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

Confirm the identity of the caller by performing a security check.

Does the caller pass the security check?

• Yes, go to Step 2
• No, end the call. Procedure ends here

Note: the customer can review the MBS online for basic claims information or attend a service centre.

Make sure that the person making the enquiry is the person the estimate is for.

The only exception is where the estimate is for a child under 14 years of age and the enquirer is the child's parent or guardian, or the person making the enquiry holds legal authority for the patient.

Determine if the patient is eligible for Medicare and is currently enrolled by using the patient's Medicare number.

Tell the caller that:

• this is an estimate only and is for the item numbers quoted at the time of the call
• Medicare Safety Net benefits are not considered in estimate calculations, nor can they be estimated

Read the disclaimer to the caller.

Disclaimer: This is an estimate only. Services Australia has calculated this benefit estimate based on the information provided at the time of the call without sighting documents. Restrictions, endorsements and other medical services not included in this estimate that may affect the final benefit have not been taken into consideration in calculating this estimate.

Take a screen shot of the pro forma claim and notate the patient's (or parent/guardian's) name and phone number.

Note:

• the claim must not be paid (processed)
• Do not override any restrictions that may present

If the customer requests a:

• written estimate, go to Step 6
• verbal estimate, go to Step 7

Tell the caller they will receive a letter to confirm the estimate.

To complete the letter:

• Complete and save a copy of the Telephone Medicare rebate estimate form. The Resources page contains a link
• Access the Estimate of Medicare benefits payable for medical services letter (see the Resources page for a link) and complete the details from the Telephone Medicare rebate estimate form or pro forma claim
• Save a copy of the letter - save the document to the 'Customer Information' folder located on the team's shared drive. Customer information must not be saved to desktops or personal H drives
• See Preparing, quality and peer to peer checking of Medicare external mail for preparing outgoing correspondence and letter checking processes

Note: the CDMS comment must include the following, ‘Estimate Letter issued for item/s 12345H and 12345H, total benefit $756.30'.

Contact a Local Peer Support (LPS) to check the pro forma claim for accuracy.

• Once confirmed provide the estimate amount verbally to the caller
• Leave a comment in CDMS Personal advising that a verbal Estimate of Medicare benefits payable was provided and the logon of the LPS who gave permission for verbal release, the item numbers used and the amount estimated. For example, 'verbal estimate provided for item/s 12345H and 12345H, total benefit $756.30. Approved by P12345'

Note: if after receiving a verbal estimate the customer states they do not require an Estimate of Medicare benefits payable for medical services letter, one does not need to be sent, but comments must be recorded in CDMS.