Charges $10,000 or more (greater than $9,999.99) for Medicare patient claims 011-43010090

Due to insufficient space in the Charge field in mainframe, the Medicare system does not allow an amount greater than $9,999.99 to be accepted for a single item. If Service Officers key a higher amount, the system returns the message 1-INV CHG.

When there is an account with:

• one item with a charge greater than $9,999.99 for an in-hospital item, see the Process page for procedure
• more than one item with a charge greater than $9,999.99 for in-hospital items:
• Face to Face Service Officers must escalate via Multi-Function Device (MFD) listing. See Manage Health Services Scanning
• Health Service Delivery (HSD) Entry Service Officers must re-categorise the work item to work type Patient Claim over Ten Thousand (PC PC OVER TEN) folder
• HSD Established/Experienced Service Officers see the Process page for procedure
• one item with a charge greater than $9,999.99 for an outpatient item, see the Process page for procedure
• more than one item with charge greater than $9,999.99 for outpatient items
• Face to Face Service Officers must escalate via Multi-Function Device (MFD) listing, see Manage Health Services Scanning
• Health Service Delivery (HSD) Entry Service Officers must re-categorise the work item to work type Patient Claim Over Ten Thousand (PC PC OVER TEN) folder
• HSD Established Service Officers must raise proficiency
• HSD Experienced Service Officers see the Process page for procedure

When multiple services are performed on the same day, by the same health professional, the multiple operation rule or Diagnostic Imaging Multiple Service Rule (DIMSR) may apply.

For more details, see:

• Multiple operations assessing rules in Medicare
• Diagnostic imaging assessment rules in Medicare

For surgical item numbers, the invoice may have individual charges for each item number. The schedule fee for each surgical item number is calculated according to the multiple operation rule. The resulting fees are totalled and used to calculate the benefit amount. The benefit calculated and the total charge are written to the patient history against the item number with the highest schedule fee.

Service Officers must make sure that when processing these claims any subsequent service lines entered must show a charge equivalent to, or higher than, the schedule fee for each item number. This avoids an underpayment being made. Service Officers should check for CHG LOW return message.

When claims over $9,999.99 have been submitted via digital self-service, see Tables 2 and 3 in Process digital self-service claims for processing information.

Note: tell customers that due to system limitations, claims for individual items with a charge greater than $9,999.99 must be submitted using the Medicare claim form (MS014).

This applies for out-of-hospital services only.

When an out-of-hospital claim exceeds $9,999.99, Service Officers must confirm the Medicare Safety Net before processing the claim.

• Face to Face Service Officers must escalate via MFD listing. See the Resources page in Manage Health Services Scanning
• Health Service Delivery (HSD) Entry Service Officers must re-categorise the work item to work type Patient Claim Over Ten Thousand (PC PC OVER TEN) folder
• HSD Established/Experienced Service Officers, see the Process page for procedure

Service Officers must issue a manual Statement of Benefit letter showing the correct charge for all claims with an item charge greater than $9,999.99. See How to issue a manual statement of benefit.

The Resources page contains contact details for the Assessing and Benefits team and a link to the Z2261 - Your statement of Medicare Benefits letter.