Medicare patient claims history or claims history statement has incorrect or missing information 011-43010130

Conduct a security check to confirm the customer's identity.

Note: there are restrictions on who can request information relating to claims history.

See Authenticating a Medicare customer for more information.

Confirm:

• patient name
• date of service (or approximate date)
• approximate charge for the service
• approximate date and how the claim was lodged (for example, online, in person, via MS014, bulk billed)
• provider details

• Key NHOI, card number, patient's IRN or first initial
• Press [Enter]

• If the service is missing on the claims history go to Step 5
• If the service is appearing on the claims history and is correct go to Step 8

Investigation has confirmed the service is not appearing on the patient history, check if claim is pended.

Where information on the patient history is missing, check whether the service has been pended before any further investigation occurs:

• key NPRI,card number
• press [Enter]

Is the missing service pended?

• Yes, recalls item lines that have been pended. Check reason for pend and advise customer of the progress of the claim. Procedure ends here
• No, when no pends are returned, consider how the claim was lodged in order to further investigate the issue. Go to Step 6

When a claim is not appearing on history, check reason why.

Confirm the reason that the service is failing to appear on the claims history because:

• The claim has not been processed in the Medicare mainframe system (CICS), either has not been received by Medicare or the claim is waiting to be processed. Advise the customer claim has not been processed. Procedure ends here
• The wrong patient selected (for example, claim was assigned to another family member). Go to Customer enquiry re incorrect information on Medicare claim history. Go to Step 5
• The claim was processed that day, and the system has not run, the claim will be displayed the following day. Advise the customer the claim will appear on their history on the following day. Procedure ends here
• Latter day adjustment and rejected claims will not be visible to the claimant through online services. See Medicare claims history and claims history statement online
• The service is for an item not intended to display on the customers history. Item numbers listed:
• Items 10990, 10991, 10992, 63491, 63494, 63497, 64990, 64991, 74990 or 74991
• Items with rejected payee codes A, E, F, J, R, S or T
• Items with reason codes 812, 814, 816, 818, 821, 888, 889, 890, 891, 892 or 898

If the enquiry has been received through the My Health Record Enquiry Line ensure the:

• claim has been processed successfully
• customer has not ‘blocked’ the service from view in their My Health Record

Note: some claims history viewable via Medicare online accounts and Express plus Medicare mobile app have a reason code recorded in Mainframe, which is not displayed to the customer. These are internal messages only and not intended for the customer.

For more information, see:

Indicators, codes, modifiers and control lines for claims processing in Medicare for the reason codes

The My Health Record system - Your Health

Where an adjustment is required and either:

• cannot be adjusted
• the maximum number of adjustments have been made on that claim

Refer to the Medicare claims helpdesk.

If the Service Officer cannot establish a reason for the customer's enquiry, inform the customer that further investigation is required and complete a Customer enquiry form. The Resources page contains a link to the Customer enquiry form.

Email the form to MPS Assessing for investigation.

Inform the customer that the patient history matches the account documents received.

Advise the customer of the option to follow up with their provider.

For customers viewing their history via Medicare online or Express Plus Medicare mobile app, inform them:

• After the claim is processed in mainframe it will not display online until the next day
• If a latter day adjustment (LDA) has been made to the claim recently advise the customer that adjustments have a processing timeframe of 7 days before it will display on their online history. Advise the customer they should wait until that time has passed and view their claims history again
• If investigation confirms an adjustment has occurred on the claim more than 7 days ago and the adjusted service displays in Mainframe, but the customer advises that it does not appear on their claims history. Advise the customer that the issue will be investigated, then lodge a mySupport request for the missing history with the customer and claim detail. The Resources page contains a link to the Medicare Digital Services intranet page
• After a customer has linked to Medicare, it takes 48 hours for history to be available online
• If the customer has transferred to a new Medicare card, their claim history on the previous card will not display
• If they require history from the previous card, they will need to request from Release of Information (ROI). See Release of information for Medicare

Note: Medicare online account and Medicare Express plus app history can ONLY be viewed for the current Medicare card.

If the enquiry has been received through the My Health Record Enquiry Line call centre, ensure the:

• claim has been processed successfully
• customer has not ‘blocked’ the service from view

For more information, see:

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

The My Health Record system - Your Health

Conduct a security check to confirm the customer's identity.

Note: there are restrictions on who can request information relating to claims history.

See Authenticating a Medicare customer for more information.

Confirm:

• patient name
• date of service (or approximate date)
• approximate charge for the service
• approximate date and how the claim was lodged (for example, online, in person, via MS014, bulk billed)
• provider details

• Key NHOI, card number, patient's IRN or first initial
• Press [Enter]

After locating the service in question:

• Check if a claim adjustment displays in mainframe that occurred more than 7 days ago but the customer advises that it does not appear on their claims history
• Advise the customer the issue will be investigated, then approach your Service Support Officer (SSO) or Local Peer Support (LPS) and ask them to lodge a Medicare Online Accounts General Enquiries issues webform with the customer and claim details. Advise the customer that ICT will investigate and resolve the issue and a Service Officer will then be advised of the outcome. The Resources page contains a link to mySupport to access the webform
• If the customer has advised that a service is appearing which did not take place and the customer has been overpaid, see the Patient voluntary refund of Medicare payment table

Is the patient history incorrect?

• Yes, the affected service lines will need to be adjusted as required by following usual latter day adjustment (LDA) protocols. Go to Step 6
• No, go to Step 8

When the patient history is incorrect:

• Adjust the affected service lines as required by following usual latter day adjustment (LDA) protocols. See Latter day adjustments (LDA) and HELD payments for patient claims for more information
• Where an adjustment
• cannot be adjusted
• the maximum number of adjustments have been made on that claim, refer to Medicare claims helpdesk
• If the Service Officer cannot establish a reason for the customer's enquiry, inform the customer that further investigation is required and complete a Customer enquiry form. The Resources page contains a link to the Customer enquiry form. Email the form to MPS Assessing for investigation

Claim was made in person at a service centre/by completing a claim form

• Staff must request the batch work processed by the Service Officer to confirm if the claim was processed incorrectly
• Advise the customer that further investigation is required
• When batch work returned, confirm if claim was processed correctly. If claim is incorrect adjust the claim accordingly
• Contact the customer to advise records are now correct

Claim was transmitted by the provider

• Service Officers refer the enquiry to Local Peer Support (LPS) and advise customer that further investigation is required
• LPS must request the data using the Search Analyse Investigate Network Tool (SAINT) and where required, contact the provider to confirm details
• Following confirmation that the claim was incorrectly processed adjust the claim accordingly
• Contact customer to advise records are now correct

Claim was bulk billed

• For manual claims, staff must request the batch work processed by the Service Officer. For online claims go to Step 9

Note: if the Service Officer cannot establish a reason for the customer's enquiry, inform the customer that further investigation is required and complete a Customer enquiry form. The Resources page contains a link to the Customer enquiry form. Email the form to MPS Assessing for investigation.

See Latter day adjustments (LDA) and HELD payments for patient claims for more information.

Procedure ends here.

Inform the customer that the patient history matches the account documents received.

Advise the customer of the option to follow up with their provider.

• for online or mobile app claims, go to Step 9
• all other claims channels, procedure ends here

For customers viewing their history via Medicare online or Express Plus Medicare mobile app, inform them:

• After the claim is processed in mainframe it will not display online until the next day
• If a latter day adjustment (LDA) has been made to the claim recently advise the customer that adjustments have a have a processing timeframe of 7 days before it will display on their online history, so they should wait until that time has passed and view their claims history again
• If investigation confirms an adjustment has occurred on the claim more than 7 days ago and the adjusted service displays in mainframe, but the customer advises that it does not appear on their claims history. Advise the customer the issue will be investigated, then email Medicare Digital Services with the customer and claim details. The Resources page contains a link to the Medicare Digital Services intranet page

Request the batch work processed by the Service Officer.

Note: this can only be requested if the claim was rejected on the system or if other claims were made on the same day. Otherwise, the claimant may be requested to provide a copy of the account.

Request that the claimant provide a copy of the account and a new claim form as the paperwork may have gone missing in the mail.

Note: postal claims may be processed up to 14 days after being received.

Advise the customer to contact their provider to confirm whether the transmission has occurred.

Note: if other transmissions have occurred that day, then Service Officers should contact the provider to see whether that service was missed.

Contact the provider to confirm details of the bulk bill claim.

Conduct a security check to confirm the customer's identity.

See Authenticating a Medicare customer for more information.

If customer is enquiring via the phone, see the Customer enquiry via phone regarding repayment of funds table.

• Key NHOI, card number, patient's IRN or first initial
• Press [Enter]

Confirm:

• patient name
• date of service (or approximate date)
• approximate charge for the service
• approximate date and how the claim was lodged (for example, online, in person, via MS014, bulk billed)
• provider details

Was payment made by cheque or Electronic Funds Transfer (EFT)?

• cheque, go to Step 5
• EFT, go to Step 6

Note: Services Australia must be in possession of a cheque prior to a cheque being cancelled.

Update:

• LOC - to cancel cheque payment
• see Cheque processing in Medicare

Procedure ends here.

If claimant refunding the money at time of enquiry:

• complete an overpayment
• notate in Consumer Directory Maintenance System (CDMS) Group Comments all voluntary refund details

When the claimant is waiting for advise to refund money:

• complete a Customer enquiry form and email to MPS Assessing. The Resources page contains a link to the Customer enquiry form
• advise the customer they will receive a letter from Services Australia with details on how to pay back the monies owing
• notate in CDMS Group Comments all voluntary refund details

Conduct a major security check to confirm the customer's identity.

See Authenticating a Medicare customer for more information.

• Key NHOI, card number, patient's IRN or first initial
• Press [Enter]

Confirm:

• patient name
• date of service (or approximate date)
• approximate charge for the service
• approximate date and how the claim was lodged (for example, online, in person, via MS014, bulk billed)
• provider details

Was payment made by cheque or Electronic Funds Transfer (EFT)?

• cheque, go to Step 5
• EFT, go to Step 6

Where the customer is in procession of the Medicare cheque, advise the customer to return the cheque to:

• GPO Box 999, in their Capital City

• complete a Customer enquiry form and email to MPS Assessing. The Resources page contains a link to the Customer enquiry form
• advise the customer they will receive a letter from Services Australia with details on how to pay back the monies owing
• notate in CDMS Group Comments all voluntary refund details