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

All Service Officers must process claims at the first point of contact, unless the claim was submitted online via:

• Medicare Online Account (MOA), or
• Express Plus Medicare mobile app

These claims are not processed on day zero. See Process digital self service claims.

See Table 2 for processing claims at first point of contact.

• Face to Face Service Officers must escalate via MFD listing. See the Resources page in Manage Medicare 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 following the process in Work Optimiser for staff
• HSD Established/Experienced Service Officers, see Table 3

Confirm family Safety Net before processing claim. See Safety Net confirmations.

• Face to Face Service Officers must escalate via Multi-Function Device (MFD) listing. See the Resources page in Manage Medicare 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 following the process in Work Optimiser for staff
• Health Service Delivery (HSD) Established Service Officers must raise proficiency
• HSD Experienced Service Officers, see Table 4

Confirm family Safety Net before processing claim. See Safety Net confirmations.

• Face to Face Service Officers must escalate via MFD listing. See the Resources page in Manage Medicare 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)
• Health Service Delivery (HSD) Established Service Officers must raise proficiency
• HSD Experienced Service Officers, see Table 5

• Face to Face Service Officers must escalate via MFD listing. See the Resources page in Manage Medicare 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)
• Health Service Delivery (HSD) Established Service Officers must raise proficiency
• HSD Experienced Service Officers, see Table 6

Has the account been fully paid?

• Yes, key NPBI, the card number and select [Enter]
• No, key NPOI, the card number and select [Enter]

On the first line:

• key the following information:
• patient or reference number
• item
• date of service (DOS)
• provider number
• 999900 in the Charge field
• press [Enter]

The message 6- CHG HIGH may show.

Note: other return messages may be displayed and should be actioned separately.

On the second line key the following information:

• Patient or reference number
• 0000 in the item field
• DOS
• Provider number
• For Pay Doctor via Claimant (PDVC) claims (unpaid account), key R in the Payee field
• For Electronic Funds Transfer (EFT) (paid account) key E
• The balance of account in the charge field - this is the charge minus $9,999.00

Examples:

• charge is $14,000.00 minus $9,999.00 balance is $4,001.00:
• Key 400100 in the Charge field of the 0000 line
• Press [Enter]
• charge is $20,0000 minus $9,999.00 balance is $10,001.00– two 0000 lines must be entered:
• Balance minus $9999.00 is $10,001
• Key 999900 in the Charge field of the first 0000 line
• Balance minus $9,999.00 final balance is $2.00
• Key 200 in the Charge field of the second 0000 line
• Press [Enter]

• Key the appropriate processing indicator (PI) code in the PI field on the service line with item 0000
• Use:
• 02 for PDVC
• 09 for EFT

See Indicators, codes, modifiers and control lines for claims processing in Medicare.

• Key RSN 232 in Reason Code field on the service line with item 0000
• Press [Enter]

Note: RSN code 232 does not appear in the online messages, but allows the claim (including in hospital claims) to be paid.

• Key RSN 523 in the Reason Code field on the highlighted service line with the high charge
• Press [Enter]

The message P to Pay and the benefit will show.

Finalise the claim on mainframe.

A manual Statement of Benefit letter must be issued showing the one item and the correct charge for the inpatient item (matching the invoice).

See:

• Resources page for link to letter Z2261 - Your statement of Medicare Benefits
• Table 15 on Patient claims processing in Medicare to issue a manual Statement of Benefit

Has the account been fully paid?

• Yes, key NPBI, the card number and select [Enter]
• No, key NPOI, the card number and select [Enter]

On the first line:,

• key the following information:
• patient or reference number
• item
• date of service (DOS)
• provider number
• 999900 in the Charge field
• press [Enter]

The message 6- CHG HIGH may show.

Note: other return messages may show and should be actioned separately.

On the last line key the following information:

• Patient or reference number
• 0000 in the item field
• DOS
• Provider number
• For Pay Doctor via Claimant (PDVC) claims (unpaid account), key R in the Payee field
• For Electronic Funds Transfer (EFT) (paid account) key E
• The balance of account in the charge field - this is the charge minus $9,999.00

Examples:

• charge is $14,000.00 minus $9,999.00 balance is $4,001.00:
• Key 400100 in the Charge field of the 0000 line
• Press [Enter]
• charge is $20,0000 minus $9,999.00 balance is $10,001.00– two 0000 lines must be entered:
• Balance minus $9999.00 is $10,001
• Key 999900 in the Charge field of the first 0000 line
• Balance minus $9,999.00 final balance is $2.00
• Key 200 in the Charge field of the second 0000 line
• Press [Enter]

For each item over $9,999.00, repeat steps 2 and 3, adding additional 0000 lines as required.

Key the appropriate processing indicator (PI) code in the PI field on the service line/s with item 0000.

Note: against each item line use:

• 02 for PDVC
• 09 for EFT

The message 6- CHG -HIGH may show.

See Indicators, codes, modifiers and control lines for claims processing in Medicare for more information.

• Key RSN 232 in Reason Code field on the service line with item 0000
• Press [Enter]

Note: RSN code 232 does not appear in the online messages but allows the claim (including in hospital claims) to be paid.

• Key RSN 523 in each Reason Code field on the highlighted line(s) with a high charge
• Press [Enter].

The message P to Pay and the benefit will show.

Finalise the claim on mainframe.

A manual Statement of Benefit letter must be issued showing the correct charges for the inpatient services (matching the invoice).

See:

• Resources page for link to letter Z2261 - Your statement of Medicare Benefits
• Table 15 on Patient claims processing in Medicare to issue a manual Statement of Benefit

Check if the family Safety Net registration has been confirmed for the relevant calendar year before processing the claim.

Has the family Safety Net been confirmed?

• Yes, go to Step 2
• No, do not process the claim. Contact the Family Contact (FC) or the claimant to confirm Family Safety Net
• Service Officers are required to make 2 attempts by telephone to confirm the Medicare Safety Net family composition and must note the details of these attempts in CDMS
• Where contact cannot be made after 2 attempts, go to Step 2

Has the account been fully paid?

• Yes, key NPBI, the card number and select [Enter]
• No, key NPOI, the card number and select [Enter]

• On the first line, key the following information:
• patient or reference number
• item
• date of service (DOS)
• provider number
• 999900 in the Charge field
• press [Enter]

The message 6- CHG HIGH may show.

Note: other return messages may be displayed and should be actioned separately.

On the second line key the following information:

• Patient or reference number
• 0000 in the item field
• DOS
• Provider number
• For Pay Doctor via Claimant (PDVC) claims (unpaid account), key R in the Payee field
• For Electronic Funds Transfer (EFT) (paid account) key E
• The balance of account in the charge field - this is the charge minus $9,999.00

Examples:

• charge is $14,000.00 minus $9,999.00 balance is $4,001.00:
• Key 400100 in the Charge field of the 0000 line
• Press [Enter]
• charge is $20,0000 minus $9,999.00 balance is $10,001.00– two 0000 lines must be entered:
• Balance minus $9999.00 is $10,001
• Key 999900 in the Charge field of the first 0000 line
• Balance minus $9,999.00 final balance is $2.00
• Key 200 in the Charge field of the second 0000 line
• Press [Enter]

Key the appropriate processing indicator (PI) code in the PI field on the service line with item 0000.

Note: against each item line use:

• 02 for PDVC
• 09 for EFT

The message 6- CHG -HIGH may show.

See Indicators, codes, modifiers and control lines for claims processing in Medicare for more information.

When the account has been paid in full or when the gap has been paid, manually calculate the benefit.

If the system paid benefit is less than the claimant is entitled to (including Safety Net benefits), a manual EFT payment is issued for the difference. See Requesting a manual EFT payment in Patient claims processing in Medicare.

If an additional Safety Net benefit is to be paid (applicable for out-of-hospital claims):

• key RSN code 151 in Reason Code field on service line with item 0000
• press [Enter]

Note: the usual procedures apply when manually calculating a Safety Net benefit.

When a part payment is recorded, verify the claim and manually calculate the Safety Net. For more information see Verify services for Medicare Safety Net.

Note: if warning message 1- SNET PND appears, send the claim for SNET PND processing to the current staff member whose P number is displayed in the return message.

Issue a manual statement of benefit showing the correct charge.

A manual Statement of Benefit letter must be issued showing the one item and the correct charge for the inpatient item (matching the invoice).

See:

• Resources page for link to letter Z2261 - Your statement of Medicare Benefits
• Table 15 on Patient claims processing in Medicare to issue a manual Statement of Benefit

Check if the family Safety Net registration has been confirmed for the relevant calendar year before processing the claim.

Has the family Safety Net been confirmed?

• Yes, go to Step 2
• No, do not process the claim. Contact the Family Contact (FC) or the claimant to confirm Family Safety Net
• Service Officers are required to make 2 attempts by telephone to confirm the Medicare Safety Net family composition and must note the details of these attempts in CDMS
• Where contact cannot be made after 2 attempts, go to Step 2

Has the account been fully paid?

• Yes, key NPBI, the card number and select [Enter]
• No, key NPOI, the card number and select [Enter]

Go to Step 3

• On the first line, key the following information:
• patient or reference number
• item
• date of service (DOS)
• Provider number
• 999900 in the Charge field
• press [Enter]

The message 6- CHG HIGH may show.

Note: other return messages may be displayed and should be actioned separately.

On the second line key the following information:

• Patient or reference number
• 0000 in the item field
• DOS
• Provider number
• For Pay Doctor via Claimant (PDVC) claims (unpaid account), key R in the Payee field
• For Electronic Funds Transfer (EFT) (paid account) key E
• The balance of account in the charge field - this is the charge minus $9,999.00

Examples:

• charge is $14,000.00 minus $9,999.00 balance is $4,001.00:
• Key 400100 in the Charge field of the 0000 line
• Press [Enter]
• charge is $20,0000 minus $9,999.00 balance is $10,001.00– two 0000 lines must be entered:
• Balance minus $9999.00 is $10,001
• Key 999900 in the Charge field of the first 0000 line
• Balance minus $9,999.00 final balance is $2.00
• Key 200 in the Charge field of the second 0000 line
• Press [Enter]

For each item over $9,999.00, repeat steps 3 and 4, adding additional 0000 lines as required.

Key the appropriate processing indicator (PI) code in the PI field on the service line with item 0000.

Note: against each item line use:

• 02 for PDVC
• 09 for EFT

The message 6- CHG -HIGH may show.

See Indicators, codes, modifiers and control lines for claims processing in Medicare for more information.

When the account has been paid in full or when the gap has been paid, manually calculate the benefit.

If the system paid benefit is less than the claimant is entitled to (including Safety Net benefits), a manual EFT payment is issued for the difference. See Requesting a manual EFT payment in Patient claims processing in Medicare.

If an additional Safety Net benefit is to be paid (applicable for out-of-hospital claims):

• key RSN code 151 in Reason Code field on service line with item 0000
• press [Enter]

Note: the usual procedure applies when manually calculating a Safety Net benefit.

• Over key NPFC with NPFP
• Press [Enter] to pay the claim

Note: the system calculates the benefit correctly if no extra line with item 0000 was required (when charges could be split or apportioned over the items).

When part payment is recorded, verify the claim and manually calculate the Safety Net. See Verify services for Medicare Safety Net.

Note: if warning message 1- SNET PND appears, send the claim for SNET PND processing to the current staff member whose P number is displayed in the return message.

A manual Statement of Benefit letter must be issued showing all items and correct charge for the outpatient service (matching the invoice).

See:

• Resources page for link to letter Z2261 - Your statement of Medicare Benefits
• Table 15 on Patient claims processing in Medicare to issue a manual Statement of Benefit

Check if the family Safety Net registration has been confirmed for the relevant calendar year before processing the claim

Has the family Safety Net been confirmed?

• Yes, go to Step 2
• No, do not process the claim. Contact the Family Contact (FC) or the claimant to confirm Family Safety Net
• Service Officers are required to make 2 attempts by telephone to confirm the Medicare Safety Net family composition and must note the details of these attempts in CDMS
• Where contact cannot be made after 2 attempts, go to Step 2

Has the account been fully paid?

• Yes, key NPBI, the card number and select [Enter]
• No, key NPOI, the card number and select [Enter]

When the account/invoice has more than one item and at least one item is under $9,999.99:

• Key, assess and P to Pay the item/s under $9,999.99 first
• Complete any safety net substantiations (if required)
• The remaining items on the invoice that are over $9,999.99 must be keyed by the same operator on the same day

Go to Step 3.

• On the first line, key the following information:
• patient or reference number
• item
• date of service (DOS)
• provider number
• 999900 in the Charge field
• Press [Enter]

The message 6- CHG HIGH may show.

Note: other return messages may show and should be actioned separately.

On the second line key the following information:

• Patient or reference number
• 0000 in the item field
• DOS
• Provider number
• For Pay Doctor via Claimant (PDVC) claims (unpaid account), key R in the Payee field
• For Electronic Funds Transfer (EFT) (paid account) key E
• The balance of account in the charge field - this is the charge minus $9,999.00

Examples:

• charge is $14,000.00 minus $9,999.00 balance is $4,001.00:
• Key 400100 in the Charge field of the 0000 line
• Press [Enter]
• charge is $20,0000 minus $9,999.00 balance is $10,001.00– two 0000 lines must be entered:
• Balance minus $9999.00 is $10,001
• Key 999900 in the Charge field of the first 0000 line
• Balance minus $9,999.00 final balance is $2.00
• Key 200 in the Charge field of the second 0000 line
• Press [Enter

For each item over $9,999.00, repeat steps 3 and 4, adding additional 0000 lines as required.

Key the appropriate processing indicator (PI) code in the PI field on the service line with item 0000.

Note: against each item line use:

• 02 for PDVC
• 09 for EFT

The message 6- CHG -HIGH may show.

See Indicators, codes, modifiers and control lines for claims processing in Medicare.

When the account has been paid in full or when the gap has been paid, manually calculate the benefit.

If the system paid benefit is less than the claimant is entitled to (including Safety Net benefits), a manual EFT payment is issued for the difference. See Requesting a manual EFT payment in Patient claims processing in Medicare.

If an additional Safety Net benefit is to be paid (applicable for out-of-hospital claims):

• key RSN code 151 in Reason Code field on service line with item 0000
• press [Enter]

Note: the usual procedure applies when manually calculating a Safety Net benefit.

• Over key NPFC with NPFP
• Press [Enter] to pay the claim

Note: the system calculates the benefit correctly if no extra line with item 0000 was required (when charges could be split or apportioned over the items).

When part payment is recorded, verify the claim and manually calculate the Safety Net. See Verify services for Medicare Safety Net.

Note: if warning message 1- SNET PND appears, send the claim for SNET PND processing to the current staff member whose P number is displayed in the return message.

A manual Statement of Benefit letter must be issued showing all items and correct charge for the outpatient service (matching the invoice).

See:

• Resources page for link to letter Z2261 - Your statement of Medicare Benefits
• Table 15 on Patient claims processing in Medicare to issue a manual Statement of Benefit