Providing Medicare benefit estimates via the Medicare General enquiries line 011-42020010

Service Officers must confirm the identity of the caller by performing a security check before answering any enquiries.

If a customer contacts Services Australia asking for an estimate on a Medicare benefit, Service Officers must follow the procedure outlined within this document.

Note:

• estimates can only be provided for unprocessed accounts
• any potential Medicare Safety Net benefits must not be included when providing estimates

Pro forma claim

To obtain an estimate, an unprocessed pro forma claim is entered into the system and assessed based on the item numbers the caller has provided. The pro forma claim must not be paid (processed). Service Officers must cancel the claim by pressing [F12].

Service Officers must never provide estimates to a caller who passes the security check without first entering a pro forma claim into the system.

There are a number of factors to be considered when a Medicare claim is being assessed, sometimes these cannot be considered at the time the estimate is provided. For example:

• patient's history has been updated since the estimate was provided
• restrictive items
• composite items
• multiple operations
• maximum services already paid
• different date of service - the Medicare Benefits Schedule (MBS) fee for the item may have changed or the item may have been deleted
• items charged may have been altered
• some services do not attract a Medicare benefit

Providing estimates for anaesthetic services is difficult as the appropriate time unit item would be unknown prior to surgery. Service Officers should tell customers that due to time dependencies, estimates cannot be provided for anaesthetic services.

The online Medicare Benefits Schedule (MBS) contains a listing of the Medicare services subsidised by the Australian Government. Customers can search MBS Online to get an estimate on the Department of Health and Aged Care website. The Resources page contains a link.