Patient claim requirements for payment of Medicare benefits 011-43010040

Section 20(1) of the Health Insurance Act 1973 requires that the Medicare benefit be paid to the person who incurs the medical expense in respect of the service.

A claimant is the person who incurred the medical costs for a service rendered.

The claimant can submit the claim via any claiming channel.

If the claimant chooses to lodge the claim via post, the claimant must complete a Medicare Claim form (MS014) and sign the declaration.

The Resources page contains a link to the MS014.

The claimant must be identified for each claim processed. The Medicare benefit is to be paid to the claimant.

Service Officers must make sure the claimant is identified for all claims irrespective of any obvious relationship between them and the patient.

For example, Joanna has seen the doctor. Joanna's friend, Sandy pays for the services provided to Joanna. This makes Sandy the claimant. Sandy is entitled to claim a Medicare benefit for incurring the expense. Sandy and Joanna do not need to be on the same card for Sandy to be paid the Medicare benefit.

Note: if a person pays for a medical service and is seeking a Medicare benefit they must be recorded as the claimant.

The Government announced in the 2015-16 budget that payment of Medicare benefits will cease to be paid via cheques from 1 July 2016. From 1 July 2016, payments are made via electronic funds transfer (EFT).

Funds are deposited into the claimant’s nominated bank account. Where the claimant does not have valid EFT details stored in the CDMS or cannot provide valid temporary or permanent EFT details at the time the claim is submitted, the payment for the claim is held until EFT details are provided.

A run is actioned each night to search CDMS and identify any new EFT details for a claimant that has a ‘HELD’ payment. If new details are found the system inserts the EFT details into the BREFTE redirect table. These details are picked up and processed in the next payment run for payment to the claimant.

All third party claimants (for example, football clubs) must provide temporary bank details on the Medicare claim form (MS014).

The Resources page contains a link to the MS014.

Any persons 14 years and over can claim a Medicare benefit where they have incurred the cost for services provided to a Medicare eligible person.

The account or receipt does not need to be in the claimant's name in order for the claimant to collect a Medicare benefit. The claimant needs only to confirm that they incurred the cost of the medical service by signing the declaration on the Medicare Claim form (MS014) or printed receipt.

Where further identification of a claimant is required, the printed receipt must be notated with the details of the identification sighted.

The Resources page contains a link to the MS014.

See also: Account and receipt documents for Medicare claims processing.

When claiming Medicare benefits at a service centre, the claimant is required to produce their Medicare card.

This policy covers situations where a claimant cannot produce a Medicare card when claiming their Medicare benefits.

Note: either a physical or a digital Medicare card is acceptable.

Claimant unable to produce a Medicare card

Before a Medicare benefit is paid, 2 forms of identification must be provided or a security check performed where either the claimant:

• cannot produce their Medicare card, or
• has incurred the expense for a Medicare eligible patient but the claimant is not eligible for Medicare enrolment. For example, a grandmother visiting from overseas takes the granddaughter to see a doctor. See section on Claimant not entitled to claim Medicare benefits below

Claimant identification where claimant unable to produce a Medicare card

Photographic identification is preferable, however if unavailable, identification with the claimant's name and signature will be enough.

Acceptable identification documents include a current:

• government issued proof of age card
• driver's licence
• passport
• credit card
• debit card
• student ID card
• security licence
• employment identification card

Service Officers must:

• provide a brief notation on the printed receipt (office copy) indicating that identification was sighted, for example, ID sighted, ID checked
• record any identification numbers associated with the type of identification provided by the claimant, for example, driver's licence numbers

Security check

The claimant must pass a security check for any benefit to be paid. See also: Authenticating a Medicare customer.

Claimant unable to provide proof of identity when unable to provide a Medicare card

A benefit is not to be paid where one or more of the following apply.

Where the claimant:

• is unable to provide acceptable identification
• did not pass the security check
• appears to be less than 14 years old, and cannot prove otherwise by student ID

Claimant and patient on different card numbers

Where the claimant and patient are on different card numbers, the claimant's details are captured and recorded during the processing of the claim.

Note: this process is not available via the Express Plus Medicare mobile app.

Claimant not entitled to Medicare benefits but incurred the cost for an eligible patient

If a claimant is not eligible for Medicare but incurred the cost for an eligible patient under Section 20(1) of the Health Insurance Act 1973 requires that the Medicare benefit be paid to the person who incurs the medical expense in respect of the service.

The claimant:

• Is entitled to receive Medicare benefits if they have incurred the cost of a service provided to an eligible Medicare patient
• Must provide proof of identity. See information above 'Claimant unable to produce a Medicare card' and 'Claimant identification'

Service Officers can search the CDMS to see if the claimant is already registered as a consumer.

The Process page provides steps on creating a claimant in CDMS for the purpose of receiving a Medicare benefit if that claimant is not eligible for Medicare.

The correct policy for the signing of the MS014 is as follows:

• the form must be signed by the claimant
• where the claimant cannot sign, an appointed Power of Attorney, Guardianship, Administrative orders and Authorised Representative for Medicare may sign on their behalf
• where there is no signature, see Incomplete or incorrect Medicare claim forms

Note:

• the claimant is the person who incurred or is liable for the expense of medical services provided
• there does not need to be any special relationship between the patient and the claimant

Power of Attorney, Guardianship, Administrative Orders and Authorised Representative for Medicare

Where the claimant is unable to sign the MS014 form, an appointed Power of Attorney, Legal Guardian, Administrator or Authorised Representative for Medicare may sign on their behalf. These orders give an individual the legal authority to act on behalf of the claimant.

Note: Service Officers must make sure the Power of Attorney, Guardianship Order, Administrative Order or Authorised Representative for Medicare provide authority for that individual to claim a Medicare benefit on the claimant's behalf.

Claimant signature differs from claimant details

Where a claimant's signature is clearly legible and obviously does not correspond with the name of the claimant detailed on the claim form, the claim must not be paid. For example, the claimant name is Mary Jones and the signature clearly reads Bob Smith.

Note: a claimant's signature does not need to be legible to be acceptable. Claimants can use any type of symbol as their signature, for example, X. Claims should only be returned where there is a difference in names.

This information provides Service Officers with information on how to pay Medicare benefits to claimants when they are claiming at a service centre.

Claims can be lodged in a service centre:

• via the staff assisted document lodgement (formerly known as the drop box), or
• as a face-to-face service

If claimants choose to lodge a claim via the staff assisted document lodgement, they must complete a Medicare claim form MS014 and attach to the original account/receipt being lodged for processing.

As a general rule, any persons 14 years and over can claim a Medicare benefit where they have incurred the cost for services provided to a Medicare eligible person.

When a claimant or any person 14 years and over and enrolled on the same Medicare card as the claimant acting on behalf of the claimant attends a service centre to claim for Medicare benefits, they are not required to fill in the Medicare Claim form (MS014), provided that the account is paid in full.

The claimant is always the person who incurred the medical expense for a service rendered. The claimant must sign the printed receipt when attending a service centre acknowledging that they have paid for the medical service rendered.

The claimant is required to produce their Medicare card and present either:

• the account and receipt
• a combined account and receipt

Where the claimant is not the patient, the claimant must either provide:

• the patient's Medicare card number if available
• sufficient details to identify the patient

Service Officers must ensure that the claimant details are correctly recorded. The customer at the counter may not necessarily be the claimant. Service Officers must ask the customer every time whether they are the claimant (incurred the expense).

The Process page contains details on how to action an EFT claim lodged via face-to-face at a service centre.

The Resources page contains information about the collection of Medicare benefits by a customer enrolled on the same Medicare card and a link to the MS014.

This information covers situations where a patient claim is submitted for payment using a Medicare card with a previous issued number.

Patient claims using a previously issued card number

Claims cannot be paid if the previously issued card number has been:

• reported as lost or stolen
• flagged as having fraudulent activity
• invest flagged
• expired more than 12 months

These claims must be returned to the claimant.

See also: Medicare cards

Where a patient claim is submitted for payment using a Medicare card with a previously issued card number, all of the following criteria must be met before the claim can be paid using the current card number:

• the claimant's details are an exact match to those contained in the Consumer Directory Maintenance System (CDMS)
• a current card number has been issued within the last 12 months and is not reported as lost or stolen or has an invest or fraud flag
• the claimant must have paid the account in full

Note: for a reported lost or stolen card where the claimant is at the service centre and the claimant's identity can be established and satisfies eligibility, the claim must be paid. Service Officers must retain the lost or stolen card being used.

The Process page contains details about:

• how Service Officers process claims made using a previously issued card number, and
• how to action a claim where the claimant is making an EFT claim using a Medicare card with a previously issued card number

Claimant is not active on the patient's Medicare card

Where the claimant is not active on the patient's Medicare card but has incurred the expense, the claim cannot be paid. Tell the claimant to contact the patient for the new card number. Ask the claimant to inform the patient they should contact Services Australia in relation to their Medicare card.

Unpaid claims (PDVC cheques) submitted by a surgery using a previously issued card number

If the claim is bulk lodged from a surgery, Service Officers must contact the surgery (where possible) and ask that they update the card issue information on their records. Note on a VG4 form that the surgery has been contacted.

Service Officers can disclose information to providers for the purposes of:

• processing Medicare claims
• making appropriate payments in relation to those claims
• administering any other legislative provisions governing the Medicare program

The Resources page contains a link to the VG4 form.

Medicare Easyclaim

Where a new Medicare card has been issued, Medicare Easyclaim has a 75 day grace period for the previously issued card number. This period begins from the date of issue of the new card number and applies to both patient and bulk bill claims.

See also: Medicare Easyclaim service

Quality control

If the information on the MS014 form differs from the information on the QBBI screen, the quality control (QC) checker must access CDMS to ensure that the claim was paid using a card issue number issued in the last 12 months. The QC checker must not automatically record the transaction as an error.

There is a minimum turnaround time for Medicare benefits. These minimum payment times vary according to the claiming channel.

The minimum payment times relate to the number of days (including weekends) the benefit is held by Medicare prior to release for payment to the claimant.

Note:

• the count for the minimum payment time starts from the date the claim is lodged
• the minimum payment times are decided by Government in consultation with peak bodies

Electronic Funds Transfer (EFT) payments are made on the next working day, depending on the timelines of individual financial institutions.

The agency does not have any control over these timelines.

The agency releases Easyclaim payments immediately, however individual financial institutions may not make funds available to their customers immediately.