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Account and receipt documents for Medicare claims processing 011-43010030

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This page contains details on how to process account and receipt documents for Medicare processing.

On this page:

Certify a copy of account/invoice documents

Record correct referral details where they have been obtained

Single service on account/invoice or receipt

Processing multiple services or multiple accounts/invoices or receipts

Processing an account/invoice with a non-referred service

Processing of unconditional discounts or paid conditions discounts

Processing accounts/invoices with miscellaneous items

Accounts/invoices and receipts requiring additional information


Certify a copy of account/invoice documents

Table 1: describes how to certify a copy of account/invoice documents when returning the originals. For service centre staff only.

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Step

Action

1

Photocopy original account/invoice documents

Photocopy the original account/invoice documents.

2

Endorse the photocopy

Use the following notations to endorse the photocopy:

  • Date stamp the copy
  • Signature and logon ID
  • All of the following words:
    • benefit paid
    • this is a true copy of the original document
    • original documents returned to claimant after photocopying
    • benefit paid (if the claim is processed in the service centre before returning to the claimant)

Record correct referral details where they have been obtained

Table 2: describes how to record the correct referral details when they are confirmed by the health professional by phone. Note: this process is mandatory.

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Step

Action

1

Record referral details

Request an amended account/invoice to be faxed from the surgery (face to face services only), or record a processing note by:

  • filling out a VG4 form (face to face services), or
  • recording a processing note on the PaNDA file with the following details:
    • who the Service Officer spoke with and their position in the practice
    • the date of referral and length of referral
    • referring provider details

2

Process claim

Process the claim.


Single service on account/invoice or receipt

Table 3: describes how to action a claim where the referral details cannot be obtained and the claim is for a single service. See also: Services not claimable for Medicare benefits section in Account/invoice documents.

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Step

Action

1

Claimant present in a service centre

Is the claimant present in a service centre?

  • Yes, go to Step 2
  • No, contact the claimant using the Z0828 - Medicare claim needs more information letter. The Resources page contains a link to the Digital Messaging Capability (DMC) to create and send letters.

2

Claimant present in service centre

Tell the claimant that:

  • the referring health professional details are incorrect, invalid, or missing and to process the claim, there must be a valid referral
  • an attempt to contact the health professional's surgery has been made to get the details, but was unsuccessful

Return the claim to the claimant and ask them to seek correct referral details from their health professional.


Processing multiple services or multiple accounts/invoices or receipts

Table 4: outlines different scenarios and instructions for processing multiple services or multiple account/invoice receipts claims when a referral is missing/invalid.

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Item

Description

1

Determine claim type

If the claim is for multiple:

  • services and has one account/invoice or receipt, go to Step 2
  • account/invoice or receipts, go to Step 3
  • accounts/invoices or receipts and has multiple services on each account/invoice or receipt, go to Step 4

2

Claim is for multiple services and has one account/invoice or receipt

Service Officers must attempt to contact the health professional to confirm referral details if during business hours.

If contact is:

  • successful:
    • fill out a VG4 form (face to face services only), or
    • record processing notes in PaNDA and continue processing the claim
  • unsuccessful:
    • reject the services that require a valid referral with the appropriate reason code
    • process all other services as usual

3

Claim is for multiple account/invoice or receipts

Service Officers must attempt to contact the health professional to confirm referral details if during business hours.

If contact is:

  • successful:
    • fill out a VG4 form (face to face services), or
    • record processing notes in PaNDA and continue processing the claim
  • unsuccessful:
    • process all services as usual
    • for the services that require a valid referral, 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 and send letters

4

Claim is for multiple accounts/invoices or receipts and has multiple services on each account/invoice or receipt

Service Officers must attempt to contact the health professional to confirm referral details if during business hours.

If contact is:

  • successful:
    • fill out a VG4 form (face to face services only), or
    • record processing notes in PaNDA and continue processing the claim
  • unsuccessful:
    • process all services as usual
    • for the services that require a valid referral, 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 and send letters

Processing an account/invoice with a non-referred service

Table 5: describes how to process a non-referred service that is submitted using a referred item number.

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Step

Action

1

2

3


Processing of unconditional discounts or paid conditions discounts

Table 6: describes how to process accounts/invoices with unconditional discounts or paid conditional discounts.

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Step

Action

1

Discount conditional or unconditional

If the discount is:

2

Conditional discount (specified amount and percentage of total charge)

Subtract the discounted amount from the total charge.

Key the discounted amount as a notional charge.

Example: an account/invoice states that a $150 discount applies if payment is made before a specified date. If the total charge is $3,085 for a number of services and the account/invoice has been paid by the required date, the discounted amount of $2,935 becomes the notional charge. Continue to process the claim.

3

Unconditional discount (Medicare benefit is accepted as full payment)

Process the claim by:

  • changing the charge for each item to match the benefit after initially entering the claim onto the system, or
  • after initially keying the claim details onto the system, add the benefits for all items together and use the end figure as a notional charge

Note: unconditional discounts only apply to out-of-hospital services.


Processing accounts/invoices with miscellaneous items

Table 7: describes how to process an account/invoice or receipt submitted for payment of a Medicare benefit and there is a miscellaneous item listed.

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Step

Action

1

Determine item type

If there is:

  • only a miscellaneous item listed, go to Step 2
  • a valid Medicare Benefits Schedule (MBS) item and a miscellaneous items, go to Step 3
  • a notional charge present (including a service or goods that does not attract a Medicare benefit), see the Background page for details about notional charges

2

Only a miscellaneous item listed

If the claimant is:

  • present at a service centre:
    • return the account/invoice or receipt to the claimant
    • tell the claimant that no Medicare benefits are payable
  • not present at a service centre, no benefits are payable. Send the claimant the Z0829 - Your claim for Medicare Benefit - not paid/already paid/paid-partially letter. The Resources page contains a link to the to the Digital Messaging Capability (DMC) to create and send letters

3

Valid Medicare Benefits Schedule (MBS) item and a miscellaneous item

Is the claimant present?

  • Yes:
    • process the valid MBS item(s)
    • tell the claimant that Medicare benefits are only payable for MBS items
    • ask the claimant if a copy is required. If so, photocopy the account/invoice or receipt and stamp 'Medicare rebate paid'. If not, endorse the back of the account/invoice 'copy not required'
  • No:
    • process the valid MBS item(s)
    • send the claimant the Z0829 - Your claim for Medicare Benefit - not paid/already paid/paid-partially letter. The Resources page contains a link to the to the Digital Messaging Capability (DMC) to create and send letters

See also: Certify a copy of account/invoice documents.


Accounts/invoices and receipts requiring additional information

Table 8: describes the process where an account/invoice or receipt submitted needs more details.

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Step

Action

1

Determine claim type

For:

2

Manual patient claim

Attempt to contact the health professional during business hours:

  • Verify the required details over the phone or ask for an amended account/invoice to be faxed (for face to face service only) and
  • Record processing notes in PaNDA or complete a VG4 form (for face to face service only)

If contact cannot be made with the health professional, issue the claimant the Z0828 - Medicare claim needs more information letter. The Resources page contains a link to the Digital Messaging Capability (DMC) to create and send letters.

3

Digital self-service claim

Attempt to contact the health professional if during business hours to request the details over the phone.

If the contact was:

  • successful:
    • Process the claim and record a processing note on the PaNDA work item
  • unsuccessful:
    • Reject the claim
    • Use a reason code appropriate for the details missing or 454 (Resubmit claim for service - some details not shown on image) if none are appropriate