Account and receipt documents for Medicare claims processing 011-43010030

Account documents, for example invoices, claimant accounts, receipts and assignment forms are the most important element in paying a claim. These documents contain essential details when processing a claim for a Medicare benefit and act as evidence for Services Australia. This is why it is essential that the agency retain all documentation associated with claims for Medicare benefits.

Lodgement advice

Lodgement advice is an advice that the claim has been lodged by the health professional's practice on behalf of the claimant. This can also be referred to as a statement of claim.

Where a claimant attempts to claim Medicare benefits using their lodgement advice and/or their statement of claim notice in person at a service centre:

• Service Officers must check the patient's claim history, to see if the service has been assessed
• If the service has been assessed advise the claimant:
• their claim has already been lodged by the health professional's practice, and
• they cannot claim the benefit again
• Where the service is not present on the patient's history, process the claim using the details on the lodgement advice

Where a claimant is not present at a service centre:

• and submits their lodgement advice notice to claim Medicare benefits
• Service Officers can process the claim and reject with RSN code 162 as a duplicate claim if the service is present on patient's history

If the claim is not present on the patient's history:

• process the claim using the details on the lodgement advice

Alterations to accounts/ invoices or receipts

Where alterations have been made on an account/ invoice or receipt and the Service Officer is unsure if the information correctly reflects the service rendered:

• contact the health professional's practice for verification, and
• complete processing notes verifying information

If the Service Officer:

• confirms with the health professional that the amended account/ invoice is not true and correct
• they must refer to their team leader or manager for escalation to the Fraud team

Note: if the health professional cannot be contacted, the claim must not be paid. The Service Officer must return the original document to the claimant, together with the appropriate letter. See also: Preparing, quality and peer to peer checking of Medicare external mail.

Services not claimable for Medicare benefits

Where a service is:

• not claimable, Service Officers must return the claim to the claimant, together with the appropriate letter. Copies of letters must be maintained on a dedicated file within the service centre for non-digital claims. See Preparing, quality and peer to peer checking of Medicare external mail for more details
• rejected by the agency, Service Officers must retain all paperwork associated with the claim

The Resources page contains a link to the Standard Letter Templates.

Accounts/ invoices and receipts requiring additional information

Where the submitted account/ invoice and/or receipt does not include all required details, the claim cannot be paid until the additional details are received:

• For manual patient claims, Service Officers must try to contact the health professional to ask for more details. If contact cannot be established the claim must be rejected with the appropriate reason code/ letter sent
• For digital self-service claims, Service Officers must try to contact the health professional to ask for more details. If contact cannot be established the claim must be rejected with the appropriate reason code

The Process page explains:

• how to ask for more details for manual claims/digital self-service claims, and
• which reason codes to use for digital self-service claims when contact cannot be established

Section 19(6) of the Health Insurance Act 1973, states that the responsibility to supply the necessary information on account documents:

• rests with the health professional
• does not rest with the patient

Health professionals or staff acting on their behalf are responsible:

• for the accuracy, and
• completeness of the information included on the account, receipt or assignment of benefit form

If account/ invoice information is incomplete, see ‘Accounts/ invoices and receipts requiring additional information’ above.

Service Officers in doubt about the validity of the claim being processed, must escalate the matter to their team leader or manager. The References page contains a link to the Health Insurance Act 1973.

Account/ invoice or receipt documents for patient claims require specific details.

Itemised account/ invoice or receipt

If a health professional bills a patient for medical services, the patient requires an itemised account/ invoice or receipt to allow the payment of a Medicare benefit.

Health professionals must provide an account/ invoice, receipt or assignment form that identifies:

• Name of patient
• Date of service
• Amount charged
• Amount paid
• Amount outstanding
• Service details:
• an item number only, or
• an item number and description

Health professionals can create their accounts/ invoices and receipts in a format that identifies the above listed information. As an example, health professionals may include the following to indicate an account/ invoice has been paid:

• Nil balance
• Balance owing $0.00
• Total Due $0.00

Note:

• Where an account/ invoice indicates the amount paid is the same as the charge for services rendered, the account/ invoice must be considered paid
• Printed accounts/ invoice may include charges and fees for prior invoices or upcoming procedures. These amounts/ invoices must not be included when determining if the listed items on the account/ invoice are paid or unpaid

The Resources page has a link to the Health Insurance Regulations 2018. See Part 3 - Medicare benefits - Division 5 for more details.

Services rendered to inpatients

Health professionals are required to identify services rendered or requested:

• while the patient was an admitted patient of a hospital, or
• an approved day hospital facility

Part 3 - Medicare benefits - Division 5 of the Health Insurance Regulations 2018 states that this can be identified by either:

• the service description, must indicate that the service was rendered as part of an episode of hospital treatment. For example including the word 'inpatient' in the service description, or
• a briefer description of the service may be used together with the item number and an asterisk (*) or the letter ‘H’

The following terms are commonly used to identify these services:

• The letter 'H' immediately after the item number
• Including the words 'in hospital' in the service description
• Including the word 'inpatient' in the service description
• Including the words 'admitted patient' in the service description
• Including the word 'admitted' in the service description

Medicare benefits for services performed to an in-patient of a hospital are assessed at 75% of the Schedule fee.

Note: health professionals are required to identify hospital substitute treatments by including in the service description:

• the words 'hospital-substitute treatment' or
• HST

See also: Hospital Substitute Treatment (HST) claims for Medicare.

The References page contains a link to the Health Insurance Regulations 2018.

Part 3 - Medicare benefits - Division 5 of the Health Insurance Regulations 2018 states that the below health professional information is required on the account/ invoice, receipt or assignment form:

• the name of the person who rendered the service and the address of the place of practice where the service was rendered, or
• provider number of the health professional who rendered the service

As per the Medicare Benefits Schedule (MBS), more details may be provided on account/ invoice documents. However the above requirements outline the minimum details.

Some accounts/ invoices show the name of more than one health professional. The name of the health professional who actually performed the service is not always shown. If documents need more details, see Account/ invoice documents on this page.

Note: if the rendering health professional cannot be positively identified, claims must not be paid.

Provider numbers on accounts/ invoices

The provision of provider numbers on the account/ invoice is not mandatory.

The claim can be processed if the Service Officer can establish:

• the service attracts Medicare benefits, and
• the practitioner as a registered health professional at the address the service was given

Health professionals must be encouraged to supply provider numbers as:

• this allows quicker processing of claims, and
• reduces the likelihood of errors

Locum details

If a locum renders a service:

• on behalf of another health professional
• the account/ invoice documents must indicate it is a locum service either by the word 'Locum' or the letters 'LT' (Locum Tenens)

The References page contains a link to the Health Insurance Regulations 2018.

Where a service is referred, the Health Insurance Regulations 2018 states that the following referral details are needed on the account/ invoice, receipt or assignment form:

• the name of the referring health professional
• address or provider number of the referring professional
• date on which the patient was referred
• period of validity of the referral

When processing claims that require a referral, Service Officers must enter the date the referral was issued, rather than the date the referral was first used. The Resources page contains an example to support staff.

Note: where referral details are missing from account/ invoice or receipt, see Incomplete, invalid, or no referral details supplied below for more details.

The name of the person receiving the service (the patient) must be shown on all accounts/ invoices.

If the name of the patient is not clearly stated on the account/ invoice documents or cannot be uniquely identified. For example, 2 people with the same surname and initial are on the Medicare card. Do not process the claim. If documents need more details, see Account/ invoice documents on this page.

Note: where an account/ invoice is received listing the patients name as newborn, baby of, or a similar variant, the claim can still be processed so long as it is clear which patient received the services. If it is not clear whom received the services, for example, twins, the claim is to be rejected and returned with the appropriate letter.

A claimant is a person, business or organisation who incurred the medical costs for a service rendered.

It is not a requirement for the claimant's details to be stated on the account/ invoice and/or receipt.

The account/ invoice does not need to be in the claimant's name in order for the claimant to receive the Medicare benefit. By accepting the Medicare claiming declaration, the claimant is confirming that they incurred the cost of the medical service.

The claimant can submit the claim via any claiming channel.

Under no circumstances must the claimant be asked to return to the surgery to have the account/ invoice or receipt changed into the claimant's name.

See also: Patient claim requirements for payment of Medicare benefits.

For accounting purposes, certain health professionals may request account reference details to be included on their Medicare statement of benefit. This allows the doctor's surgery to determine which account the Medicare benefit has been paid for.

The patient's account/ invoice or receipt contains an account reference number. This number can be up to 11 alpha and numeric characters. This number can be referred to as the:

• account number
• receipt number
• folio number, or
• invoice number

Note: ACRF lines are keyed when the account/ invoice is unpaid, using payee code 2.

The message 1-ACRF REQ is displayed when an ACRF line is required. This message prompts the Service Officer to key the ACRF line immediately after the services for the health professional.

Once the patient's account/ invoice has been processed, the account reference details are recorded on the patient's history and are printed on the statement of benefit.

Scanned, emailed, faxed, handwritten or photocopied accounts/ invoices or receipts may be used for processing. If Service Officers have any concerns about the validity of an account/ invoice or receipt, they must phone the health professional to verify the details. For quality control purposes, complete processing notes verifying details.

Scanned accounts/ invoices and receipts for Medicare Two-way claims

The agency can accept scanned claiming documentation if it has been:

• received from a private health fund, and
• certified as a true copy of the original

Note: claiming documentation includes accounts/ invoices, receipts and claim forms.

Emailed accounts/ invoices and receipts

If a claimant presents emailed accounts/ invoices or receipts for processing. Service Officers must assess the document to confirm it complies with the minimum claim requirements.

Faxed accounts/ invoices and receipts

Faxed accounts/ invoices or receipts are only acceptable when the fax is transmitted:

• directly to the agency from the health professional’s practice
• from a state government body, such as state trustees

Note: certified copies received directly from state trustees are acceptable. However, a completed Medicare Claim form must clearly identify the state trustee as the claimant. The benefit must be made to the bank account of the state trustee. Payment must not be paid into a personal bank account.

If state government body bank details are not supplied on the claim form, return the original document to the state trustee, together with the appropriate letter.

Handwritten accounts/ invoices and receipts

Handwritten accounts/ invoices, receipts or assignment forms can be accepted for assessment if the documentation contains all the required details as set out under Account/ invoice requirements on this page.

Photocopied accounts/ invoices and receipts

If a Service Officer believes that the claimant has provided a photocopied account/ invoice or receipt:

• they must try to contact the practice, and
• request the account/ invoice or receipt be faxed to the agency, or
• complete processing notes verifying information all required service details in order to pay the claim and attach it to the claim documents

If the Service Officer is unable to contact the practice:

• to confirm that the account/ invoice or receipt is valid
• they must tell the claimant, if in person, that a duplicate account/ invoice or receipt is required

Note: if a claim has been received through the mail or digital channels and:

• the practice cannot be contacted, or
• the Service Officer cannot confirm that the account/ invoice or receipt is valid
• return the supplied documents back to the claimant with the appropriate letter

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

The Resources page contains links to Standard Letter Templates.

Regulation 49 of the Health Insurance Regulations 2018 states:

• the total amount paid in respect of the service must be included on the health professional’s receipt
• a Medicare benefit can only be paid in favour of the claimant if there is a receipt showing the total amount paid for the service

A claim is to be treated as a paid patient claim if:

• an unpaid account/ invoice is supplied along with acceptable proof that the claimant has made payment
• via post office, internet BPAY®, credit card, EFTPOS or direct bank transfer

The References page contains a link to the Health Insurance Regulations 2018.

Accepted proof of payment

The following documents are acceptable as proof of payment:

• Post office receipts
• Internet receipts including:
• BPAY
• BPOINT
• PayPal
• Online bank transfer
• Thermal credit card or EFTPOS receipts
• Bank transfer receipts

The claimant must produce both the health professional’s account/invoice, and a printed copy of the appropriately detailed payment receipt. If both the account /invoice and a printed copy of the receipt are not provided, Service Officers must:

• contact the health professional and confirm payment has been received (only if the claimant has provided proof of payment on a mobile/smart device), or
• advise the claimant that the claim can only be paid in favour of the health professional unless an appropriate receipt is supplied

The Resources page contains a link to the Services Australia website for proof of payment and advice on taking/scanning clear photos and documents.

Details required in the receipts

Receipts must detail the following information to be accepted as proof of payment:

• A link between the payment and either the:
• invoice
• account
• health professional, or
• practice where the service was rendered, and
• The actual amount paid, and
• The date of payment, and
• A receipt or confirmation number

Note: bank transfer receipts are only acceptable if the health professional’s account/ invoice includes:

• a Bank State Branch (BSB) and account number for payment, and
• the details match those on the bank deposit receipt

Not enough details on proof of payment or missing proof of payment

If there are not enough details on the proof of payment or the Service Officer thinks that the proof of payment supplied by the claimant may be fraudulent. Contact the health professional and confirm if the payment has been received. Service Officers must complete processing notes verifying details.

If the health professional confirms payment was not received, advise the claimant that the claim can only be paid in favour of the health professional unless they can provide proof of payment. If the claimant disputes non-payment, return the original document to the claimant and advise them to contact the health professional.

If the health professional cannot be contacted:

• return the original document to the claimant and
• advise the claimant to contact the health professional to get a detailed receipt

If the health professional cannot confirm that the service being claimed took place and the Service Officer believes that the claim may be treated as fraudulent, refer to the External fraud intranet page. The Resources page contains a link to the page.

Returning accounts/ invoice or receipts when no Medicare benefit is payable

Where there is no Medicare benefit payable on an account/ invoice or receipt:

• Service Officers must cancel the claim or delete the service line/s (for that account only), and
• return the claim to the claimant with the appropriate letter

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

This policy impacts claims that do not attract a Medicare benefit. For example, when the item is not covered by Medicare.

Note: do not send letters to claimants as they automatically receive a statement notifying that the claim was not paid, when either the:

• services are suspected duplicate (162 reason code), or
• maximum number of services have already been claimed (160 reason code)

Returning accounts/ invoice or receipts when the account/ invoice or receipt contains both Medicare Benefits Schedule (MBS) and non-MBS items

Where a claim is processed:

• and the account/ invoice or receipt contains both MBS items and non-MBS items
• the agency must retain the documentation associated with the claim

A copy of the account/ invoice documents must be returned to the claimant together with the appropriate standard letter.

Note: if there is no Medicare benefit payable (regardless of whether it contains both MBS and non-MBS items), Service Officers must:

• either cancel the claim or delete the service line/s (for that account only), and
• return a copy of the account/ invoice or receipt and Medicare Claim form (if applicable) to the claimant, together with the appropriate standard letter

Returning account/ invoices or receipts by claimant request

Where a claimant wishes to retain:

• their medical accounts/ invoices or receipts and they are present at a Service Centre:
• the Service Officer must copy and return all paperwork associated with the claim

If the claimant is not present at a service centre:

• and has specifically requested their medical accounts/ invoices or receipts, the Service Officer
• retains all paperwork associated with the claim, and
• returns a certified copy of the accounts/ invoices or receipts to the claimant with the 'Documents enclosed' standard letter

The Process page contains details on how to certify a copy of account documents.

The Resources page contains a link to the Standard Letter Templates page.

The Health Insurance Regulations 2018 provide details of what is required for a valid referral. The following information outlines the requirements where an account/ invoice has incomplete, invalid or no referral details supplied.

Obtaining correct referral details

If a claim is submitted with incorrect, invalid or no referral details. Service Officers must try to contact the practice where the service was provided to get the correct referral details.

Note:

• if the health professional cannot be contacted, the Service Officer may choose to contact the referring health professional to get the correct referral details
• if no details are presented on the account/ invoice and the claimant is in receipt of a valid referral, Service Officers must follow the process on the Process page

The Process page contains details on how to record referral information where correct referral details have been obtained.

Referral details not obtained

Service Officers must not reject the claim in the first instance.

Under no circumstances should Service Officers guess the details of the referring practitioner.

Note: patient claims history is not an acceptable source for referral details. The Medicare Benefits Schedule (MBS) details the account/ invoice requirements, including the information that is to be included on accounts/ invoices and receipts by a specialist or consultant physician, for a patient who has been referred.

The Process page contains:

• details on how to action accounts/ invoices where referral details cannot be obtained and the claim is for a single service
• scenarios and instructions where referral details cannot be obtained and the claim is for multiple services

Multiple services or multiple accounts/ invoices or receipts

If referral details cannot be obtained and the claim is for multiple services, it is not practical to return the claim to the claimant.

The Process page contains details about how to process multiple services or multiple accounts.

Bulk bill claims

If a bulk bill claim is submitted with incomplete, invalid or no referral details. Service Officers must reject the claim using the appropriate reason code.

Service Officers must use the help key F1/cursor on the claims processing screen where required. This help message will help Service Officers in determining what action must be taken and the appropriate rejection code.

If more guidance is needed, Service Officers must seek help from their team leader or manager.

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

Non-referred services

If a service is provided without a current or valid referral, the service is deemed as a non-referred service.

The Process page contains details:

• on how to action a non-referred service, and
• details if a Service Officer is unable to verify the service was non-referred

The definition of digital image is anything that is provided to Services Australia in a digital image form such as:

• photographs
• pictures
• written documents
• GIFs
• Memes, and
• Text

Sometimes customers may upload inappropriate or aggressive material that is not relevant to the agency’s functions. These images must not be retained on a customer’s record but cannot be deleted.

A notional charge can be used where the:

• health professional has raised a total charge to cover a group of services
• services are rendered by the same health professional
• services are for a patient/s enrolled on the same Medicare card
• services dates are the same or different

Exception - this policy does not relate to manually keyed radiation oncology items.

The Resources page contains a table showing a notional charge example.

Notional charges and health professional's discounts

Health professionals may offer a discount to the notional charge stated on the account/ invoice. There are 2 types of discounts that can apply:

• Conditional
• Unconditional discounts

Note: if the account/ invoice shows:

• one charge for the services, this charge becomes the notional charge under which the services are processed
• individual charges for each service and the health professional has applied:
• an unconditional discount, this discount charge becomes the notional charge under which the items are processed
• a conditional discount, the Service Officer must key the full charge, not the discounted amount

Conditional discounts

A conditional discount applies where the patient must pay the account/ invoice within a specified time in order to receive the discount.

Where the account is:

• paid within the specified timeframe, Service Officers must key the discounted amount as a notional charge. The Process page contains details about how to process conditional and unconditional discounts
• unpaid and a Pay Doctor via Claimant cheque is to be issued, Service Officers must key the undiscounted amount as the notional charge. See the 'Accounts/ Invoices' section in Patient claims processing in Medicare

Unconditional discounts

An unconditional discount applies when the health professional accepts the discounted charge as full payment, regardless of when the account/ invoice is paid.

These accounts/ invoices are usually recognised by wording to the effect 'Medicare benefit will be accepted as full payment' or 'your refund cheque will be accepted as full payment'.

Note: unconditional discounts where health professionals have indicated that the Medicare benefit is accepted as full payment only apply to out-of-hospital services.

By changing the charge to equal the benefit there is no need to substantiate the claim for Medicare Safety Net purposes, as the patient has no out-of-pocket expenses.

The Process page contains details about how to process conditional and unconditional discounts.

Rejected items under a notional charge

If an item or items on an account/ invoice where a notional charge applies is rejected, contact the surgery and request an amended account/ invoice that states the individual charges for each item.

Note: Service Officers must key the rejected item/s as the last service.

The Legal Services Division has advised that the agency does not have a function under the Human Services (Medicare) Act 1973 to:

• collect and process information for the purpose of the Income Tax Act 1986, or
• for any services that do not attract a Medicare benefit

By entering miscellaneous items into the system, the agency is acting outside its legal function.

Service Officers are advised that it is not their responsibility to determine if a miscellaneous item is considered to be clinically relevant in accordance with the Medicare Benefits Schedule (MBS).

Service Officers must not:

• record details of miscellaneous items appearing on an account/ invoice or receipt, or
• key either 'MISC', '0000' or '99' for any miscellaneous charges

If an account/ invoice does not contain an item number or a description sufficient to identify the service, it is considered to be a miscellaneous service and must not be keyed. The same applies to accounts/ invoice with the wording 'miscellaneous'.

Miscellaneous items examples

Below are examples of miscellaneous items:

• Non-claimable pathology, for example, Thin Prep
• Facility fees
• Bandages
• Medications
• Any charge on an account/ invoice that is not for a clinically relevant service (MBS item). For example the account / invoice indicates a service charge, admission fee, call out fee

This list is by no means exhaustive and other miscellaneous items may appear on an account/ invoice.

The References page contains links to the Human Services (Medicare) 1973 legislation.

The Process page contains details about how to process accounts/ invoices with miscellaneous items.

MBS items over $9999.99 (charges over $10,000)

The use of '0000' is only acceptable where the charge is over $9999.99 for a clinically relevant service. The Medicare payment system is unable to accept amounts greater than this figure.

For more details and process steps, see Charges $10,000 or more (greater than $9,999.99) for Medicare patient claims.

Section 129AC of the Health Insurance Act 1973 (the Act) states that where, as a result of a false or misleading statement:

• an amount paid, purportedly by way of benefit, or
• payment under the Act, exceeds the amount (if any) that should have been paid
• the amount of the excess is recoverable as a debt due to the Commonwealth from the person by or on behalf of whom the statement was made

Therefore, where an account/ invoice is submitted to the agency for processing and the item is either:

• incorrectly marked as an outpatient service, or
• not specified as an in-patient service, and
• the benefit is processed at 85% of the schedule fee

Debt recovery must be sought from the health professional who issued the account/ invoice, not the patient.

All processed claims where Medicare benefits have been overpaid, whether they are less than or more than $100, must be sent to Assessing and Benefits for recovery action.

The References page contains a link to the Health Insurance Act 1973 legislation.

Gap statements

If a claim has been incorrectly processed at the 85% (outpatient) level instead of the 75% (in-patient) level:

• Service Officers can issue a manual statement of benefit letter
• a manual statement of benefit will allow for the patient to claim the 25% gap from their private health fund, if eligible, and
• recovery action must be pursued

Note: Service Officers are not required to wait until the overpayment has been repaid before issuing a manual statement of benefit.

Medicare benefits are not payable where a health professional accepts a barter arrangement in settlement of their account/ invoice.

Barter arrangements do not meet account/ invoice requirements. See the Account/ invoice requirements section above.

A barter arrangement may also be known as:

• bartering
• exchange
• barter exchange
• trade exchange
• countertrade exchange

Bartercard is an organisation that works on a form of barter trade. This is where members buy goods and services from other members with their value being credited and debited in what are termed 'trade dollars'. No money changes hands.

The References page contains a link to the Health Insurance Act 1973 legislation.