Patient claims processing in Medicare 011-43010000

A patient claim is a claim submitted for the payment of a Medicare benefit after a medical service is provided to the patient.

The Medicare benefit is paid to the person who incurred the cost (has fully paid the account/invoice) and is known as the claimant.

If the account/invoice is unpaid or partially paid, the benefit is paid to the health professional by cheque (Pay Doctor via Claimant (PDVC)).

The patient and claimant do not have to be the same person or be on the same Medicare card.

Customer contacts Services Australia (the agency)

When a customer contacts the agency by phone about their claim, suitably skilled Service Officers must attempt first contact resolution.

Note: Service Officers must not process Medicare online account (MOA) claims on the same day they are lodged (day zero) if the total Medicare benefit amount of the claim is greater than or equal to $100.

If the customer is in financial hardship and insisting the claim is paid on day zero, Service Officers must call the clinic to confirm the account/invoice is valid. See Suspected Medicare fraud and Business Integrity (BI) flags.

Service Officers not skilled in this work type must escalate to Medicare and Aged Care Local Peer Support (LPS) for help.

Patient and claimant

The difference between a patient and a claimant:

• Patient - the person who received a medical service. Note: the patient is identified on the health professional's invoice
• Claimant - the person who incurred, or is liable for, the costs associated with the medical service

The claimant:

• is entitled to the Medicare benefit because they have paid for the service provided to themselves or another person
• may be a business or organisation (for example, a sporting body) that is entitled to the Medicare benefit if they have incurred the cost on behalf of the patient. The Process page contains details on how to process a claim for a business or organisation

An organisation funded for the provisions of medical services under section 19(2) of the Health Insurance Act 1973 is unable to claim a Medicare benefit.

Medicare benefits for patient claims can be submitted by:

• post
• in person at a service centre
• digitally
• phone
• using an Access Point

Medicare benefits can be paid by:

• Electronic Funds Transfer (EFT) for fully paid accounts
• At point of service, credit EFTPOS via Medicare Easyclaim using a debit card
• PDVC cheque

If claims are lodged digitally via self-service channels, the patient must be on the same Medicare card as the claimant.

Progress of Medicare claim lodged

Service Officers must:

• confirm receipt of the claim and status (received/paid/rejected), when the claimant enquires about the progress of a patient claim lodged in the relevant timeframe
• not process the claim. Tell the claimant the agency will assess and pay any Medicare benefit owing as quickly as possible

The Process page contains information about the process to follow if a customer indicates they are in financial hardship.

Customers can view the status of their recent Medicare claims online using their:

• Medicare online account, or
• Express Plus Medicare mobile app

Services Officers must tell customers about this option when they get enquiries about the progress of an online patient claim.

See Track Medicare claims online for more details.

The Resources page contains a link to the Services Australia website with the relevant timeframe for claiming a Medicare benefit.

If the claim was received outside the relevant timeframe:

• via online or through the App, see Enquiries received via telephone for digital self service claims
• by mail or at a service centre, process the claim, see the Process page

Manual EFT payment

Manual EFT payments are needed for:

• Safety Net payments for outpatients with individual charges over $9,999.99
• Safety Net partial payments
• Stale Safety Net cheques
• Stale cheques that cannot be processed on the system
• Stop on a cheque but BILI control line is not actioned and cheque goes stale
• Patient claims late lodgement over 7 years
• Cheques manually cancelled by finance operator number 08448

All manual EFT payment requests are prepared by Medicare Provider Services (MPS) and actioned by Accounting Operations.

The Process page contains information on how to request a manual EFT payment for MPS Service Officers.

Same Day Delete

Where a claim has been identified as submitted/ processed incorrectly, an adjustment can be performed/ requested on the same day as the claim was processed. This is limited to certain claiming channels.

See Delete electronic Medicare claims for eBusiness Service Centre for more details.

A statement of benefit provides customers with a summary of their claims and the total Medicare benefits paid. It can be printed in service centres or can be a system generated receipt. It is also confirmation of payment.

Service Officers must only issue a statement of benefit when processing claims. This applies to all Medicare claiming channels.

If a claimant or patient requests a duplicate statement of benefit, Service Officers must make sure the statement is issued only to the claimant or patient for that service.

Note: Service Officers must be aware when:

• a transfer of history has occurred. Details about the original patient must not to be included on the manual statement
• Medicare Online Account (MOA) claims are rejected using RSN 151. These lines are removed from the manual statement of benefit as they are deemed as a separate claim

Statement of benefits for accounts/invoices processed via Simplified Billing

A duplicate statement of benefit cannot be issued to the patient if the service was billed to Medicare via the Simplified Billing channel.

These statements can only be issued to the relevant health fund or billing agent that lodged the claim with Medicare.

If a health fund or billing agent is requesting a statement of benefit see, Statement of benefit for Simplified Billing in Medicare.

Manual statement of benefit

A manual statement of benefit letter (Z2261) is manually completed by Service Officers and can be issued to customers for claims with:

• a service date over 7 years
• adjustments that cannot be actioned in mainframe or result in an overpayment
• Safety Net adjustments
• Safety Net payments for claims over $9,999.99
• manual payments

A requested manual statement of benefit letter is addressed to the claimant.

The letter contains a field where the applicable reason code is entered.

See Indicators, codes, modifiers and control lines for claims processing in Medicare for more details on reason codes.

If the manual statement of benefit is for an adjustment of any type, then place details from the previous assessment lines with RSN 888 and the revised adjusted lines.

A manual statement of benefit must be issued for an inpatient service. If eligible, the claimant can forward this statement to their private health fund to claim more gap benefits.

Service Officers:

• can issue a statement of benefit to the claimant where outstanding overpayments are recorded on the patient's history related to this service
• must not withhold the statement until the overpayment has been repaid, or contact debt recovery to enquire on the status of the overpayment

See Account and receipt documents for Medicare claims processing for more details.

The account/invoice is the main document when processing patient claims. It contains the essential details that allow a Medicare benefit to be paid.

For a claim to be processed, the account/invoice and/or the receipt must be provided as evidence. The account/invoice can be:

• paid or partially paid (confirmation of payment must be included either by receipt or noted on the account/invoice), or
• unpaid (only the account/invoice is needed)

The details supplied on the account/invoice or receipt should be used to uniquely identify both the patient and the claimant.

If a customer completes the Organ donor registration section on the Medicare claim form (MS014), see Register a new organ donor in the Australian Organ Donor Register (AODR) for steps to register their decision.

Following the Australian Government announcement in the 2015-16 Budget, payment of Medicare benefits to claimants by cheque stopped from 1 July 2016. Pay Doctor via Claimant (PDVC) cheques will continue as these are legislated in the Health Insurance Act 1973.

Payment of benefits for paid accounts/invoices are deposited into the claimant’s nominated bank account. For a processed claim where the claimant has not provided a bank account, the payment for the claim will be held until EFT details have been provided.

If a claim is processed at a service centre and the account/invoice is paid in full or via phone claiming, the claimant does not need to complete and sign a claim form.

See Patient claims requirements for payment of Medicare benefits.

Held EFT payments for children under 14 years of age (health professional error)

Medicare benefits are held if:

• a health professional selects a child under 14 years of age as the claimant
• submits a claim online, and
• no EFT details are recorded

The Service Officer must decide who the correct claimant is.

If a customer (other than the child) contacts Medicare and claims to be the claimant, the Service Officer must decide if:

• the customer is the actual claimant, and
• the health professional has transmitted the child as the claimant incorrectly

To decide if the customer is the claimant, the Service Officer must complete a security check and ask the customer the following questions:

• what was the date of service
• who was the health professional
• how much was paid for the service

If the customer successfully answers these questions, the claim should be adjusted to reflect the correct claimant.

Unpaid or partially paid accounts/invoices

Medicare benefits for unpaid or partially paid accounts/invoices can only be paid by cheque. For claims that are not submitted online, the claimant must present both:

• the account/invoice or receipt
• a completed and signed Medicare Claim form (MS014)

Medicare benefits for unpaid or partially paid accounts/invoices are paid:

• via a computer-generated PDVC cheque
• in favour of the health professional who is entitled to the Medicare benefit

The PDVC cheque is posted:

• to the claimant using the address:
• on the claimant’s record, or
• on the claim form (when the claimant nominates a temporary address)
• with 2 Statements of Benefit for both the claimant and the health professional

The claimant must forward to the health professional:

• the PDVC cheque and a copy of the Statement of Benefit
• the balance of the account/invoice, if applicable

When the account has been fully paid, the account/invoice receipt can be presented at a service centre as evidence. The claim can then be substantiated and will accumulate towards the Medicare Safety Net threshold for all out-of-hospital services.

See Verify services for Medicare Safety Net.

These requirements cannot be varied as they are legislated in the Health Insurance Act 1973, Section 20(2).

See 90 Day Pay Doctor Cheque Scheme.

A permanent address change may be actioned:

• during claims processing by Medicare Claim form (MS014)
• during telephone claiming, or
• in person at a Medicare Service Centre

If the claim is later reversed, the amended address must not be reversed with the claim.

The claimant's address must remain updated in CDMS.

There is a minimum turn-around time for Medicare benefits to be paid. These minimum payment times vary according to the claim type and relate to the number of days (including weekends) the benefit is held by the agency.

Customers should not be penalised when the Medicare system mainframe is not available in service centres.

Service Officers should tell customers that the system is down and they can either:

• fill in a Medicare Claim form (MS014) and the claim will be processed as soon as the system is available into their nominated back account by electronic funds transfer (EFT)
• lodge the claim through their Medicare Online Account via myGov or on the Express Plus Medicare mobile app

Medicare benefits for fully paid accounts/invoices can only be paid by EFT with funds deposited into a nominated bank account.

Payment for the claim will be held until EFT details have been provided where the claimant:

• does not have valid EFT details stored in the CDMS, or
• cannot provide valid temporary or permanent EFT details at the time the claim is submitted

See Standards for helping customers complete claims and forms.

The Process page contains a table outlining the situations and the action needed when patient claims submitted for payment are over 2 years old from the date of service.

Contact Medicare Customer Local Peer Support (LPS) for help with processing a patient claim when:

• claim is received via the PaNDA work tool
• claimant has an RHCA entitlement, and
• has already left the country

Processing radiation oncology can be complex. Service Officer must take extra care when processing these accounts.

Service Officer must check the patient account/invoice and/or transmitted claims have all the relevant details provided, to assess the claim according to legislation.

If any errors are keyed during the processing:

• an incorrect benefit is paid, and
• a latter day adjustment is needed

Only experienced Service Officers can process radiation oncology claims. If a Service Officer is not skilled to process radiation oncology claims:

• proficiency raise the claim in PaNDA, and/or
• escalate to the Claims interpreter (CI) queue

See Processing radiation oncology.