Account and receipt documents for Medicare claims processing 011-43010030

Account documents, such as invoices, accounts, receipts, and assignment of benefit forms, are important for assessing and paying Medicare claims. They contain essential information needed to process a claim and provide evidence for Services Australia. This is why the agency must retain all documentation associated with claims for Medicare benefits.

Lodgement advice

Lodgement advice is a document that tells a claimant their claim has been lodged electronically by the health professional on their behalf. It may also be called a statement of claim.

If a claimant attempts to claim Medicare benefits using a lodgement advice or a statement of claim, the patients' claim history is to be reviewed to see if the service has already been processed.

• If the service:
• has been processed, the service cannot be claimed again and will be rejected with reason code 162
• is not on the patient's claim history, Service Officers will process the claim using the details on the lodgement advice

Alterations to accounts/invoices or receipts

If an account/invoice or receipt has been altered and the information to the services rendered is not clear, Services Officers must:

• verify the details with the health professional, and
• make sure all verifications are documented on the processing note

If the health professional confirms the amended account/invoice is not true and correct, Service Officers must submit a fraud tip off. See Suspected Medicare fraud and Business Integrity (BI) flags. See the Process page > Table 8.

The Resources page contains a link to the Digital Messaging Capability (DMC) to create and send letters.

Services not claimable for Medicare benefits

If a service is not claimable, the service must be rejected, and all related associated claim documentation retained. See the Process page > Table 7

The Resources page contains a link to the Digital Messaging Capability (DMC) to create and send letters.

Accounts/invoices and receipts requiring additional information

If the submitted account/invoice or receipt does not include all required details, the claim cannot be paid until the missing information is received.
For:

• manual patient claims, see the Process page > Table 8 > Step 2
• digital self-service claims, see the Process page > Table 8 > Step 3

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 refer to Suspected Medicare fraud and Business Integrity (BI) flags and submit a fraud tip off if required.

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 claim Medicare benefits.

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 is considered paid:

• Printed accounts/invoices 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
• Documents provided by the health professional prior to the service that estimate charges or services are not an accurate or valid proof of service and are therefore not considered as an account/invoice or receipt and cannot be used to pay a claim

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 brief 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
• An asterisk (*) immediately after the item number
• Including the word/s:
  • 'in hospital' in the service description
  • 'inpatient' in the service description
  • 'admitted patient' in the service description
  • 'admitted' in the service description

If not sure whether the item was performed in-hospital, see the Process page Table 8.

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

Note:

• account/invoice or receipt documents showing a hospital name does not mean the patient was treated as an admitted patient or inpatient
• 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 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.

Service Officers can process the claim if they can establish that the:

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

Health professionals are 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 key 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).

See Process page > Table 4.

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 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 applicable claiming channel. For digital self service claims, the patient and claimant must be on the same Medicare card.

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 for unpaid Medicare claims (payee code 2). This helps the health professional 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
• reference number
• folio number, or
• invoice number

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

See Table1 > Step 11 in Patient claims processing in Medicare for what to key on the ACRF line.

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

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, record processing notes verifying details.

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

Services Australia 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.

Where the state government body bank details are not supplied on the claim form (MS014), the claim is rejected, and correspondence to be addressed to the designated business contact listed on the claim form. See Table 8.

The Resources page contains a link to the Digital Messaging Capability (DMC) to create and send letters.

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.

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

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

Accepted proof of payment

A claim is to be treated as a paid patient claim if a proof of payment has been supplied using one of the following accepted documents:

• Internet receipts including:
  • BPAY
  • BPOINT
  • PayPal
  • Online bank transfer
• Post office receipts
• 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 a receipt is not provided, see the Process page > Table 8

The Resources page contains links to the:

• Services Australia website for proof of payment and advice on taking/scanning clear photos and documents
• Digital Messaging Capability (DMC) to create and send letters.

Details required in the receipts

Receipts must detail all of 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
• The actual amount paid
• The date of payment
• 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 Service Officers believe the proof of payment may be fraudulent, they must:

• contact the health professional to confirm if the payment has been received
• complete processing notes detailing the action taken

If the health professional:

• confirms payment was not received, or if the health professional cannot be contacted, send the claimant the Z0828 - Medicare claim needs more information letter.
  The Resources page contains a link to the Digital Messaging Capability (DMC) to create an send letters
• cannot confirm that the service being claimed took place and the Service Officer believes that the claim may be fraudulent, refer to Suspected Medicare fraud and Business Integrity (BI) flags

See the Process page > Table 7, or Preparing, quality and peer to peer checking of Medicare external mail, where the account/invoice or receipt:

• does not contain a payable Medicare Benefits Schedule (MBS) item, or
• contains MBS and non-MBS items

Service Officers must only key MBS payable items in Mainframe.

Note: no manual letter is required when a digital self-service has been rejected in Mainframe.

Returning account/invoices or receipts by claimant request

If a claimant is at a service centre and wants to keep the medical accounts/invoices or receipts, the Service Officer must copy all paperwork associated with the claim and return the original to the claimant.

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

The Resources page contains a link to the Digital Messaging Capability (DMC) and Standard Letter Templates.

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 servicing health professional during business hours, 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 instructions on the Process page.

The Process page contains details on how to record referral information where 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, see the Process page for details about how to process multiple services or multiple accounts.

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 details:

• how to action a non-referred service, and
• what to do if a Service Officer is unable to verify a 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. See Removing a digital image from customer records for more details.

A notional charge can be used where the:

• health professional has raised a total charge to cover a group of services
• health professional has discounted their 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

If the account/invoice shows one charge for the services, this charge becomes the notional charge under which the services are processed.

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

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'.

For unconditional discounts, this discount charge becomes the notional charge under which the items are processed.

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

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

Rejected items under a notional charge

All accounts and invoices subject to notional charge must itemise the individual cost of each service. See Process page > Table 8.

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

Services Australia's functions under the Human Services (Medicare) Act 1973 do not include collecting and processing information for:

• the purposes of the Income Tax Act 1986, or
• services that do not attract a Medicare benefit

Entering miscellaneous items into the system is outside, the agency's legal function.

Service Officers are not responsible for determining whether a miscellaneous item is clinically relevant in accordance with the Medicare Benefits Schedule (MBS).

Service Officers must not:

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

Accounts and invoices lacking a specific MBS item number or sufficient service details, including those designated as ‘miscellaneous’, do not meet our processing requirements. They will be classified as miscellaneous charges and will not be processed..

Miscellaneous items examples

The below are some examples of miscellaneous items:

• Non-claimable pathology, for example, Thin Prep
• Facility fees
• Bandages/plaster casts
• Crutches
• Hiring of medical equipment
• Medications
• Any charge that is not for a clinically relevant service (MBS item). For example, fees for:
  • additional non-MBS services
  • cancellation or missed appointments
  • admissions
  • travel expenses
  • call outs
  • surcharges for payments made by credit card for example

Medicare only pays for services that are provided to the patient. Medicare does not pay for goods or other costs that are not part of the service, for example travel services. If the claimant is charged a fee for a cancellation or missed appointment, this is a matter between them and the health professional.

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 $9,999.99 (charges over $10,000)

The use of '0000' is only acceptable where the charge is over $9,999.99 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.

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.