Account and receipt documents for Medicare claims processing 011-43010030

Photocopy the original account/ invoice documents.

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)

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

• filling out a VG4 form (face to face services), or
• making a processing note on the PaNDA file and placing a comment in CDMS personal

The Resources page contains a link to the VG4 form.

Process the claim.

Is the claimant present in the service centre?

• Yes, go to Step 2
• No, return the document to the claimant, together with the appropriate letter. Record note in Consumer Directory Management System (CDMS)

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

Advise the claimant that:

• the referring health professional details are incorrect, invalid or missing and in order 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.

The Service Officer must:

• reject the services that require a valid referral with the appropriate reason code
• process all other services as usual
• photocopy or print the account/ invoice, notate that it is a copy and return to the claimant with the appropriate standard letter and blank claim form

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

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

The Service Officer must:

• attach the claim form to the accounts/ invoices or receipts that were processed
• photocopy or print the account/ invoice, noteate it is a copy and return the accounts/ invoices or receipts that require a valid referral to the claimant with the appropriate standard letter and a blank claim form MS014

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

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

The Service Officer must:

• reject the services that require a valid referral with the appropriate reason code
• process all other services as usual
• photocopy or print the accounts/ invoices that were not processed, notate that it is a scanned copy and return to the claimant with the appropriate standard letter and a blank claim form MS014

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

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

Confirm the services were non-referred.

Get the correct non-referred item number for the service rendered.

Record a processing note by:

• filling out a VG4 form (face to face services), or
• making a processing note on the PaNDA file and placing a comment in CDMS personal

The Resources page contains a link to the VG4 form.

Process the claim.

Is the service verified as non-referred and claimant present in the service centre?

• Yes, go to Step 2
• No, go to Step 3

Advise the claimant that no benefit is payable under a referred item number where there is no valid referral.

Explain that if no referral was issued, the claimant must seek an account/ invoice with non-referred item numbers from the health professional.

Return the document to the claimant, together with the appropriate letter.

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

If the discount is:

• conditional, go to Step 2
• unconditional, go to Step 3

Subtract the discounted amount from the total charge.

Raise 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 $3085 for a number of services and the account/ invoice has been paid by the required date, the discounted amount of $2935 becomes the notional charge.

Process the claim by either:

• changing the charge for each item to match the benefit after initially entering the claim onto the system
• 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.

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 Background page for details about notional charges

Return the account/ invoice or receipt to claimant.

Note: if the claimant is not present at a service centre, return the original document to the claimant, together with the appropriate letter. See Preparing, quality and peer to peer checking of Medicare external mail.

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

Is the claimant present?

• Yes,
• Process the valid MBS item(s)
• 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)
• Copy the account/ invoice, notate that it is a copy and return to the claimant with the appropriate standard letter

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

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

• For manual patient claim, go to Step 2
• For digital self-service claim, go to Step 3

Attempt to contact the health professional, request either:

• a faxed amended account/ invoice, or
• the required details over the phone and complete processing notes verifying information

Record a processing note by:

• filling out a VG4 form (face to face services), or
• making a processing note on the PaNDA file and placing a comment in CDMS personal

If contact cannot be made with the health professional, return the claim to the claimant with the appropriate letter.

Note: copies of letters must be uploaded into PaNDA. See Preparing, quality and peer to peer checking of Medicare external mail.

Attempt to contact the health professional. Request the details over the phone and complete processing notes verifying information.

Record a processing note by making a comment in CDMS personal.

If contact cannot be made with the health professional reject the claim with reason code 454 (resubmit claim for service - some details not shown on image).

If the account/ invoice or receipt was not submitted reject the claim with reason code 455 (resubmit claim for this service - include account and receipt).