.

When closing a provider number, use the date of the telephone call, or date of request lodgement as the end date. Requests for a future end date can only be accepted via an email request, a signed written request or indicated on the application form for a provider number. Provider locations cannot be closed retrospectively. This makes sure benefits can be paid for services provided before the health professional's request for closure. Service Officers need to make sure the health professional understands they will not be able to claim any Medicare benefits for services provided at that location in the future.

Service Officer should escalate the enquiry if suspicious that:

• closing a provider number may result in some claims or referrals not being paid
• the health professional may not be aware of the consequences of the closure
• the request may be related to a dispute or suspected fraud

Escalate the enquiry to Medicare and Aged Care - Local Peer Support (LPS) if more assistance is needed.

Service Officers can allocate a second provider number for the same health professional at the one location in the following circumstances:

• Health professionals working at a location covered under a section 19(2) or 19(5) Direction where the second provider number is used for afterhours services, generally an Aboriginal Community Controlled Health Service
• Additional provider number is for an approved Medicare Urgent Care Clinic (UCC), Priority Primary Care Centre (PPCC) or a Government funded General Practitioner Led Respiratory Clinic (GPRC)
• Specific services provided within certain specialties, for example, angiography, where the cardiologist provides both the surgical and radiological service, yet the radiology service is to be paid to the radiology practice
• A health professional working in separate, distinct suites or departments at the one street location
• Business name is different
• A different ABN has been supplied for the second provider number
• A second 3GA placement is received
• Where a medical centre is located within hospital facility/grounds

See the Process page for more details.

Some simplified billing agents prefer a health professional to have more than one provider number at a location to assist them in splitting payments. Services Australia will not allocate a second provider number for this purpose. Provider numbers are not allocated for account keeping purposes.

Claims transmitted electronically through Services Australia's electronic channels (Medclaims and online services) use a minor identification number. Only one provider number per minor identification number is permitted.

An automated system update calculates claiming activity for each open practice location on a fortnightly basis. The Resources page contains a table describing the indicators used.

A provider location identifier is a flag added to a provider number in PDS. The provider location identifier denotes the location falls under a section 19(2) or 19(5) Direction or a class exemption is applied to a medical practitioner subject to section 19AB. One or more location types can be selected when creating new provider number locations or updating existing provider number locations.

Provider number location identifier information is released to the Department of Health and Aged Care via the Provider File Release and is used for reporting purposes.

The Resources page contains a table of the location type identifiers and when they should be used.