Patient Claims quality checking processing 111-22090020
This page contains information about the error status codes (including the non-error code), attachments and intranet links.
Status code categories
Table 1: this table lists the categories of status codes for patient claims quality checking.
Category |
Displayed in QCS as… |
Error-free |
OK |
Document status codes |
ADM |
Processing status codes |
PRO |
Referred for further attention |
REF |
Error-free status code
Table 2: this table lists the error free status code for manual and online patient claims quality checking.
Error-free status code |
Definition |
Processing Tip |
001 |
Error-free |
Quality check did not detect errors |
Document error status codes
Table 3: this table lists the document error status codes for patient claims quality checking.
Note: the following processing tips apply to all channels unless otherwise stated.
Error status codes |
Definition |
Processing tip |
100 |
Address change not notated, or the address section of the claim form not completed. |
Claim form It is an error when the address section of the claim form is partially complete and there is no notation of a confirmed address. It is an error when an address change has not been notated. |
101 |
Claim form not attached to supporting documentation or account not endorsed by claimant. |
Claim form It is an error when:
Telephone claiming It is an error when the account/receipt for claims received via the telephone are not endorsed by the claimant and no contact was made by the Service Officer. Note: Access Point (MAAP) As there is no paperwork to check against any claims selected for quality checking, these are currently being entered 001 (error-free) on the QBBI screen. |
102 |
Agent's authority section of claim form not completed in full. |
It is an error when the Agent's Authority Section has not been fully completed and is not detected by the Service Officer. |
104 |
S4B (3) item paid without the delegate's approval. |
It is an error when a delegate's approval is not endorsed on the documentation for payment of an item under the S4B (3) rule and it is not detected by Service Officer. |
105 |
Patient's/Claimant's Medicare card number cannot be uniquely identified from details supplied. |
It is an error when the source documents do not have sufficient information to uniquely identify the patient's or claimant's Medicare card number, and no contact was made by Service Officer. |
106 |
No evidence of confirmation of service or claim details recorded. |
It is an error when the Service Officer failed to record details of confirmation to support action taken. |
110 |
Claimant's signature omitted or mismatched to claimant details. |
It is an error when:
Note: it is not an error if the claimant details have been verified and there is a VG4 form to support action taken. Claimants can use any type of symbol as their signature, for example, X. Claims should only be returned where there is a difference in names. |
111 |
Inappropriate/insufficient documentation to support payment. |
It is an error when:
|
118 |
Statement of Benefit not attached to supporting documentation. |
It is an error when a:
|
199 |
More than four document errors. |
When four document errors are detected, key all four error codes. When more than four document errors are detected, key the first three error codes followed by error code 199. When more than four errors are made and there is a combination of processing and document errors, use 299 as the fourth error code. |
Processing error status codes
Table 4: this table lists the processing error status codes for patient claims quality checking.
Error status codes |
Definition |
Processing tip |
200 |
Patient keyed or selected incorrectly. |
It is an error when the patient details on claims history does not match the supporting documents. |
201 |
Item keyed incorrectly. |
Manual It is an error when the:
Online It is an error when a Service Officer has inserted or copied a line and keyed the item number incorrectly. |
202 |
Date of service keyed incorrectly. |
Manual It is an error when the date of service does not match supporting documents. Online It is an error when a Service Officer has inserted or copied a line and keyed the date of service incorrectly. |
204 |
Charge keyed incorrectly. |
It is an error when:
Note: it is not considered a 204 error when an account or receipt indicates that a notional charge should have been keyed. Refer to error code 211. |
205 |
Item paid incorrectly as outpatient. |
It is an error when an ‘H’ suffix has not been keyed at the end of the relevant item numbers and there is indication of the service being performed in hospital. |
206 |
Incorrect processing indicator (PI) keyed. |
Manual and online It is an error when the incorrect PI has been keyed. Note: only the highest PI code used is stored by the system. |
207 |
Reason code not keyed, keyed incorrectly or keyed when not required. |
Manual and online It is an error when a reason code is
Note: it is not an error when the system has automatically inserted a reason code. |
208 |
Medicare card number for claimant or patient keyed incorrectly or consumer ID for claimant keyed incorrectly. |
It is an error when the:
has been keyed incorrectly. Note: when both fields are in error this would be considered one error for quality checking purposes. |
209 |
LSPN keyed incorrectly. |
It is an error when the Location Specific Practice Number (LSPN) for a diagnostic or oncology item does not match:
|
210 |
Service provider keyed incorrectly. |
It is an error when the service provider keyed or selected does not match supporting documents. |
211 |
Notional charge not applied or applied incorrectly. |
It is an error when a notional charge has:
Note: when a Service Officer has applied a notional charge, reason code 113 will be displayed on the patient's history in the RSN field. When a system generated notional charge has been applied reason code 241 or 242 will be displayed on the patient's history in the RSN field. |
212 |
Text transmitted not actioned appropriately. |
It is an error when the transmitted text was not acknowledged, and the Service Officer did not action the claim appropriately as per the business rules. |
213 |
Telephone claim paid incorrectly. |
It is an error when a telephone claim has been paid without following the business rules in Operational Blueprint. |
214 |
Items not keyed. |
It is an error when one or more items on supporting documents have not been keyed. |
215 |
SCP keyed incorrectly. |
It is an error when the Specimen Collection Point (SCP) for a pathology item does not match:
|
216 |
Radiation oncology fields not keyed or keyed incorrectly. |
It is an error when:
|
217 |
Over 2-year-old claim paid incorrectly. |
It is an error when:
|
218 |
PAYP line not keyed or keyed incorrectly. |
It is an error when the:
Note: PAYP line must only be keyed where 'Locum' or 'LT' is indicated on the supporting documents. |
220 |
Miscellaneous line keyed. |
It is an error when a miscellaneous line is keyed, and the charge is not greater than $9,999.99. Note: this error code does not apply to online claiming. |
221 |
Incorrect or inappropriate manual calculation of schedule fee. |
Manual and online It is an error when:
|
Processing error status codes (continued)
Table 5: this table lists the processing error status codes for patient claims quality checking.
Error status codes |
Definition |
Processing tip |
224 |
Provider location keyed or selected incorrectly. |
It is an error when the provider location keyed or selected does not match supporting documentation. |
228 |
Address not changed or changed incorrectly. |
It is an error when the:
|
229 |
Restrictive item paid incorrectly. |
Manual and online It is an error when a restriction has been overridden without supporting documents. Note: it is not an error when the rooms have transmitted a NNAC override, and the system has automatically inserted a PI 44. |
232 |
Cancel and re-issue cheque issue |
It is an error when the request for the cancellation of a Medicare cheque was:
|
233 |
EFT paid inappropriately. |
It is an error when an EFT:
|
235 |
Cheque paid to provider on paid account. |
It is an error when a benefit was paid via cheque to the provider and an account has been paid. |
238 |
Item paid incorrectly as inpatient. |
It is an error when an 'H' suffix has been keyed at the end of an item number and there is no indication of the service being performed in hospital. |
239 |
Referral details (SR and AH) keyed incorrectly. |
It is an error when the referral details (FST DT, LST DT, Provider number, sub/con) are keyed incorrectly. It is also an error when referral details keyed when not listed on account/receipt and no comments in PaNDA/CDMS to substantiate this action. Note:
|
240 |
Diagnostic request details (DI) keyed incorrectly. |
It is an error when the diagnostic request details keyed do not match supporting documents. |
241 |
Pathology request details (PA) keyed incorrectly. |
It is an error when the pathology request details keyed do not match supporting documents. |
242 Non-critical Errors must:
|
ACRF details keyed incorrectly. |
It is an error when the ACRF details keyed are not identifiable on supporting documents. Note: when ACRF is requested and there is no information on supporting documents, the Service Officer should key '0' or 'No'. |
245 |
Claimant’s name or claimant's reference number keyed or selected incorrectly. |
It is an error when the claimant keyed or claimant selected does not match supporting documents. |
247 |
Service verified inappropriately or has not been verified. |
It is an error when:
Note: verified also refers to recording of gaps and partial payments. |
248 |
Verified amount incorrect. |
It is an error when the:
Note: verified also refers to recording of gaps and recording of partial payments. |
249 |
Additional item lines keyed without justification. |
It is an error if additional lines have been keyed without justification. Note: it is not an error when additional lines have been keyed in accordance with business rules. |
250 |
Item lines rejected in error. |
It is an error when item lines have been rejected when not in accordance with business rules. |
253 |
EFT details keyed or stored incorrectly. |
It is an error when the claimant’s EFT details keyed and/or stored do not match supporting documents, this includes:
Note:
|
299 |
More than four processing errors. |
When four processing errors are detected, key all four error codes in the status value available. When more than four processing errors are detected, key the first three errors with applicable code followed by error code 299 in the fourth field. When more than four errors are made, and there is a combination of processing and document errors, use 299 as the fourth error. |
310 |
Two-way claim form not transmitted/transmitted incorrectly. |
It is an error when the Medicare Two-way claim has not been processed or transmitted correctly. |
311 |
Work item not actioned completely. |
It is an error if a work item:
|
312 |
AODR not actioned in patient claim form. |
It is an error if AODR claim form is:
|
313 Noncritical Errors must:
|
Comments not keyed when appropriate or completed inappropriately. |
It is an error when comments are not keyed in PaNDA/CDMS as per the business rules. |
314 |
Claim adjustment completed incorrectly. |
It is an error when adjustment:
|
315 |
Letter created contains errors. |
It is an error when it has customer privacy implications. Refer the non-critical error code if it does not impact on customer privacy. |
316 Noncritical Errors must:
|
Letter created contains minor errors. |
It is an error when it does not impact on customer privacy. |
Referral error status codes
Table 6: this table lists the referral error status codes for patient claims quality checking.
Error status codes |
Definition |
Processing tip |
301 |
Photocopied or altered documents not certified. |
It is an error when:
Note: this may require referral to National Compliance Operations. |
302 |
No documents to support payment. |
It is an error when:
Note: this may require referral to National Compliance Operations. |
Attachments
Do not share these attachments externally. See Freedom of Information - Information Publication Scheme.
Guide to completing the online Error Explanation Sheet
The Quality Control System (QCS) for Medicare
Contact details
Health Service Delivery Division – Quality, Performance and Technical Support
Medicare National Portfolio - Face to Face