Indicators, codes, modifiers and control lines for claims processing in Medicare 011-43020000

Pre 1 November 2002 Abatement indicators

Table 1: this table lists abatement indicators prior to 1 November 2002.

Abatement indicator	System application
A	Top fee item in multiple procedure.
B	Second fee item in multiple procedure.
C	Minor fee item in multiple procedure.
D	Medicare Benefits Advisory Committee (MBAC) determination.
E	MBAC determination/precedent where a fee is entered by Service Officer.
G	Item qualifier for non - MBAC item or equipment.
J	Diagnostic Imaging Multiple Service Rule A.
K	Diagnostic Imaging Multiple Service Rule B (>$40.00).
L	Diagnostic Imaging Multiple Service Rule C.
M	Diagnostic Imaging Multiple Service Rule B and C (>$40.00).
N	Diagnostic Imaging Multiple Service Rule B (<$40.00).
O	Diagnostic Imaging Multiple Service Rule B and C (<$40.00).
S	Assistant surgeon (pay surgeon).
T	Assistant surgeon (pay assistant).
U	$35.00 deduction from a consultation item.
V	$15.00 deduction from a consultation item.
W	$5.00 deduction from a General Medical Services Table (GMST) item.
X	$20.00 deduction from a consultation or Diagnostic Imaging (DI) item.
Y	$25.00 deduction from a DI item.

Post 1 November 2002 assessment indicator fields

Table 2: this table lists the fields that display assessment indicators.

Field name	Description
MULTI	Displays assessment indicators associated with the application of Multiple Operations Rule (MOR).
DIMSR	Displays assessment indicators associated with the application of Diagnostic Imaging Multiple Services Rule (DIMSR).
MVUSSR	Displays assessment indicators associated with the application of Multiple Vascular Ultrasound Services Site Rule (MVUSSR).
AST	Displays assessment indicators associated with the application of Assistant surgeon (AST).

Post 1 November 2002 assessment indicators

See the Post 1 November 2002 assessment indicator changes section.

Table 3: this table list the assessment indicators, their meanings and the field in which they are displayed.

Field	Indicator value	Meaning
MULTI	A	Highest fee item.
MULTI	B	Secondary fee item.
MULTI	C	Lower Fee Item/s.
DIMSR	A	Indicates Diagnostic Imaging Multiple Services Rule (DIMSR). A has been applied.
DIMSR	B	Indicates DIMSR B HI (Consultation greater than $40.00) has been applied.
DIMSR	C	Indicates DIMSR B LO (Consultation less than $40.00) has been applied.
DIMSR	D	Indicates DIMSR C applied.
DIMSR	E	DIMSR B HI (Consultation >$40) and DIMSR C applied.
DIMSR	F	DIMSR B LO and DIMSR C applied.
DIMSR	G	DIMSR B HI (Consultation >$40) applied to Consultation.
DIMSR	H	DIMSR B HI (Consultation >$40) adjusted to Consultation.
DIMSR	I	DIMSR B LO (Consultation <$40) applied to Consultation.
DIMSR	J	DIMSR C applied to GMS.
DIMSR	K	DIMSR applied to primary Multiple Vascular Ultrasound Services Site Rule (MVUSSR) item.
DIMSR	M	DIMSR manually applied.
DIMSR	X	DIMSR exempt.
MVUSSR	A	MVUSSR A applied.
MVUSSR	B	MVUSSR B applied.
MVUSSR	C	MVUSSR C applied.
MVUSSR	M	MVUSSR manually applied.
AST	A	Pay Assistant for their service.
AST	S	Pay Surgeon for service of Assistant.

Post 1 November 2002 assessment indicator changes

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Table 4: this table list the assessment indicators, their meanings and the field in which they display.

Field	Indicator value	Meaning
MO	A	Highest fee item.
MO	B	Secondary fee item.
MO	C	Lower Fee Item/s.
DIMS	A	Indicates Diagnostic Imaging Multiple Services Rule (DIMSR). A has been applied.
DIMS	B	Indicates DIMSR B HI (Consultation > $40.00) has been applied.
DIMS	C	Indicates DIMSR B LO (Consultation < $40.00) has been applied.
DIMS	D	Indicates DIMSR C applied.
DIMS	E	DIMSR B HI (Consultation >$40) and DIMSR C applied.
DIMS	F	DIMSR B LO (Consultation <$40) and DIMSR C applied.
DIMS	G	DIMSR B HI (Consultation >$40) applied to Consultation.
DIMS	H	DIMSR B HI (Consultation >$40) adjusted to Consultation.
DIMS	I	DIMSR B LO (Consultation <$40) applied to Consultation.
DIMS	J	DIMSR C applied to GMS.
DIMS	K	DIMSR applied to primary Multiple Vascular Ultrasound Services Site Rule (MVUSSR) item.
DIMS	L	Indicates DIMSR has been applied to primary Multiple Musculoskeletal MRI Services (MMMRISR) item.
DIMS	M	DIMSR manually applied.
DIMS	N	Indicates DIMSR has been applied to primary Multiple Echocardiogram Services (MESR) item.
DIMS	X	DIMSR exempt.
VU	A	MVUSSR A applied.
VU	B	MVUSSR B applied.
VU	C	MVUSSR C applied.
VU	M	MVUSSR manually applied.
MMRI	A	Indicates MMMRISR A has been applied.
MMRI	B	Indicates MMMRISR B has been applied.
MMRI	M	Indicates MMMRISR has been manually applied.
ME	A	Indicates MESR A has been applied.
ME	B	Indicates MESR B has been applied.
ME	M	Indicates MESR has been manually applied.
AST	A	Pay Assistant for their service.
AST	S	Pay Surgeon for service of Assistant.

Processing indicators

Table 5: this table lists processing indicators and their associated system application.

Processing indicator	System application
1E	Emergency service.
1L	Referral details for service is lost.
01	Rejected claim - cheque to cardholder.
02	Rejected claim - cheque to provider.
03	Rejected claim - cash.
04	Rejected claim - manual cheque.
05	Rejected claim - cheque to claimant other than cardholder.
06	Rejected claim - bulk bill cheque to provider.
09	Rejected claim - EFT to claimant.
10	Service has been referred.
11	Diagnostic and pathology service has been self-determined.
12	Pathology service has been requested.
14	Ignore hospital contract flag on provider file.
15	Service is emergency care (Reciprocal Health Care Agreements (RHCA) visitor).
16	Pay this claim using the card number quoted.
17	Pay claim over 2 years old (patient claim) or pay claim over 6 months old (bulk bill).
21	Ignore hospital categorisation of item number and pay benefit according to the presence or absence of the suffix H on the item number.
22	Provider should be regarded as a specialist.
24	Provider is recognised.
25	Sex and/or age restriction for the item should not be applied.
41	Item should not be treated as a composite.
42	Item should not be treated as restrictive.
43	Service is not a duplicate.
44	Service is not aftercare.
45	Time dependant restriction does not apply.
46	Operation or anaesthetic can be performed by provider more than once on the same day.
47	Pay assistant surgeon or anaesthetist service.
48	Pay a long cycle IVF claim (if noted as long cycle).
58	Use fee entered in FEE field to calculate benefit.
60	Fracture is not related to the other fracture items (fee may be entered).
61	Do not use multiple operation rule to assess operation or anaesthetic item (fee may be entered).
62	Indicates to the system to use the fee keyed in the FEE column when DIMSR has been manually calculated.
98	Substantiation - benefit paid subject to the 100% rule.

Post 1 July 2016 Medicare payee codes

Table 6: this table lists payee codes and their associated payment methods post 1 July 2016.

Payee code	Payment method
2	Unpaid account - send computer produced cheque made payable to provider via claimant's address.
4	Paid account - manual cheque over the counter to claimant. (Manual cheque over the counter ceased December 2016).
6	Bulk bill - benefit assigned to provider.
7	Easy claim - Electronic Funds Transfer at Point of Sale (EFTPOS) patient claim services.
8	Simplified billing - benefit assigned to provider.
9	Paid account - electronic funds transfer (EFT) payment to claimant.
A	Billing agent claim - reject service.
E	EFT claim - reject service.
F	Simplified billing - reject service.
H	Record details on patient's history only.
J	EFTPOS - rejected patient claim service.
P	Pend the item line details.
R	Cheque claim - rejected service.
S	Bulk bill - rejected service.
X	Substantiated service.

Pre 1 July 2016 Medicare payee codes

Table 7: this table lists payee codes and their associated payment methods pre 1 July 2016.

Payee code	Payment method
1	Paid account - send computer produced cheque made payable to group contact.
2	Unpaid account - send computer produced cheque made payable to provider via claimant's address.
3	Paid account - cash over the counter to claimant.
4	Paid account - manual cheque over the counter to claimant.
5	Paid account - send computer produced cheque made payable to claimant (other than group contact) at screen name and address.
6	Bulk bill - benefit assigned to provider.
7	Paid electronic funds transfer at point of sale (EFTPOS) patient claim service.
8	Simplified billing - benefit assigned to provider.
9	Paid account - electronic funds transfer (EFT) payment to claimant.
A	Billing agent claim - reject service.
E	EFT claim - reject service.
F	Simplified billing - reject service.
H	Record details on patient's history only.
J	EFTPOS - rejected patient claim service.
P	Pend the item line details.
R	Cheque claim - rejected service.
S	Bulk bill - rejected service.
X	Substantiated service.

Reason codes

Table Legend:

** - The code is for internal use only and will not appear on the statement issued to the claimant
$ - Charge for service will not be printed on Statement of Benefit

Table 8: this table contains reason codes that are used in Medicare claims processing to indicate the reason a claim was paid, rejected or pended. Search the list using [Ctrl+F].

Reason code number	Description
101	More details of service required to assess benefit.
102	No amount charged is shown on voucher (bulk bill). No amount charged is shown on account/receipt (patient claims).
103	Letter of explanation is being sent separately.
104	Balance of benefit due to claimant.
105	Benefit paid to provider as requested.
106	Servicing provider unable to be identified.
107	Benefit paid on item number other than that claimed.
108	Benefit is not payable for the service claimed.
110**	Benefit paid - details verified with provider/claimant (internal message only).
111	No benefit payable – claim(s) over 2 years old.
113	Total charge shown on account apportioned over all items.
115	Benefit recommended for this item.
117	Benefit not recommended for this item.
120	Age restriction applies to this Item.
122	Associated referral/request line not required.
123	Benefit paid on radiology item other than service claimed.
124	Item is restricted to persons of opposite sex to patient.
125	Not payable without associated operation/anaesthetic item.
126	Service is not payable without radiology service.
127	Maximum number of additional fields already paid.
128	Benefit paid on associated fracture/amputation item.
129	Service is not payable without the base item(s).
130	Referred to National Office for decision.
131	Date of service not supplied/invalid.
134	Single course of treatment paid as subsequent attendance.
135	Provider not a consultant physician - specialist rate paid.
136	Referral details not supplied- paid at general practitioner (GP) rate.
137	Details of requesting provider not shown on account/receipt.
138	Benefit only payable when self-determined/deemed necessary.
139	Approved pathologist should not use this item number.
140	Non-specialist provider.
141	No benefit payable for service performed by this provider.
142	Documents forwarded to Tier 2 Assessing and benefits.
144	Claim benefit not paid - further assessment required.
150	Member has not supplied details to permit claim payment.
151	Associated service already paid-adjustment being processed.
154	Diagnostic Imaging Multiple Service Rule applied to service.
155	Overseas service - refer to MPS Assessing.
157	Service possibly aftercare - refer to provider.
158	Benefit paid on associated abandoned surgery/anae item.
159	Item associated with other service on which benefit payable.
160	Maximum number of services for this item already paid.
161	Adjustment to benefit previously paid.
162	Benefit has been previously paid for this service.
163	Surgical/anaesthetic item(s) already paid for this date.
164	Assistant surgeon benefit not payable.
166	Claim over 2 years old - pended to Tier 2 Assessing and benefits.
168	Not payable without associated operation/anaesthetic item.
169	Operation/anaesthetic item not claimed.
170	Assistant anaesthetic benefit not payable.
171	Benefit not payable - provider may only act in one capacity.
173	Patient episode coning - maximum number of services paid.
174	Patient episode coning adjustment.
175	Benefit paid on associated foetal intervention item.
176	Pay each foetal intervention item as a separate item.
177	Foetal intervention item paid using derived fee item.
179	Benefit not payable - associated service already paid.
184	Benefit paid for additional time item using a derived fee.
190**	Short term pend - to look at another screen (Internal message only).
194	Provider under investigation - refer to supervisor.
195	Patient under investigation - refer to supervisor.
205**	Re-issue of previously cancelled cheque (Internal message only).
206	Item number does not attract a benefit at date of service.
208	Card number used has expired.
209	Claimant’s name stated is different to that on card number.
211	Patient not covered by this card number at date of service.
212	Date of service used is in the future.
214	Claim form not complete.
215	Service claimed prior 1 February 1984.
217	Patient cannot be identified from information supplied.
222	Benefit paid on associated anaesthetic item.
223	Service not payable - specified item not claimed/present.
225	Patient contribution substantiated-additional benefit paid.
226	Date of service is prior to patient’s date of birth.
227	Date of service prior to date eligible for Medicare benefit.
228	Date of service after benefit period for overseas visitor.
229	Benefit paid at 100% of schedule fee.
230	Combination of 85% and 100% of schedule fee paid.
232	Service claimed not covered by Medicare.
233	Provider not entitled to Medicare benefit at date of service.
234	Service for diplomat - benefit not payable.
236	Health screening services.
237	Health screening - insufficient information.
238	Not paid because all associated services rejected.
240	Gap adjustment to benefit previously paid.
241	Total charge and benefit for multiple procedure.
242	Service is part of a multiple procedure.
243	Apportioned charge and total benefit for multiple procedure.
244	Benefit not paid - service line in error.
245	Benefit paid on service other than that claimed.
246	Patient cannot be identified from information supplied.
250	Explanation/voucher will be forwarded separately.
251	Details of requesting provider not supplied.
252	Service possibly aftercare.
253	Radiotherapy assessed with other item number on statement.
254	Assessment incomplete - further advice will follow.
255	Benefit assigned has been increased.
256	Benefit not payable on this service for a hospital patient.
260	Benefit assessed with associated item on statement.
261	Associated surgical items/anaesthetic time not supplied.
262	Insufficient prolonged anaesthetic time - service not paid.
264	Benefit not payable - compensation/damages service.
265	Service not covered by reciprocal health care agreement.
267	Service not payable - associated service not present.
271	Not payable without associated ophthalmological item.
272	Benefit paid on associated ophthalmological item.
274	Provisional payment.
280	Cannot identify service. Resubmit with correct Medicare Benefits Schedule (MBS) item.
282	Date of Service outside of referral/request period.
306	Card# not valid at date of service-future claims may reject.
307	Claim not paid - card number not valid for date of service.
308	In vitro fertilisation (IVF) service - conditions not met - no benefit payable.
316	Benefit not payable - item cannot be self-determined.
317	Benefit not payable - additional item to those requested.
320	Quoted Medicare card number is incorrect.
322	Provider not approved for this Medicare pathology benefit.
325	Laboratory not accredited for benefits for this service.
326	Laboratory not accredited for benefits at date of service.
328	Benefit paid on associated tomography item.
329	Not payable without associated tomography item.
331	Benefit not payable - Health Insurance Act 1973 section 20A (1).
332	Category 5 lab - benefit not payable for requested service.
333	Provider must claim time-based items.
334	All associated pathology/Patient Episode Initiation (PEI) items must be either inpatient or outpatient services.
335	Service is not payable without nuclear medicine service.
336	Benefit paid on nuclear medicine item other than one claimed.
337	Provider must claim content-based items.
338	Provider not registered to claim benefits at date of service.
339	Benefit paid at the concession rate.
340	Refund of co-payment amount.
341	No referral details - details required for future claims.
342	Referral expired - paid at un-referred (GP) rate.
343	Card number quoted on claim form has been cancelled.
344	Concession number invalid - benefit paid at general rate.
345	No safety net entitlement - benefit paid at general rate.
346	Co-payment not made - $2.50 credited to threshold.
347	Safety net threshold reached - benefit increased.
348	Overpayment of claim - invalid concession number.
349	Replacement for requested electronic funds transfer (EFT) payment rejected by bank.
350	Hospital referral - paid at specialist/consultant rate.
351	Benefit not payable - LCC number incorrect or not supplied.
352	Service date outside LCC registration dates.
353	Pathology items not present. No benefit payable.
356	Documentation required to process service.
358	Documentation not received - unable to process claim.
359	Documentation not received - unable to process claim.
360	No benefit payable when requested by this provider.
361	Diagnostic Imaging (DI) exemption - items not approved.
363**	PEI paid in association with R3EX pathology services.
364	Items claimed must be as a combination item.
365**	Benefit paid for S4B3 item.
366**	Benefit paid for Rule 3 Exemption item.
367	Service associated with Medicare Benefits Advisory Committee (MBAC) item in a multiple procedure.
370	Benefit paid on item number other than that claimed.
371	Future claims quoting old style card no. will be rejected.
372	Old style card number quoted - benefit not payable.
373	Expired card - benefit not payable.
374	Old card issue used - benefit not payable - also refer @.
375	Service being processed manually.
377	Number of patients seen not indicated.
378	Provider cannot refer/request service at date of request.
380**	Pend - referred to Assessing section (Internal message only).
385**	Pend - Telephone claim (Internal message only).
388**	Pend - referred to Partial Payments Control Section (Internal message only).
390	Documentation not received.
391	Service provider on db1 differs from transmitted data.
392	Benefit amount changed.
393	No benefit payable - baby not an admitted inpatient.
395	Transport Accident Commission (TAC) medical excess.
397	Service not related to current compensation case (Internal message only).
400	Equipment number missing or invalid.
401	Benefit not payable - charge amount missing or invalid.
402	Benefit not payable- number of patients attended required.
403	Subsequent consultation - referral details required.
404	Benefit not payable - referral/request details required.
405	Equipment number invalid for servicing provider.
406	Supporting text required to assess the claim.
407	Benefit not payable - overseas student.
408	Date of service prior to 29 May 1995.
409	Card number for this enrolment needs to be verified.
410	Age restriction applies for this item - verify details.
411	MBAC determination/precedent number not supplied or invalid.
412	Benefit not payable - provider unable to claim this service.
413	Benefit not payable - date of service prior to date of request.
414	Provider practice location is closed at date of service.
415	Referral details same as rendering provider - self-deemed?
416	Services form a composite item - composite item required.
417	Referral needed - if no referral, NR item to be transmitted.
418	Item cannot be claimed more than once in one attendance.
419	Benefit already paid on item - verify if multiple pregnancy.
420	Operation(s) schedule fee does not meet item description.
421	Wrong assistant item used for the operation(s) performed.
422	Benefit paid has been reduced (benefit = charge).
423	Optical condition not specified - No benefit payable.
424	More information required - which eye was treated.
425	Benefit not payable - individual charges required.
426	Indicate whether new treatment or continuing management.
427	Compensation related services - please forward documents.
428	Date of service over 2 years - late lodgement form required.
429	Patient cannot be identified from the information supplied.
430	Conflicting referral details - please clarify.
431	Initial consultation previously paid - query subsequent con.
432	Not Multi-op - more information required to pay benefit.
433	Associated referral/request line not required.
434	Expired or invalid card. Benefit not payable.
435	Service for nursing home care recipient/benefit not paid.
436	Cannot claim out of hospital service through Simplified bill.
437	Card details invalid. A new Medicare number has been issued.
438	Consultation and DI item/s not payable on same day.
439	Referring/requesting provider not in eligible area.
440	Multiple echocardiogram services rule applied.
441	Multiple echocardiogram and DI services rule applied.
442	Patient not MyMedicare registered with provider practice.
443	Patient MyMedicare registered with another provider practice.
444	Required eligible base item not present in the same claim.
445	Benefit paid on associated base item.
446	Total benefit for plastic & reconstructive procedure paid.
449	HELD EFT payment reprocessed - incorrect claimant selected.
450	EFT details invalid - cheque issued for benefit.
451	Service provided in an ineligible location.
452	Resubmit claim for this service – image not claim related.
453	Resubmit claim for service – claim details do not match image.
454	Resubmit claim for service – some details not shown on image.
455	Resubmit claim for this service – include account and receipt.
457	No action required – line adjusted to process claim.
458	No action required – benefit paid on adjusted claim.
461	Adjustment to benefit previously paid.
475	Patient/service details invalid or missing.
500	Rejected in association with another item in this claim.
501	Group attendance or item format invalid (Bulk Bill).
502	Patient is not eligible to claim benefit for this item.
503	Referral date format is invalid.
504	Charge amount missing /invalid - no benefit payable.
505	More information required - evidence of condition.
506	Consultation not payable on same day as surgical procedure.
507	Site not accredited for this service.
509	Service paid as item 2712/2719.
510	Service paid as item 52-96/or similar item.
511	Extended Medicare Safety Net (EMSN) threshold reached - cap applied to benefit.
512	Multiple Musculoskeletal magnetic resonance imaging (MRI) Service Rule applied.
513	Multiple Musculoskeletal MRI and DI Services Rules applied.
514	Required Equipment Type Code not on Location Specific Practice Number (LSPN) Register.
515	Equipment is older than allowable age for this item.
516	Ben paid for base and derived radiotherapy items claimed.
517	EMSN threshold reached - 80% out of pocket paid.
518	Benefit paid at 100% schedule fee + EMSN.
519	EMSN threshold reached - partial 80% out of pocket paid.
520	Benefit paid at 100% schedule fee + part 80% out of pocket.
521	Part 80% out of pocket + between 85% and 100% increase.
522	Benefit paid – EMSN + between 85% and 100% schedule fee.
523**	Charge entered is greater than 350% of the schedule fee.
524	Safety net benefit adjusted.
525	Only attracts benefit when claimed via Medicare bulk billing.
528	Provider not in eligible area (incorrect Rural, Remote and Metropolitan Areas (RRMA), SSD or state).
529	Bulk bill additional item claimed incorrectly.
530	Patient not on concession/under 16 years at Date of Service.
535	Missing data.
536	Location Specific Practice Number not supplied.
537	Location Specific Practice Number invalid.
538	Location Specific Practice Number not recognised.
539	Location Specific Practice Number not valid at date of service.
540	Enhanced Primary Care Plan not previously claimed.
549	Bulk bill incentive item already paid - adjustment required.
550	Associated service not claimed - no benefit payable.
551	Specimen Collection Point is incorrect or not supplied.
552	Specimen Collection Point not valid at date of service.
553	Approved Collection Centre number not supplied.
554	Total benefit for Anaesthetic service.
555	Benefit paid on Main Relative Value Guide (RVG) Anaesthetic item.
556	RVG time item not claimed.
557	Associated RVG anaesthetic service not claimed.
558	RVG anaesthetic item not claimed.
559	Patient outside age range - please verify age.
560	RVG item restriction.
561	Benefit paid on RVG item claimed.
562	Benefit paid on associated RVG anaesthetic item.
563	Associated RVG service already paid.
564	Multiple Vascular Ultrasound services site rule applied.
565	Multiple DI and Vascular Ultrasound service rules applied.
566	Total benefit for Diagnostic Imaging Service.
567	Benefit paid on main Diagnostic Imaging Item.
568	Item cannot be substituted.
569	Provider unable to substitute.
600	Requesting/referring provider unable to be identified.
601	In hospital services cannot be claimed as out of hospital.
602	Out of hospital service cannot be claimed as in hospital.
603	Newborn not yet enrolled with Medicare - no benefit payable.
604	Service over 2 years old - late lodgement form required.
605	Referral expired - no benefit payable.
606	Referring provider number not open at date of referral.
607	Referral date has been omitted.
608	Referring and servicing provider same - no benefit payable.
609	Service/Claim cancelled at provider's request.
610	Provider specialty not consistent with item claimed.
611	Referral/request details not supplied - no benefit payable.
612	Date of referral after date of service - no benefit payable.
613	Card number cannot be identified from information supplied.
614	No benefit payable - please note time of each visit.
615	Multiple procedures - note times and area of treatment.
616	Item cannot be claimed as an in hospital service.
617	Item cannot be claimed as an out of hospital service.
618	No benefit if requested by this provider at date of request.
619	Servicing provider number not open at date of service.
620	Duplicate transmission - no further payment made.
621	Item not claimable electronically (internal message only) This reason code is used to reject services that are not permitted to be claimed via any electronic claiming method such as Bulk Bill EDI, HIC Online, Pharmacy Connectivity Incentive (PCI), PCS or DBS, Eclipse or Simplified Billing EDI.
622	Positron Emission Tomography (PET) drop-down items not claimable via EDI.
623	PET items only claimable via direct bill.
624	PET items - payee provider required.
625	Payee provider not eligible to claim PET items.
627	PDT statement NOT provided by the Service Officer.
629	Initial PDT therapy item NOT present on patient history.
633	Refer back to the specialist referring provider closed.
634	Refer back to the specialist - servicing provider is closed.
635	Late Lodgement not approved - Letter being sent separately.
636	Benefit reduced - dental cap broken.
637	No benefit payable - dental cap reached.
638	Derived fee and other item cannot be claimed in-hospital.
639	Provider not in an eligible area to claim this item.
640	More than one base and derived item claimed.
641	More than one base item claimed.
642	Benefit paid for derived and other item claimed.
643	Derived item assessed with other item on statement.
700	Benefit cannot be determined for this service.
701	Benefit cannot be determined due to complex assessing rules.
702	Item restrictive with another item.
703	Duplicate of item already quoted.
704	Provider not permitted to claim this item.
705	No associated pathology service.
706	Provider not associated with a pathology laboratory.
707	Pathology laboratory not registered at date of service.
708	Item cannot be claimed from this pathology laboratory.
709	Another assistant item should be claimed.
710	Associated surgical items not present.
711	Unable to determine associated surgery.
712	Base item not present or in incorrect order.
713	Radiotherapy fields greater than maximum allowable.
714	Benefit not determined - number of time units not present.
715	Number of time units exceeded maximum allowable.
716	Service forms a composite item - composite item required.
717	Benefit not payable on this service for a hospital patient.
718	Provider location closed at date of service.
719	Benefit cannot be calculated for Hyperbaric Oxygen Therapy.
720	Eligibility cannot be determined for this item.
732	Referral period not valid for referring provider.
812	Details of transferred Medicare assessment - underpayment.
814	Details of transferred Medicare assessment - overpayment.
815**	Overpayment of transferred benefit recorded.
816	Details of revised Medicare assessment - underpayments involved.
818	Details of revised Medicare assessment - overpayments involved.
819**	Partial overpayment of benefit recorded.
821	No Change to original benefit - recorded for history purposes.
831**	Underpayment of less than $2.00 - no adjustment cheque issued.
841**	No change to Original Benefit - Record transferred for history purposes.
851**	Underpayment of less than $2.00 - Transferred - no cheque issued.
861**	Adjustment to Medicare benefit previously paid.
881**	Adjustment to transferred Medicare benefit previously paid.
888	Details of previous Medicare assessment.
889**	Details of previous Medicare assessment (transferred).
890	Details of suppressed unrelated service - HIC.
891	Details of suppressed unrelated service - MOL.
892	Details of suppressed unrelated service - Fraud.
898	Details of previous Medicare assessment - Suppressed.
980	Item line adjusted by system - patient contribution.
999	Line has been reversed.
LCR**	Repay cancelled service.
LOC**	Service cancelled.
LSC**	Stale cheque written back.
LSE	Left eye treated.
RSE	Right eye treated.
SRG	Pay benefit to surgeon for service of assistant.
SUB**	New referral period generated from subsequent con item.
UCS**	Unclaimed cheque cancelled - returned address indicator set.
WOD**	Overpayment written off - no recovery attempted.
@	New card issued - quote this number on future claims.
#	Card used at time of service not old issue.
%	Card expired - future claims may be rejected.
+	New card number used - claimant no longer on card used.

Provider classification codes

Table 9: this table lists and describes provider classification codes.

Classification	Description
C01	Medical practitioner
C02	Approved pathologist
C04	Approved dentist
C05	Optometrist
C50	Dentist (extras)
C51	Physiotherapist
C53	Chiropodist/podiatrist
C56	Chiropractor
C64	Accredited orthodontist

Claims history modifiers

Table 10: this table lists the modifiers that can be used at the end of control line NHOI or NHSI to shortcut to specific patient information.

Modifier	Description
PATIENT	History for patient.
FROM/ddmmyy	From date specified.
TO/ddmmyy	To date specified.
FROM/ddmmyy,TO/ddmmyy	History between specified periods.
FROM/ddmmyy,TO/ddmmyy,item/nnnnn	History of an item between specified periods.
SORT/DOS	Sort date of service.
SORT/DOS,PROV/nnnnnnnn	Sort date of service for specified provider.
PATH/ITEM	History for pathology items.
ITEM/nnnnn	History for item number specified.
ITEM/nnnnn-nnnnn	History for items within range specified.
PROV/nnnnnnnn	History for provider specified.
PROA/nnnnnnnn	All practice locations for provider specified.
DOP/ddmmyy	History for the date of processing specified.
DOL/ddmmyy	History for the date of lodgement specified.
PEND/ONLY	Pended lines only.
ADJ/ALL	All Latter Day Adjustment (LDA) claims.
ADJ/BB	LDA claims for bulk bill.
ADJ/PC	LDA claims for patient claims.
ADJ/SB	LDA claims for simplified billing.
CLM/annnn	Display direct bill claim ID specified.
CLM/BB	Display all direct bill.
CLM/SB	Display all simplified billing claims.
CLM/HBC	Displays home based claiming claims.
CLM/PCM	Displays manual patient claims.
CLM/PCO	Displays electronic patient claims.
PART/NN	Used to upload a specified part of the MBS: 01 - Professional attendances 02 – Obstetrics 03 – Anaesthetics 04 - Regional Field Nerve Block 05 - Assistance in the administration of anaesthetics 06 - Miscellaneous procedure 07 - Pathology 7A - Computerised Tomography 08 - Radiology services 8A - Radiotherapy 09 - Assistance at operations 9A - Magnetic Resonance Imaging 10 - Operating
ITEM/ACRF	Displays account reference number on history.
PSYC/YY	Psychiatric consultation paid for the year specified.
Card number,IRN or name, DENT/ALL,SORT/DOS	Displays card history for all dental services by date of service.
PIN,DENT/ALL,SORT/DOS	Displays Personal Identification Number (PIN) history for all dental services by date of service.

Medicare patient history PDOR, DOR and DOS modifiers

Table 11: this table lists and describes the three modifiers that have been created for history screens (NHOI and NHSI) to allow Service Officers to find claim items more easily.

Modifier	Description
PDOR/ddmmyy	Use to display all pathology items processed for a specific patient episode by the Date of Request (DOR). For example, checking the coning rule was applied correctly for pathology services which were requested on a specific day, for a specific patient.
DOR/ddmmyy	Use to display all items that have the same Date of Request. This excludes referred specialist consultations.
DOS/ddmmyy	Use to display all items (pathology and non-pathology) by Date of Service (DOS) for a single day.

Note: for a referred specialist consultation the modifier DOR/ddmmyy is used by the system to automatically pick the most recent referral DOR, there are many circumstances where referral dates are incorrectly entered on a patient claim, which are not necessarily the same as what the specialist has used or transmitted for the initial consultation.

Modifiers to use with other modifiers

For example, for the patient display all pathology records for the patient episode and sort by date of service (DOS) rather than by processing date: NHOI,1234567890,1,PDOR/150411,SORT/DOS.

Table 12: this table lists modifiers that can be used with other modifiers to locate claim items.

Modifier	Description	PDOR	DOR	DOS
ADJ/PC ADJ/BB ADJ/SB	Displays history of adjusted services.	Yes	Yes	Yes
CLM/annnn	History for a bulk bill claim specific to the card number.	Yes	Yes	Yes
CLM/BB	Bulk bill claims only.	Yes	Yes	Yes
CLM/HBC	Home Based Claiming.	Yes	Yes	Yes
CLM/PCM	Patient Claims - Manual.	Yes	Yes	Yes
CLM/PCO	Patient Claims - Online.	Yes	Yes	Yes
CLM/SB	Simplified Billing.	Yes	Yes	Yes
DOL/ddmmyy	Date of lodgement.	Yes	Yes	Yes
DOP/ddmmyy	Date of processing.	Yes	Yes	Yes
FROM/ddmmyy	Services from the specified date of service.	Yes	Yes	No
IRN	Medicare card reference number/sub-numerate of the required patient.	Yes	Yes	Yes
ITEM/nnnnn	Display specified item.	No	Yes	Yes
ITEM/nnnnn-nnnnn	Services for the specified item range.	No	Yes	Yes
name	First name of the patient.	Yes	Yes	Yes
PART/??	Items in specified part of Medicare Benefits Schedule (MBS).	No	Yes	Yes
SORT/DOS	Sort display in date of service.	Yes	Yes	Yes
TO/ddmmyy	Services to the nominated date of service.	Yes	Yes	No

Service Officer daily claims modifiers

ROMI,<modifier(s)>

RSMI,<operatorno>,<modifier(s)> Supervisor

Table 13: this table lists the modifiers that can be used to display claims processed by a Service Officer for the current day.

Modifier	Description
MEDICARE	Medicare Patient claims.
REBATE	Private Health Incentive 30% rebate claims.
CARD/ccccccccc	Medicare Claims for a specific Medicare card number.
FUND/aaa	Rebate Claims for a specific Private Health Fund.
POLICY/ppppppppppppppp	Rebate Claims for a specific policy number.
CHEQ	Medicare Claims with Payee codes 2.
EFT	Medicare Claims with Payee codes 9, E. Rebate claims N/A
PAYEE/n	Claims with the specified payee code. Valid payee codes are: H, P, R, O, 2, J, 9, E.
BEN/nnnnnn	Claims with Benefit amount equal to the specified amount.
LESS/nnnnnn	Claims with a Benefit amount less than the specified amount.
MORE/nnnnnn	Claims with a Benefit amount more than the specified amount
FROM/hhmm	From a particular time.
TO/hhmm	Up to a particular time.

Operational Information