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Patient claims processing in Medicare 011-43010000

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This document explains details about the lodgement and processing of claims for Medicare benefits.

On this page:

Process a Medicare patient claim

Process a Medicare patient claim where the claimant and patient are on different Medicare cards

Process a Medicare patient claim for a business or organisation

Process a claim for customers experiencing financial hardship

Process a Reciprocal Health Care Agreements (RHCA) claim when claimant has left the country

Unauthorised agents or carers acting on behalf of claimants who are vulnerable

Patient claims - date of service between 2-5 years

Process patient claims - date of service between 2-5 years requiring SAS report

Patient claims - date of service between 5-7 years

Assessing process for patient claims - date of service over 5 years

Assessing process for patient claims - date of service over 7 years

Service Officer - requesting a manual EFT payment or cheque

Quality Assurance Officer - managing requests for manual EFT payments and manual cheques

Program Officer - managing requests for manual EFT payments

Issue a duplicate statement of benefit

Issue a manual statement of Medicare benefit


Process a Medicare patient claim

Table 1

Expand table

Step

Action

1

Check account or invoice details

Check the account or invoice matches the claim form and both documents contain all required information.

Do the details match and are both complete?

2

Go to claimant processing screen

Using the details on the Medicare claim form (MS014):

  • Key 'NPOI', Medicare card number in Mainframe
  • Press [Enter], blank claimant identification fields will display
  • Check if the patient claim is using a previously issued card number

For claims where the patient is using a previously issued card number, see Patient claim requirements for payment of Medicare benefits.

If the return messages 1-EXP>28, 2-AFT EXP, or 8-EXP 28DY show, follow the details in the message.

3

Follow the prompts
  • Identify the claimant (REF)
  • Confirm if the claim is paid (Y) or Unpaid (N)
  • Press [Enter]

4

Confirming address

Does the address on the claim form match the address recorded on the system?

5

Confirm address already recorded
  • Key the first 2 letters of the street name in the ADR field line. If the address is a PO Box, key the first 2 letters of the suburb
  • Press [Enter], go to Step 7

6

Update the address

If the claimant's address needs to be updated, place the cursor under return message 8-ADDR CK, press [F1] and follow the message instruction.

  • Key the claimant's postal address in the ADR field
  • Key 'T' for a temporary address or 'P' for a permanent address update
  • Press [Enter]
  • If processing in a service centre, and the address is updated permanently, keep a copy of the claim documents in batch work to show the change

7

Add, amend, or confirm electronic funds transfer (EFT) details

In the EFT field on line 6 of the screen, key the correct value:

  • C - if the claimant's bank account details are already stored in CDMS and match the claim form
  • T - EFT details keyed are temporary and used for this claim only. Use this where a business or third party is the claimant, or where the claimant requests a one-off payment
  • P - if the EFT details keyed are to be stored permanently for the claimant. Use this to:
    • replace old, stored banking details
    • add new EFT details
  • N - if EFT details are unavailable:
    • Try to contact the claimant to update the EFT details. If contact is unsuccessful, continue to process the claim with 'N' in the EFT field
    • The Medicare benefit will be held until EFT details are provided
    • Once details are provided, the payment is released automatically overnight

Note: if message 1-INV EFT returns, remove BSB and ACC in Mainframe if the bank account status is closed in CDMS, then continue processing the claim.

8

EFT statement

Key 'P' in the STM field to issue a statement to the claimant.

If the claim is processed in a service centre, key 'R' in the STM field to print a receipt so the claimant can verify the bank details and sign.

9

Date of lodgement
  • In the DOL field, key the date Services Australia received the claim
  • Press [Enter]

10

Locum

For details about recipient providers/locums, see Professional services related to Medicare patient claims.

Did a locum render the service?

  • Yes, on the first line in the:
    • ITEM field, key PAYP
    • NO field, key number of services, for example, 01. If the NO line does not show, press [F2]
    • PROVIDER field, key the provider number for the health professional the locum is performing the services for (the payee provider)
    • Go to Step 11
  • No, go to Step 11

11

Key service details using the account or invoice

Key all service details, in the required fields:

  • Patient's name, in the PATIENT field
  • Item number (if service is in-hospital, key 'H' after the item), in the ITEM field
  • Date of service, in the FST DT field
  • servicing provider number (locum where applicable), in the PROVIDER field
  • Payee code, for example, 2 for unpaid claim and 9 for a paid claim
  • Charge amount, in the CHARGE field
  • Press [Enter]

If the message 1-ACRF REQ returns for an unpaid account, key:

  • ACRF in the ITEM field
  • the invoice or reference number from the account in the PROVIDER field
  • 'NO' if there is no invoice or reference number

The Medicare system will calculate the maximum Medicare benefit payable to the claimant.

12

Referral details

Does the account or invoice include referral details?

13

Key referral details
  • Key patient's name in the PATIENT field
  • Key the appropriate referral code in the ITEM field:
    • SR - for specialist referral
    • AH - for allied health referral
    • DI - for diagnostic imaging
    • PA - for pathology
  • FST DT field, key the date the referral was written or issued
  • LST DT field, if the referral period is:
    • 12 months, do not key anything in this field because the system will calculate the end date
    • not 12 months, for example, 24 months or indefinite:
      Press [F2] for full screen and key the number of months in the LST DT field. For example, where the referral is 24 months, key '24'.
      For an indefinite referral, key '99'. The system will calculate the end date
  • Key the referring provider number, in the PROVIDER field

14

Assessing the claim

Service Officers:

  • must review and apply assessing restrictions by following warning messages
  • must action warning messages in order from left to right
  • can view more details by placing the cursor at the beginning of the return message and pressing [F1]

If the claim cannot be finalised and a latter day adjustment is required, for example 6-MULTI SPL, add an explanatory processing note in PaNDA and re-categorise the work item to the PC_PCADJ folder. See Work Optimiser for how to re-categorise work items in PaNDA.

If message:

Note: when an unpaid claim has a partial payment that is equal to the out-of-pocket amount and exceeds the Safety Net threshold, the message 8-SUB REQ appears prompting the Service Officer to manually verify the claim.

If message 1-INVEST displays, see Suspected Medicare fraud and Business Integrity (BI) flags. If a claim is confirmed as fraudulent do not pay the claim. For claims:

15

Two-way claims

If the claim is a Medicare Two-way claim:

  • Key 'Y' in the FUND field if a gap statement is needed
  • Key 'N' in the FUND field if a gap statement is not needed

If in-hospital items are keyed, complete the FUND field.

See Medicare Two-way claims processing for more details.

16

Finalise the claim
  • Press [Enter]
  • Key 'P' to pay claim

17

Finalise the claim in PaNDA
  • Add processing notes if needed
  • On the Work Item and Document details page, complete:
    • Medicare Number field - claimant's Medicare number, if it is not already included
    • Surname First Name: this is the claimant's surname and first name with no spaces
    • Status: Completed
    • Complete Reason: Request Rejected, Request Approved, Already Completed
    • Select Save
    • Procedure ends here

Note: see Work Optimiser for staff for more details about using PaNDA.


Process a Medicare patient claim where the claimant and patient are on different Medicare cards

Table 2

Expand table

Step

Action

1

Check account or invoice details

Check the account or invoice matches the claim form and both documents contain all required information.

Do the details match and are both complete?

2

Go to claimant processing screen

Using the details on the Medicare claim form (MS014):

  • Key 'NPOI', Medicare card number of the patient in Mainframe
  • Press [Enter]
  • Blank claimant identification fields will display

3

Follow the prompts
  • Identify the claimant's Medicare card number
  • In the Claimant field, key the claimants Medicare card number
  • Press [Enter]
  • In the REF field, key the claimant's reference number as shown on their Medicare card
  • Confirm if the claim is paid (Y) or Unpaid (N)
  • Press [Enter]

4

Confirming address

Does the address on the claim form match the address recorded on the system?

5

Confirm address already recorded
  • Key the first 2 letters of the street name in the ADR field line. If the address is a PO Box, key the first 2 letters of the suburb
  • Press [Enter]
  • Go to Step 7

6

Update the address

If the claimant's address needs to be updated, place the cursor under return message 8-ADDR CK, press [F1] and follow the message instruction.

  • Key the claimant's postal address in the ADR field
  • Key 'T' for a temporary address or 'P' for a permanent address update
  • Press [Enter]

7

Add, amend, or confirm electronic funds transfer (EFT) details

In the EFT field key the correct values:

  • C - if the claimant's bank account details are already stored in CDMS and match the claim form
  • T - if the EFT details keyed are temporary and used for this claim only:
    • For example, the claimant requests a one-off EFT payment into a different bank account to the details stored and this is shown on the claim form
  • P - if the EFT details keyed are to be stored permanently for the claimant. Use this to:
    • replace the old, stored banking details
    • add new EFT details
  • N - if the EFT details are unavailable:
    • Try to contact the claimant to update the EFT details. If contact is unsuccessful, the Medicare benefit will be held until EFT details are provided
    • Once details are provided, the payment is released automatically overnight

Note: if message 1-INV EFT returns, remove BSB and ACC in Mainframe if the bank account status is closed in CDMS, then continue processing the claim.

8

EFT statement

Key 'P' in the STM field to issue a statement to the claimant.

If the claim is processed in a service centre, key 'R' in the STM field to print a receipt so the claimant can verify the bank details and sign.

9

Date of lodgement
  • In the DOL field, key the date Services Australia received the claim
  • Press [Enter]

10

Locum

For details about recipient providers/locums, see Professional services related to Medicare patient claims.

Did a locum render the service?

  • Yes, on the first line in the:
    • ITEM field, key PAYP
    • NO field, key number of services, for example, 01. If the NO line does not show, press [F2]
    • PROVIDER field, key the provider number of the health professional the locum is performing the services for (the payee provider)
    • Go to Step 11
  • No, go to Step 11

11

Key service details using the account or invoice

Key all service details, in the required fields:

  • Patient's name, in the PATIENT field
  • Item number (if service is in-hospital, key 'H' after the item), in the ITEM field
  • Date of service, in the FST DT field
  • servicing provider number (locum where applicable), in the PROVIDER field
  • Payee code, for example, 2 for unpaid claim and 9 for a paid claim
  • Charge amount, in the CHARGE field
  • Press [Enter]

If the message 1-ACRF REQ returns for an unpaid account, key:

  • ACRF in the ITEM field
  • the invoice or reference number from the account in the PROVIDER field
  • 'NO' if there is no invoice or reference number

The Medicare system will calculate the maximum Medicare benefit payable to the claimant.

12

Referral details

Does the account or invoice include referral details?

13

Key referral details
  • Key patient's name in the PATIENT field
  • Key the appropriate referral code in the ITEM field:
    • SR - for specialist referral
    • AH - for allied health referral
    • DI - for diagnostic imaging
    • PA - for pathology
  • FST DT field, key the date the referral was written or issued
  • LST DT field if the referral period is for:
    • 12 months, do not key anything in this field because the system will calculate the end date
    • not 12 months, for example, 24 months, or indefinite:
      Press [F2] for full screen and key the number of months in the LST DT field. For example, where the referral is 24 months, key '24'.
      For an indefinite referral, key '99'. The system will calculate the end date
  • Key the referring provider in the PROVIDER field

14

Assessing the claim

Service Officers:

  • must review and apply assessing restrictions by following warning messages
  • must action warning messages in order from left to right
  • can view more details by placing the cursor at the beginning of the return message and pressing [F1]

If the claim cannot be finalised and a latter day adjustment is required, for example 6-MULTI SPL, add an explanatory processing note in PaNDA and re-categorise the work item to the PC_PCADJ folder.

If message:

Note: when an unpaid claim has a partial payment that is equal to the out of pocket amount and exceeds the Safety Net threshold, the message 8-SUB REQ displays prompting the Service Officer to manually verify the claim.

15

Two-way claims

If the claim is a Medicare two-way claim:

  • Key 'Y' in the FUND field if a gap statement is needed
  • Key 'N' in the FUND field if a gap statement is not needed

If in-hospital items are keyed, complete the FUND field.

See Medicare Two-way claims processing for more details.

16

Finalise the claim
  • Press [Enter]
  • Key 'P' to pay claim
  • Press [Enter]

17

Finalise the claim in PaNDA
  • Add processing notes if needed
  • On the Work Item and Document details page, complete:
  • Medicare Number field - claimant's Medicare number if it is not already included
  • Surname First Name: this is the claimant's surname and first name with no spaces
  • Status: Completed, Pended
  • Complete Reason: Request Rejected, Request Approved, Already Completed
  • Select Save
  • Procedure ends here

Note: see Work Optimiser for staff for more details about using PaNDA.


Process a Medicare patient claim for a business or organisation

Table 3

Expand table
StepAction

1

Go to claimant identification

Using the details on the Medicare claim form (MS014):

  • Key 'NPOI', Medicare card number in Mainframe
  • Press [Enter]
  • Blank claimant identification fields will display

2

Follow the prompts
  • Identify the claimant is a business or organisation
  • In the CTYPE field key 'B' for business or organisation
  • Press [Enter]
  • In the POSTAL NAME, key the name of the organisation followed by a comma
  • Confirm if the claim is paid (Y) or Unpaid (N)
  • Press [Enter]

3

Add address
  • Key the postal address of the claimant (business or organisation) in the ADR field
  • Key 'T' for temporary storage of the address in the last field after the postcode
  • Press [Enter]

Note: businesses and organisations cannot have address details stored permanently in CDMS unless the customer is under financial management or another guardianship order.

4

Business/organisation bank account details

Has the business or organisation provided bank account details on the claim form?

5

Add temporary bank account details for the claimant

In the EFT field, key T - EFT details keyed are temporary and used for this claim only.

Note: businesses and organisations cannot have banking details stored permanently in CDMS unless the customer is under financial management or another guardianship order. See Power of Attorney, Guardianship, Administrative Orders and Authorised Representative for Medicare.

6

Bank account details missing from the claim form

Has the claim been paid?

  • Yes, if bank account details have not been provided on the claim form:
  • No, as the claim is unpaid:
    • a cheque will be issued to the Business or Organisation
    • bank details are not needed
    • go to Step 7

7

Issue EFT statement

Key 'P' in the STM field to issue a statement to the claimant.

Note: a statement must be issued when the claimant is a business or organisation.

8

Date of lodgement
  • In the DOL field, key the date Services Australia received the claim
  • Press [Enter]

9

Process items using details on account/invoice

Key all of the following:

  • Patient's name, in the PATIENT field
  • Item number (if item is in-hospital, key 'H' after the item) in the ITEM field
  • Date of service, in the FST DT field
  • Provider number, in the PROVIDER field
  • Payee code, for example, 2 for unpaid claim and 9 for a paid claim
  • Charge amount in the CHARGE field
  • Press [Enter]

If the message 1-ACRF REQ returns for an unpaid account, key:

  • ACRF in the ITEM field
  • the invoice or reference number from the account in the PROVIDER field
  • 'NO' if there is no invoice or reference number

Repeat this step for each service being claimed.

Note: for locum-tenens, see Professional services related to Medicare patient claims.

Has the Medicare system calculated the maximum amount of the Medicare benefit payable to the claimant without returning any restriction or warning messages?

10

Assessing the claim

Service Officers:

  • must review and apply assessing restrictions by following warning messages
  • must action warning messages in order from left to right
  • can view more details by placing the cursor at the beginning of the return message and pressing [F1]

For more details on pathology items, see Assessing Pathology claims.

If message 1-PREV CON displays, see Table 20 in Latter day adjustments (LDA) and HELD payments for patient claims.

11

Finalise the claim
  • Press [Enter]
  • Key 'P' to pay claim
  • Press [Enter]

Process a claim for customers experiencing financial hardship

Table 4

Expand table

Step

Action

1

Claim type proficiency

Is the Service Officer proficient in processing the claim?

2

Processing the claim

Apply First Contact Resolution (FCR) principles if skilled in this work type.

If the:

See also:

Procedure ends here.

3

Escalating a claim when Service Officers are non-proficient
  • Contact Local Peer Support (LPS)
  • Tell LPS the Service Officer is not proficient in processing work for customers experiencing financial hardship
  • Procedure ends here for Service Officers
  • For LPS action, go to Step 4.

4

LPS action

See also:


Process a Reciprocal Health Care Agreements (RHCA) claim when claimant has left the country

Table 5: this process must only be completed by Medicare Customer Local Peer Support (LPS).

Note: this process only applies to claims submitted using a Medicare claim (MS014) form.

Expand table

Step

Action

1

Assess Medicare claim form

Check the account or invoice matches the claim form and both documents contain all required information.

Do the details match and are both complete?

  • Yes:
    • MS014, go to Step 2
    • Medicare online account (MOA) or myGOV - process claim. See Table 1 in Process digital self service claims
  • No:
    • Add a comment in PaNDA and CDMS Personal for the claimant. For example, incomplete or incorrect details on the claim form, unable to contact customer. Reciprocal Health Care Agreements (RHCA) customer has left Australia
    • If it is a MOA or myGov claim, reject the claim using an appropriate reason code. See Table 1 > Step 6 in Process digital self service claims
    • Complete the work item in PaNDA
    • Procedure ends here

2

Search for customer

In CDMS:

  • Select Amend Consumer Details
  • The Amendment Search screen displays
  • Do a customer search to identify the customer
  • Select Group
  • The Amend Medicare Card Details screen displays

3

Amend group end dates
  • Select Card Requests tab
  • Note the current Group eligibility end date (this is needed for Step 6)
  • Amend the Group eligibility end date to the date that the claim is being processed

4

Validate amended details

Once the date has been amended:

  • Scroll down and select Validate [Alt+V]
  • A message displays advising whether the request is acceptable:
    • Select OK to acknowledge the message
    • If not acceptable, change the request as required
  • Scroll down and select Validate [Alt+V]
  • The Confirm Amended Medicare Card Details screen displays the updated details
  • Select Update [Alt+U]
  • A confirmation message displays, select OK

5

Process claim

Using the details on the MS014:

  • Key NPSI, Medicare card number in Mainframe
  • Press [Enter]
  • Blank claimant identification fields will display
  • Process the claim, see Table 1 > Step 2

Once completed, go to Step 6.

6

Amend CDMS

Once the claim has been processed:

  • Change the group eligibility end date back to the date original noted in Step 3
  • Go to Step 2 and follow the process to amend group eligibility end date
  • Procedure ends here

Unauthorised agents or carers acting on behalf of claimants who are vulnerable

Table 6

Note: this process applies for claims submitted at a service centre only.

Expand table

Step

Action

1

Process claim using Medicare Claim form (MS014)

Offer to process the claim using a Medicare claim form completed by the unauthorised agent or carer.

When processing the claim:

  • benefits can only be paid to the bank account currently recorded in CDMS
  • carers can sign forms; however they must clearly indicate the signature is not that of the customer
  • make sure the correct claimant is recorded when processing these claims
  • issue a statement of benefit to the claimant
  • make a note on the claim form or VG4 form that the customer is unable to complete or sign the claim form, including the reasons why
  • record a note in CDMS

See Standards for helping customers complete claims and forms.

2

Make a note describing circumstances
  • Add a processing note in PaNDA to describe the circumstances. For example, 'Assistance required as per providing assistance to claimants with a disability'
  • When the claim form is signed by a carer, leave a processing note in PaNDA to state that the claim form is signed by a carer and not the claimant
  • See Standards for helping customers complete claims and forms

Patient claims - date of service between 2-5 years

Table 7

Expand table

Step

Action

1

Check the claim is supported by appropriate evidence

The Medicare claim form must be supported by:

  • an original account or invoice
  • a duplicate account or invoice, or
  • a receipt for payment

Sort claims into date order for each patient.

Medicare benefits for fully paid accounts or invoices can only be paid by Electronic Funds Transfer (EFT). If no EFT details are provided or stored in CDMS, the payment will be 'held' until EFT details are provided.

Check the patient history to assess if the claim has already been processed after the cull history date.

Is there evidence of a duplicate payment on the history?

2

Culled history date

Check the patient history to find the culled history date.

  • Key NHSI, Medicare card number in Mainframe
  • Press [Enter]

The culled history line will display as CULL with the date against the patient record.

Mainframe holds about 2 years of service history.

Does the claim have a date of service after or before the cull history date?

3

Claims with date of service after the culled history date

If there is no evidence of a duplicate payment on the patient history, process the claim. See Table 1 > Steps 1 to 9, then return to this process and go to Step 4.

4

Return message GT-2YR

The return messages GT-2YR and 6-REJ/PEND will show for claims with a date of service greater than 2 years ago.

  • Over key NPBC with 'NPSC'
  • Press [Enter]
  • Key '17' in the PI line
  • Press [Enter]

5

Assessing and finalising the claim

For more details on pathology items, see Assessing Pathology claims.

Service Officers:

  • must review and apply assessing restrictions by following warning messages
  • must action warning messages in order from left to right
  • can view more details by placing the cursor at the beginning of the return message and pressing [F1]
  • must key 'P' to pay claim
  • procedure ends here

6

Claims with date of service before the culled history date

Search the claims history for each date of service by keying 'DOS/DDMMYY' at the end of the NHSI control line.

All Service Officers skilled to process patient claims with a date of service over 2 years must have access to the SAS Portal to review culled claims history.

Is the Service Officer skilled to process claims over 2 years old?

7

Re-categorise work item in PaNDA

Select Reassign.

If prompted, key additional work item details and select Reassign again.

  • In the Assign pop up window:
    • Service Officer must key their User ID
    • Select Re-categorised as the reason from the Reason field
  • Select the Re-categorise to field. A dropdown menu will display a list of work types. Search and select the relevant work type:
    • PaNDA system work type program - Patient Claims
    • PaNDA work type process - Claims
    • PaNDA work type name - PC_CLAIM_2TO5YEARS
  • After moving the work item to the correct category:
    • make sure the card and name details are correct on the work item
    • Save any changes
    • then Unassign the work item as User Unavailable

The work item will then be processed in date of lodgement order.


Process patient claims - date of service between 2-5 years requiring SAS report

Table 8: this process applies to Service Officers processing patient claims with a date of service between 2-5 years requiring SAS report. All staff skilled in patient claims must have access to the SAS Portal.

Expand table

Step

Action

1

Check all relevant documentation has been provided

The Medicare claim form must be supported by:

  • an original account or invoice
  • a duplicate account or invoice
  • a receipt for payment

2

Get the patient Personal Identification Number (PIN)
  • Key NHSI, Medicare Number, Patient name, or IRN (Individual Reference Number) in Medicare
  • Press [F9] to display the patient PIN
  • Copy the patient's PIN

3

Generate the 2-5 year claims history report

In the SAS Information Delivery Portal:

  • Select Parameter Based Reporting
  • Select Medicare Patient History
  • In Consumer Details, key the patient's PIN, excluding the last letter
  • In Date of Service, key the required date range, ensuring it includes any time dependency periods for the specific item(s), using format of DD/MM/YYYY
  • Under Report Format Options:
    • Change Output Type to PDF
    • Select Yes for 'results in New Window'
    • Select Submit Request

Save a copy of the report and attach it to the PaNDA work item.

4

Check the account or invoice against the SAS history report

Anaesthetic services may not display all item numbers.

Verify the account or invoice:

  • Check details against the SAS history report for confirmation of payment
  • Check for any other restrictive services based on item requirements
  • Determine whether the claim has been previously paid, or contains restrictive items
  • Go to Step 5

5

Go to the claims processing screen

Using the details on the Medicare claim form (MS014):

  • Key NPOI, Medicare card number in Mainframe
  • Press [Enter], blank claimant identification fields will display

Follow the prompts:

  • Identify the claimant (REF)
  • Confirm if the claim is paid (Y) or Unpaid (N)
  • Press [Enter]

Check claimant's address:

  • Key the first 2 letters of the street name in the ADR field line
  • For a PO Box, key the first 2 letters of the suburb

6

Confirm EFT details and issue statement

In the EFT field, key the correct value:

  • C - if the claimant's bank account details are already stored in CDMS and match the claim form
  • T - the EFT details keyed are temporary and used for this claim only:
    • For example, the claimant requests a one-off EFT payment into a different bank account to the details stored and this is shown on the claim form
  • P - if the EFT details keyed are to be stored permanently for the claimant. Use this to:
    • replace old, stored banking details
    • add new EFT details
  • N - if EFT details unavailable:
    • Try to contact the claimant and update the EFT details. If contact is unsuccessful, the Medicare benefit will be held until EFT details are provided
    • Once details are provided, the payment is released automatically overnight

Note: if message 1-INV EFT returns, remove BSB and ACC in Mainframe if the bank account status is closed in CDMS, then continue to process the claim.

Key 'P' in the STM field to issue a statement to the claimant.

7

Date of lodgement
  • In the DOL field, key the date Services Australia received the claim
  • Press [Enter]

8

Key claim details

Key the claim details based on the relevant option below.

Service previously paid and no note exists to allow payment of the second service

For these claims:

  • Reject the service with RSN 162 - SUS DUP in Reason field
  • For fully paid claims (payee code 9), key 'E' in the P field
  • For Unpaid or partially paid claims (Payee code 2), key 'R' in the P field and 162 in the Reason field
  • Go to Step 9
Service has restrictive items, has been previously paid and no note exists to allow payment of the second service

For these claims:

  • Reject the service using the appropriate Reason Codes in the Reason field
  • For fully paid (Payee code 9) claims, key 'E' in the P field
  • For Unpaid/ partially paid (Payee code 2) claims, key 'R' in the P field
  • Go to Step 9
Services have not been previously paid

For these claims:

  • Process the claim, see Table 1
  • Return messages GT-2YR and 6-REJ/PEND will display
  • Over key NPBC with 'NPSC'
  • Press [Enter]
  • Key '17' in the PI line
  • Press [Enter]

9

Assess and finalise the claim
  • Review and apply assessing restrictions by following warning messages
  • Warning messages must be actioned in order from left to right
  • More details can be viewed by placing the cursor at the beginning of the return message and pressing [F1]
  • When assessment of the claim is completed and warning messages actioned, press [Enter]
  • Key 'P' to pay claim
  • Press [Enter]

Attach the SAS report to the PaNDA work item, add relevant processing notes, and mark the work item as Complete.

For more details on pathology items, see Assessing Pathology claims.


Patient claims - date of service between 5-7 years

Table 9

Expand table

Step

Action

1

Check all relevant documentation has been provided

The Medicare claim form must be supported by:

  • an original account or invoice
  • a duplicate account or invoice
  • a receipt for payment

When processing claims:

  • pay any claim with a date of service under 2 years
  • process and pay claims with a date of service between 2-5 years before re-categorising
  • add a note to the PaNDA work item outlining which services have been processed and that the work item will be re-categorised to over 5 years

Medicare benefits for fully paid accounts or invoices can only be paid by Electronic Funds Transfer (EFT). If no EFT details are provided or stored in CDMS, the payment will be 'held' until EFT details are provided.

2

Re-categorise work item in PaNDA

Select the Reassign.

If prompted, enter additional work item details and select Reassign again:

  • In the Assign pop up window:
    • Service Officer must key their User ID
    • Select Re-categorised as the reason from the Reason field
  • Select the Re-categorise to field. A dropdown menu will display a list of work types. Search and select the relevant work type:
    • PaNDA system work type program - Patient Claims
    • PaNDA work type process - Claims
    • PaNDA work type name - PC_CLAIM_OVER_5YEARS
  • After re-categorising:
    • Confirm Medicare card number and name details are correct
    • Save any changes
    • Unassign the work item as User Unavailable

The work item will be processed in date of lodgement order.


Assessing process for patient claims - date of service over 5 years

Table 10

Expand table

Step

Action

1

Check accounts or invoices

Check all accounts, invoices or receipts are sorted in date order for each patient, from earliest to latest date.

2

Get the patient PIN
  • Key NHSI, Medicare Number, Patient name or IRN (Individual Reference Number) in Mainframe
  • Press [F9] to display the patient PIN
  • Copy the patient's PIN

3

Access the SAS Information Delivery Portal

Service Officers must have access to the SAS Portal - Medicare GT 5 Year.

In the SAS Information Delivery Portal, select:

Note: there are 2 selections available, select the top option.

4

Request the culled history report
  • Select New Patient Request
  • Key the patient PIN, excluding the last letter
  • Key the Reference Date from (start of calendar year for claims over 7 years old)
  • Key the Reference Date to (end of calendar year)
  • After keying all details, select Validate Request

Feedback will display in a new window.

  • Delete unwanted patients by selecting the check box next
  • Select Submit Request

The system will display a confirmation page with the Request and Report date.

To ensure no time restrictions, the date range requested must reflect the time dependency of the item claimed. For example, item 2715 can only be claimed once every 12 months. The report needs to cover the 12 months before and post item being claimed.

Note: reports may take up to 3 weeks to be available. Culled history can only be viewed when the report is available.

After submitting the request, add a note to the work item in PaNDA including:

  • report requested
  • date range requested
  • estimated available date

Take a snip of the confirmation of request page and upload to PaNDA. Save the snip to the secure Customer Information folder using the naming format, Service Officer's logon ID, or P Number. For example: P11111.PaNDAWID.

The Service Officer must Pend the work item to themselves:

  • Pend reason 'Previous Work in Progress Extended'
  • Save the work item
  • Select Assign to Me

5

Second culled history request

If a second report is required for the same patient within the same 2 week cycle, the system will not allow Service Officers to proceed.

  • Delete the first request by going to the Manage Current requests tab
  • Select View request
  • Tick the box to remove the request
  • Select Remove Selected Requests

The system will then state Request Removed and a new report can be re-ordered within an expanded date range to include all dates of service for the relevant claim(s).

6

Report available

On the date the report is available, access the SAS Information Delivery Portal and select:

Note: the SAS Portal over 5 years has 2 selections available, select the top option.

7

Download report

To filter the reports:

  • Select Produce Report tab
  • Search report parameters by selecting PIN in search type and placing the PIN number in Search text box
  • Select View Request

If the report does not appear, check the date range. The system will only display a date range 2 weeks from the current date. If the report was ordered before the 2 weeks, expand the date range to include the date the report was ordered.

8

Search result

All available reports matching the search criteria are listed in the new window.

  • Scroll to the bottom of the page
  • On the results page, Service Officers can retrieve reports by selecting Email Reports

The system will email all reports displayed on this page to the requesting Service Officer.

Reports are only accessible by the original requestor. If no report is available, check the View Requests tab and key the customer's PIN to check if a report has been ordered.

If more than one report returns, as the report will return all reports requested for that date, narrow the search to the customer's PIN and select Email Reports.

Service Officers must save SAS reports to their team's secure folder Customer Information under their User ID. The file name must include the Service Officer's logon ID, or P Number. For example: P11111.PaNDAWID.

9

Key the claim
  • Key NPOI, Medicare card number in Mainframe
  • Press [Enter]
  • To process the claim, see Table 1

10

Update claim

Key the claim details based on the relevant option below.

Service previously paid and no note exists to allow payment of the second service

For these claims:

  • Reject the service with RSN 162 - SUS DUP in Reason field
  • For fully paid claims (payee code 9), key 'E' in the P field
  • For Unpaid or partially paid claims (Payee code 2), key 'R' in the P field and 162 in the Reason field
  • Go to Step 11

Claims over 7 years can be keyed and rejected with RSN 162.

Service has restrictive items, has been previously paid and no note exists to allow payment of the second service

For these claims:

  • Reject the service using the appropriate Reason Codes in the Reason field
  • For fully paid (Payee code 9) claims, key 'E' in the P field
  • For Unpaid/ partially paid (Payee code 2) claims, key 'R' in the P field
  • Go to Step 11
Services have not been previously paid

For claims:

11

Assess and finalise the claim
  • Review and apply assessing restrictions by following warning messages
  • Warning messages must be actioned in order from left to right
  • More details can be viewed by placing the cursor at the beginning of the return message and pressing [F1]
  • When assessment of the claim is completed and warning messages actioned, press [Enter]
  • Key 'P' to pay claim
  • Press [Enter]

Attach the SAS report to the PaNDA work item, add relevant processing notes, and mark the work item as Complete.


Assessing process for patient claims - date of service over 7 years

Table 11

Expand table

Step

Action

1

Check if claim has been previously paid

Confirm using from the SAS culled history report that the service has not been previously paid.

2

Check QITI

Using Mainframe:

  • Key:
    • QITI
    • item number
    • date of service (DOS)
    • 'M01H' in the Table field if the service is in-patient
  • Press [Enter]
  • Press [F5] to display the schedule fee and benefit amount
  • Confirm:
    • Schedule fee and the benefit
    • Greatest Permissible Gap
    • Standard percent and benefit
    • EMSN cap and threshold amounts

Check all assessing rules in QITI and confirm patient gender at date of service (DOS) in CDMS.

Note: some assessing rules are not retrospective and may differ from the date of service to the date of claim.

3

Safety Net benefit payment

Determine if the claim has Safety Net benefit payment considerations.

In CDMS, check Safety Net balances.

Are safety net balances available for the relevant year?

4

Extended Medicare Safety Net (EMSN) payments

Family registration cannot be backdated. If CDMS does not show family registration or thresholds, assess based on individual general threshold only:

  • If the SAS report shows higher Medicare benefits were previously paid:
    • Apply EMSN calculation. An additional EMSN benefit should be paid to any new claims processed for that calendar year
    • Request a manual EFT payment (claim cannot be processed in Mainframe)
    • Add a comment in CDMS Personal under the claimant with the payment details. See Table 12
  • If the SAS report shows higher Medicare benefits were not previously paid:
    • manually calculate the out of pocket (OOP) amounts on the SAS report
    • include the current claim OOP
  • If the OOP exceeds the general threshold:
    • apply the EMSN calculation, an additional EMSN benefit will be paid
    • Request a manual EFT payment (claim cannot be processed in Mainframe)
    • add a comment in CDMS Personal under the claimant with the payment details. See Table 12
  • If the SAS report shows the general threshold was not exceeded as an individual, and the current claim OOP does not exceed general threshold as an individual, then process the claim - no additional EMSN payment is required. Pay benefit based on QITI for the date of service. See Table 12

5

Processing patient claims
  • SAS shows higher Medicare benefits were previously paid
  • EMSN benefit to be paid for all non-duplicate claims processed, or
  • the current claim takes the patient over the individual general threshold then the patient is eligible for EMSN benefits

Safety Net calculation example

  • Item - 13200
  • Date of service - 1 Jan 2015
  • Charge - $6000.00
  • 2015 General Safety Net threshold amount from QITI = $2000.00
  • Standard benefit (from QITI for DOS): $3032.35
  • OOP from this service:
    • $6000 − $3032.35 = $2967.65
  • OOP after SafetyNet threshold for the year 2015 reached:
    • $2967.65 − $2000.00 = $967.65
  • EMSN benefit is paid at 80% (with cap amount as per QITI $1675.50) = $967.65
  • 80% of $967.65 = $774.12 (check for capping amount or % capping if applicable)

Total benefit paid after all calculations is $3032.35 + $774.12, = $3806.50 (rounded to nearest 5 cent).

Total amount is entered on the Z2261 - Your statement of Medicare benefits and requested as manual EFT.

If multiple claims are received on the same day the threshold is reached, process in this order:

  • Patient DOB (oldest to youngest)
  • Paid/Unpaid account
  • Date of service (earliest to latest)
  • Capped/Uncapped items

See the Resources page in Extended Medicare Safety Net (EMSN) for examples of processing a patient claim for a multiple operation where the EMSN cap is less than 80% of out-of-pocket expenses.


Service Officer - requesting a manual EFT payment or cheque

Table 12: this process applies to Service Officers trained to request a manual EFT payment or cheque.

Note: see Table 16 for details of how to issue a Z2261 Your statement of Medicare benefits, which must be issued for all manual payments. This must be sent with the remittance advice or manual cheque where issued.

Expand table

Step

Action

1

Determine if EFT payment or cheque required

Was the account fully paid?

2

Confirm bank account details

In CDMS, check whether valid bank account details are recorded for the claimant.

Are valid bank account details recorded?

3

Valid bank details not recorded

If valid banking details are not recorded:

If details are not provided, or contact is unsuccessful the claim cannot be paid. The claimant will have to submit a new Medicare claim with valid account details:

  • Request the information using the Z0828 - Medicare claim needs more information letter
  • Include in the free text option, 'Please provide banking details for your claim to be paid. Include the following details:
    • name of the financial institution
    • branch number (BSB) and account number
    • name of the account holder'
    • The Resources page contains a link to the Digital Messaging Capability (DMC) - Health to create and send letters

Add comments in CDMS and PaNDA. Complete the work item in PaNDA.

Procedure ends here.

4

Complete a Manual EFT Payment (PP048) Request form

Open the PP048 template and complete all required fields.

The Resources page contains a link to the PP048.

Service Officers must complete one PP048 for each claimant regardless of whether they have the same bank account. Include the total amount due for all services.

Save the completed PP048 as a PDF:

  • Select Print
  • Change Printer to 'Microsoft Print to PDF'
  • Save to the Customer Information folder located on the Service Officer's team shared drive
  • Attach a copy to the PaNDA work item
  • Add a comment in CDMS under Personal and PaNDA including:
    • PaNDA ID
    • Claimant name
    • Payment amount
    • Service details
      For example, 'PaNDA ID xxx, manual EFT requested for (claimant's name) and (amount). Manual statement of Medicare benefits created (patient's name)'
  • Send the work item for quality checking using the Send for Delegation button in PaNDA
  • After quality checking, and the manual EFT payment released:
    • the work is then returned to the originating PaNDA folder with the remittance advice and allocated to the next available Service Officer
    • the Service Officer must print and post the manual statement of benefit and the remittance advice
    • mark the PaNDA work item as complete. See Table 16 for details on how to issue a Z2261 - Your statement of Medicare benefits

5

Complete Manual Cheque Request form

Using the Manual Cheque Request form:

  • complete required fields only:
    • Check box - select MDC
    • BATCH REFERENCE - Service Officer to enter their P number and Source Office Code
    • TYPE OF MANUAL CHEQUE REQUEST - tick box PD
    • ORIGINAL CHQ NO - leave blank
    • AMOUNT
    • PROVIDER NUMBER
    • CLAIM ID - leave blank
    • PAYEE NAME - enter if a payee provider:
      Access Medicate portal.
      Select Source Office code.
      Select Provider Directory System (PDS).
      Select Provider location and select View.
      Key the provider number in the Provider Stem field - numerals only. In the Provider Location field add the first letter of the provider number only.
      Select Search.
      In the section Associated details if there is a payee group select the link which will provide the name and address of the payee provider. These details must be added under the Payee Name field on the form.
      If there is no payee group enter the full name of the health professional who the cheque is to be made payable to and key the address displayed under the Address Details section
    • ADDRESS - claimant's address
    • P/CODE - claimant’s postcode
    • MANUAL CHEQUE AMOUNT
    • PREPARED BY - Service Officer's name
    • OPERATOR NO - Service Officer's P number
    • CONTACT NO - Service Officer's Team telephone number
    • DATE - date Service Officer completed the form
    • QUALITY CHECKER - leave blank
    • DATE - leave blank
  • Upload the Manual Cheque Request form to the PaNDA work item.
  • Add the following processing note to the claimant in PaNDA and CDMS in Personal: 'PaNDA ID xxx, manual cheque requested for [claimant’s name, health professionals name and amount]. Manual statement of Medicare benefits (Z2261) created [patients name].'
  • Send the work item for quality checking by selecting the Send for Delegation button in PaNDA

Quality Assurance Officer - managing requests for manual EFT payments and manual cheques

Table 13

Expand table

Step

Action

1

Perform quality checking

Is the PaNDA work item for a manual EFT payment or a manual cheque?

2

Complete quality check for a manual EFT payment request
  • Check all required documents have been uploaded, including:
    • manual calculation spreadsheets
    • Manual EFT Payment Request form (PP048)
    • SAS portal reports if claim is greater than 2 years
    • Z2261 - Your statement of Medicare benefits letter
  • Confirm:
    • the claim and calculations are correct
    • claimant details on PP048 are correct and match the Z2261
  • Ensure one PP048 per claimant
  • Confirm:
    • bank details are correct on the PP048
    • benefit amounts match PP048 and Z2261
    • comments are recorded in CDMS and PaNDA
  • If errors are identified, correct the errors and submit feedback through the Staff Feedback Tool
  • Add a comment in PaNDA confirming quality check
  • Re-categorise the PaNDA work item to Medicare Payments MC_SDST
  • Procedure ends here

3

Complete quality check for a manual cheque request
  • Check all required documents have been uploaded, including:
    • manual calculation spreadsheets
    • Manual Cheque Request form
    • SAS portal reports if claim is greater than 2 years
    • Z2261 - Your statement of Medicare benefits letter
  • Confirm:
    • the claim and calculations are correct
    • the Manual Cheque Request form matches PDS. See Table 12
    • benefit amounts match the Manual Cheque Request form and the Z2261
    • comments are recorded in CDMS and PaNDA
  • If errors are identified, correct the errors and submit feedback through the Staff Feedback Tool

4

Forward the manual cheque request to Treasury

Service Officers must:

  • Save the manual Cheque Request form to their team's shared folder
  • Amend the form by keying their name and P number in the Quality Checker field to certify that the work has been quality checked
  • Key the date of the quality checking in the Date field
  • Save as a PDF
  • Email the Manual Cheque Request form and the Z2261 to Treasury Helpdesk and CC’ in their team leader
  • Add a comment in the PaNDA work item 'Quality check has been completed. Request for manual cheque has been forwarded to Treasury'
  • Change the status of the PaNDA work item to Complete

Program Officer - managing requests for manual EFT payments

Table 14

Expand table

Step

Action

1

Manual EFT payment requests

Manual EFT requests are received in Medicare Payments MC SDST PaNDA.

Add the request to the Vendor Bulk Upload and Payment Run templates.

Refer to the Resources page on how to complete these.

To obtain a vendor maintenance number:

  • Forward the vendor request template from the Medicare Customer email box
  • Use subject 'Patient claim payments - Vendor requests - Medicare Customer Services' - PNTC
  • Send to the Accounting Operations (AO) team

The AO team will create a new vendor maintenance number.

Add the allocated vendor number to the Vendor Request spreadsheet.

2

Update the Payment Run Request template

Access the Payment Run Request Template.

Update the following, copy the:

  • claimant's name and paste to column N 'Line Item Text'
  • vendor number to column A 'Vendor'

Note: any errors in the Payment Run Request will cause the whole payment run to fail. If the payment run fails, a new request will be required for all payments.'

3

Request Delegate approval

Once the templates have been completed:

  • Add total payment amount to the Payment Run Request template
  • Save the email from the AO team, the newly created Vendor Bulk Upload template and the Payment Run template into a new email
  • Email the template to the appropriate delegate from the Medicare Customer Services email box with the following details:
    • Subject: Patient Claim Payments - Manual EFT Payment Run - Medicare Customer PNTC - date
    • Body of email: Please find attached for your approval, a request for <insert number of payments> manual EFT payments for the total amount of $<insert total amount>

4

Forward both templates to the AO team

Once approval is received by the delegate, email the templates to the Accounting Operations (AO) team.

Use the following details:

  • Subject: Patient Claim Payments - Manual EFT Payment Run - Medicare Customer - PNTC
  • Body of email: Please find attached the spreadsheet for <Insert number of payments> payments for the total amount of $<Insert Total amount> which has been approved for payment as per delegation limit of <Insert Delegate name>

5

Remittance advices

Accounting Operations will email the remittance advice to Medicare Customer Service Delivery Support Team (MC SDST) once payment has been processed and released to the Reserve Bank of Australia.

Once MC SDST receives confirmation of payment, they must:

  • upload a copy of the remittance advice to the PaNDA work item
  • re-categorise the PaNDA work item to the original Service Officer

The original Service Officer must:

  • post the remittance advice and the manual statement of benefit to the claimant and then finalise the work item
  • if working from home, arrange for a colleague in the office to print and mail the documents
  • upload the documents to the Secure Print folder in their colleague's team Customer Information folder
  • Add a processing note confirming the manual EFT payment has been released and that the remittance advice and manual statement of benefit have been sent to the claimant
  • mark the PaNDA work item as complete

Issue a duplicate statement of benefit

Table 15

Expand table

Step

Action

1

Identity the claim details
  • Key NHSI, card number, patient name in Mainframe
  • Press [Enter]
  • Medicare Patient History screen will display, locate the claim
  • Note the date of processing in PRC DT column
  • To identify the claimant, place the cursor on the CHARGE for that date of claim and press [F1] - the claimant's details will display at the bottom of the screen
  • The date of processing of the claim is needed when issuing a duplicate statement of Medicare benefits

Note: duplicate statements cannot be issued for Latter Day Adjustments (LDA) or claims over $9,999.99. See Table 16 to issue a manual statement of Medicare benefits.

2

Check group contact

Is the requesting person the group contact?

3

Update contact before issue statement of benefit
  • Key NDSI, card number, date of processing (DDMMYY)
  • Press [Enter]
  • Duplicate Statement screen displays

If the person requesting the duplicate statement is not the group contact, (for example, a business organisation is the claimant), over-type the following contact details:

  • CONTACT field key surname, title first name
  • ADR field key address details

4

Confirm service details

Check the NDSI screen:

  • Key NDSI, card number, date of processing (DDMMYY)
  • Press [Enter]
  • Duplicate Statement screen will show

Does the statement have the correct processing date, patient, and health professional?

5

Multiple claims processed on the same day or within 30 days of the date of processing

If multiple claims are processed on the same day, the system lists a separate statement for each health professional.

Use the [F2] and [F3] keys to move from statement to statement until the correct one is located.

6

Multiple Services from the health professional on the statement

Each screen shows up to 8 services. If there are more than 8 services, use [F7] and [F8] function keys to view all the services for that health professional.

7

Issue the statement
  • In control line, over key 'I' with either 'P' to post or 'M' to print statement in a service centre
  • Press [Enter]
  • Press [Ctrl] + [Alt] + [P]

Issue a manual statement of Medicare benefit

Table 16

Expand table

Step

Action

1

Check service details

Check service details to include in the Z2261 - Your statement of Medicare benefits:

  • Key NHSI,Medicare number,patient name or IRN,DOS/DDMMYY in Mainframe, check date of processing (DOP) for each claim to be included on the manual statement of Medicare benefits
  • Change control line to NHSI, Medicare number, patient name or IRN,DOP/DDMMYY, for each claim to be included on the manual statement:
    • DOP screen shows all lines processed on that DOP

Are there adjustment codes (888 or 816)?

2

List of adjustments

Change control line to NHSI, Medicare number, patient name or IRN,ADJ/PC.

The Patient History (NHSI) screen shows all the adjusted payments including original and revised lines.

The Service Officer must check each claim/ adjustment to be included on the manual statement.

3

Manual statement of Medicare benefits

To prepare a manual statement of benefits:

  • Service Officers launch the Z2261 - Your statement of Medicare benefits letter from CDMS or DMC. The Resources page contains a link to the Digital Messaging Capability (DMC) - Health to create and send letters
  • The Address and Signatory tab must have following details:
    • Recipient's full name and address as listed in CDMS
    • Our Reference (PaNDA work ID or Source Code, where work type is not completed in PaNDA)
    • Patient's Medicare card number

Note: a Z2261 should only be issued to the claimant or the patient. The only exception is where a two-way claim form has been provided, and a copy of the statement issued in the name of the claimant or patient can be forwarded to the health fund. This must be sent with an Unable to transmit two-way claim letter (Z3112). See Medicare Two-way claims processing for more details.

4

Continue with the Benefits Details tab

For each service to be included on the statement, select Benefits Details tab, and then for each individual item and service:

  • Key the health professional's title, first name, surname, and provider number
  • If multiple services for the same health professional/patient are involved, select 'retain provider' and 'retain patient' fields
  • Key patient's full name, item number, date of service
  • Select if the service is fully paid or unpaid
  • Key the relevant RSN code (for example, 104, 179, 225, 242, 888, 816 etc.)
  • If the service was in-hospital, tick the Inpatient box- RSN code 000 will auto populate

Service Officers must:

  • Key in the service line exactly as it appears in Mainframe
  • Key the item numbers in the exact order as they appear in NHSI
  • Press [F1] under the RSN code on patient history and only include reason codes which display a 'Statement message'
  • Referral and service request lines (SR, DI, PA, and AH) and UPAY/OPAY lines as a result of LDA's must not be placed on the manual Statement of Benefit
  • Notional charges where the Multiple Operation Rule (MOR) has been applied, these must be keyed for the first item only, along with the total derived schedule fee and total benefit amounts. The rest of the related MBS Items will have a '0' value for charge, schedule fee, and benefit
  • For a service over $9,999.99, do not key the 0000 line. The total charge for the service as shown on the invoice and the relevant item number should be included on the statement, as one line
  • Outpatient:
    • First line of the manual statement of Medicare benefits - Key the total charge for the service and the relevant item number(s)
    • Second line - Key the charge as $0.00 and the schedule fee as $0.00
    • Key the total amount of the Manual EFT payment in the Benefit field
    • Key reason code 225: Patient contribution substantiated-additional benefit paid
  • The Z2261 should include item numbers and reason codes for any rejected services
  • See Indicators, codes, modifiers and control lines for claims processing in Medicare

Any previous assessing RSN codes will be overwritten if a Latter Day Adjustment has been actioned.

See Charges $10,000 or more (greater than $9,999.99) for Medicare patient claims.

5

Multiple Operation Rules (MOR) and Multiple Service Rules (MSR)

The reason code usually shows in Mainframe. However, if an adjustment has been made where the MOR or MSR rule(s) have been applied, the original code will not show. The Service Officer must check the MOR/MSR and identify the reason code to be used in the letter.

Press [Shift] + [F4] on history screen to find out if an MOR and/or MSR has been applied.

Has a MOR and/or MSR been applied?

6

Decide the corresponding reason code to be included in the Z2261

See the Resources page for multiple processing rules and adjacent statement of benefit reason (RSN) codes to decide the reason code to be included in the Z2261.

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

7

Continue with the Benefits Details tab
  • Key in charge and benefit amounts as per NHSI screen
  • For schedule fee, in Mainframe on the NHSI screen press [F4] to display the schedule fee displayed under the 'fee' field
  • Select Add, to add the service line to the list to be included on the statement
  • Repeat these steps for each service line to be included on the manual statement

Do not refer to the QITI for schedule fees because:

  • there may be derived fees for operations with more than one item, or
  • where there have been multiple services performed, and multiple service rules such as the Multiple Operation Rule (MOR) or Diagnostic Imaging Multiple Service Rule (DIMSR) have applied

Notional charges must be placed for the first item only with the derived schedule fee and benefit where the MOR has been applied. The rest of the MBS Items will have a'0' value for charge, schedule fee, and benefit.

If there are any remaining items, enter them individually and add to the statement.

There are also REMOVE and Edit Information buttons in the Z2261 template.

Note: 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.

8

Quality assurance

Service Officers in telephony

Service Officers in telephony must follow the quality assurance process before mailing out the manual statement of benefit to the customer.

See Preparing, quality and peer to peer checking of Medicare external mail.

Service Officers in service centres

Service Officers in service centres must follow their branch's quality assurance process before handing out the manual statement of benefit to the customer.

See Preparing, quality and peer to peer checking of Medicare external mail.

9

Upload a copy of the manual statement of Medicare benefits to PaNDA and update comments

Service Officers must upload a copy of the manual statement of benefit and attach it to the PaNDA work item.

Add a processing comment in PaNDA.

10

Add comments in CDMS

Add a comment:

  • select Comments tab in Personal under the claimant
  • add a comment confirming statement created, including details of patient and date of service

For example - 'Manual statement of Medicare benefits created for DOS DD/MM/YY patient FULL NAME.'