Bulk bill claims in Medicare 011-43030000

Bulk billing:

• also known as direct billing, is when a health professional bills Medicare directly for any medical or allied health service that a patient receives
• is available to all persons in Australia who are eligible for a Medicare benefit under the Medicare program

Where a health professional and a patient enter into a bulk bill arrangement, the:

• servicing health professional undertakes to accept the relevant Medicare benefit as full payment for the service. Additional charges for that service cannot be raised, and
• patient assigns their right to the Medicare benefit to the servicing health professional, allowing the benefit to be paid directly to the health professional

Health professionals must lodge claims for assigned benefits in accordance with the approved forms and within the applicable claim limit period.

For services provided:

• before 5 September 2025, health professionals must submit claims within 2 years of the date of service
• on or after 5 September 2025, health professionals must submit claims within 1 year of the date of service

See Bulk bill late lodgement claims in Medicare.

There is no minimum age restriction for a patient to assign their right to a Medicare benefit to the servicing health professional. However, the patient must have the capacity to understand what they are signing. Health professionals must use their discretion to decide a patient's capacity.

Bulk bill incentive (BBI) items are additional payments made to medical practitioners when they bulk bill eligible patients for unreferred services. For more information about BBI's, see Bulk bill incentive items in Medicare.

Bulk billing cannot be used as a form of debt collection for unpaid accounts.

Note: section 20A of the Health Insurance Act 1973 allows a patient to assign their right to a Medicare benefit to the health professional who has rendered the service.

The Resources page contains a link to the Medicare Benefit Schedule (MBS) Online Explanatory Note GN.7.17, which has more details about bulk billing.

If health professionals cannot get patient agreement in writing or by email for telehealth services, they can get verbal agreement from their patient during the telehealth consultation.

Health professionals must complete the form approved for the purposes of s 20A of the Health Insurance Act 1973 electronically:

• Bulk bill voucher - electronically transmitted claims form (DB4E)
• Assignment of benefit Medicare bulk bill Webclaim form (DB020)

The Resources page contains links to the forms.

Health professionals must:

• explain to the patient how they will fill in the patient signature field in the approved form, and
• confirm that the patient agrees

If the patient agrees, health professionals must

• type patient verbally agreed in the patient signature field, and
• send the completed form electronically to the patient

If the patient does not agree to assign their benefits, the health professional can send them a private bill for the service.

Health professionals should keep a copy of all correspondence, claims, and forms for at least 2 years. This is for auditing purposes if they are subject to a compliance review.

Getting verbal agreement is a temporary measure.

Note: patients can also assign their right to a Medicare benefit by email.

The Resources page contains a link to the Email agreement on the Services Australia website for more details.

A patient can assign their right to a Medicare benefit to the servicing health professional by signing a completed assignment of benefit form for manual and online claiming. See Assignment of benefit in Medicare bulk billing.

If a health professional bulk bills for a service, the health professional agrees to accept the relevant Medicare benefit as full payment for the service. Additional charges for that service cannot be raised.

This includes but is not limited to:

• any consumables that would be reasonably necessary to perform the service, including bandages and dressings
• record keeping fees
• a booking fee to be paid before each service
• an annual administration or registration fee

Exception

An additional charge can only be raised against a bulk billed patient if the patient is given a vaccine or vaccines from the health professional's own supply held on the premises.

This exception only applies to general practitioners and other non-specialist health professionals in association with attendance items 3 to 96 and 5000 to 5267 (inclusive). It only relates to vaccines that are not available to the patient:

• free of charge through Australian Government or state government funding arrangements
• through the Pharmaceutical Benefits Scheme (PBS)

The additional charge must only be to cover the supply of the vaccine.

Where a health professional chooses not to bulk bill a patient, they may privately raise an additional charge against a patient, such as for a consumable.

The Resources page contains a link to the Medicare Benefit Schedule (MBS) Online Explanatory Note GN.7.17, which has more details about bulk billing.

Health professionals can submit their Medicare bulk bill claims:

• electronically through Medicare Bulk Bill Webclaim, or
• by ordering manual bulk bill forms by completing a Medicare stationery order form

Medicare Bulk Bill Webclaim can be accessed using HPOS. If the health professional does not have HPOS access, they need to apply for PRODA to be able to access HPOS.

Note: manual bulk bill forms were removed from Services Australia website on 15 May 2017.

A valid claim must include the appropriate bulk bill claim header for the assignment of benefit form(s) used. The header can only be signed by the servicing health professional.

Services that were performed as in-patient and out-patient services cannot be 'batched' together and submitted under the one claim. These claims need to be submitted separately and the appropriate header completed.

All fields on the manual bulk bill claim header are expected to be completed by the health professional. However, there a few exceptions to this, which are listed below:

• witness name for sole health professionals
• payee provider section (only completed where the payee and servicing health professional are not the same)
• missing or incorrect information that may be confirmed over the phone

The Process page contains more details.

A 'Signature of Witness' is required on all manual bulk bill claim headers. An eligible witness is a person who works at the health professionals practice but is not the person or health professional who:

• rendered the service, and
• signed the declaration

Note: sole health professionals who cannot get a witness signature on the bulk bill header must notate 'sole practitioner' in the witness signature field.

Where a patient is unable to provide their Medicare card number to the health professional, the health professional may get it by:

• using the Patient Verification facility through HPOS
  Note: this facility is only available to health professionals with a PRODA registration
• calling the Medicare provider enquiries line for exempted groups only

For more details, see 'Medicare card enquiries' in Release of claims information in Medicare.

Medicare card close to expiry date or has expired

If the Medicare card used in a bulk bill claim is within 75 days either before or after the expiry date, the bulk bill statement tells the health professional that the card is about to, or has, expired.

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

Alterations on bulk bill claims not previously processed

When a bulk bill claim is received for an initial assessment (that is a bulk bill not previously processed by Services Australia) and details on the assignment of benefit form have been altered, the health professional is required to have either:

• the patient's initials endorsing the alterations to indicate they are aware of and agree to the alterations, or
• complete a new assignment of benefit form with the correct details and have the patient sign the new form before submitting to Medicare for processing

See Bulk bill late lodgement claims in Medicare.

Inappropriate alterations to assignment of benefit forms

It is an offence under section 128A, 128B and 129 of the Health Insurance Act 1973 for a servicing health professional to make a false or misleading statement in relation to a Medicare claim. The servicing health professional must not under any circumstances amend any details, for example, an item number, simply because Services Australia rejected the original claim.

The Resources page contains links to the:

• Assignment of benefit, and
• Application for bulk bill claim adjustment forms

Contact Medicare Public Local Peer Support (LPS) for help with processing a patient claim when the:

• claim is received through the PaNDA work tool
• claimant has an RHCA entitlement, and
• claimant has already left the country

Where the servicing health professional asks about the payment of a manually submitted bulk bill claim that has not been received, Service Officers must ask them if they retained a copy of the claim.

Note: the copy of the claim retained by the health professional must include a signature from the patient on the assignment of benefit form.

Health professional has retained a copy of the claim

If the health professional has retained a copy of the claim, they must do the following:

• resend the claim to Services Australia
• attach a brief covering letter explaining the reason for the photocopied claim being submitted

The agency will accept photocopied assignment of benefit forms if:

• the information on the form is clear, and
• there is no evidence suggesting alterations have been made

Health professional has not retained a copy of the claim

If the health professional has not retained a copy of the claim, they must:

• complete the assignment of benefit agreement(s) with the original service details
• get the assignor's signature or agreement
• complete a bulk bill claim header
• send the claim to the agency for processing

Note: while health professionals are no longer required to retain a copy of the bulk bill forms, the agency suggests they retain a copy until the account has been reconciled.

The Resources page contains links to various bulk bill forms on the Services Australia website.

All heath professional bulk bill payments are made through electronic funds transfer (EFT). A health professional must have their bank details stored with Services Australia in the Provider Directory System (PDS) in order to receive bulk bill payments.

Health professionals that have not registered their EFT details and lodge bulk bill claims will have their payments HELD. Once the health professional registers their nominated bank account, any HELD Medicare benefits will be automatically released by the system.

A list of EFT payments can be viewed by keying control line BRNA. This transaction will allow a view of specific Medicare deposits for a provider number.

The data available via the BRNA transaction is updated daily, See Medicare benefit not received (EFT dispute).

A bulk bill electronic funds transfer (EFT) dispute is when a health professional states they have not received a Medicare benefit into their nominated bank account for a claim that was processed and not rejected.

Service Officers are to determine the reason the health professional has not received their Medicare benefit as claimed. For example, HELD payment, claim rejected or not processed.

Health professional error

If the health professional provided incorrect bank details to Services Australia , Service Officers must complete an EFT dispute form and forward to MPS Assessing.

If a claim is processed against the wrong health professional and it can be identified who received the payment, Service Officers must:

• complete a Customer enquiry form, and
• forward the form to MPS Assessing, noting overpayment details

If an EFT retrieval is unsuccessful where the health professional has provided incorrect information, the agency is not obligated to repay the funds.

Services Australia error

If a Medicare benefit was paid into an incorrect bank account due to agency error, the agency must repay the health professional at the first point of contact.

If it is:

• known where the incorrect payment was made, raise a debt through MPS Assessing
• not known where the incorrect payment went, complete a Manual EFT Payment Request form (PP048) form and send via email to MPS Assessing. The Resources page contains a link to the form

Note: repayments can only be actioned by Service Officers with the appropriate skill tag.

Bulk bill resubmissions are Medicare bulk bill claims that have been resubmitted by a health professional with additional or amended details. Resubmissions generally occur after a claim header or assignment of benefit agreement is returned or rejected because of missing or incorrect information, such as:

• Incomplete or incorrect Medicare card number or patient details
• Bulk bill header or assignment of benefit agreement is incomplete. For example, patient has not signed the assignment of benefit agreement
• Claim information such as the item number or referral details

Health professionals resubmitting a bulk bill claim header or assignment of benefit agreement that has been previously rejected by Medicare, must lodge the resubmitted claim with all the required paperwork.

Each type of resubmission has different requirements in order for the claim to be processed. If there are missing documents or paperwork, the claim must be returned with the appropriate letter.

A health professional can resubmit a claim electronically for the same service if:

• an electronic bulk bill claim is rejected, and
• the assignor has initially signed or agreed to the assignment of benefit agreement

If the claim cannot be resubmitted electronically, and to determine the required paperwork, Service Officers must identify if the claim is for:

• an initial assessment, or
• a resubmission of a previously rejected service

Resubmission of a previously rejected claim for the same service

Where a practice cannot resubmit the claim electronically, they must provide Medicare with the following documents:

• a completed header, signed by the servicing health professional and witness, and
• an assignment of benefit agreement accompanied with either:
  • a patient assignor signature
  • letter indicating the claim was originally submitted electronically, or
  • a notation that the 'patient has signed the Medicare copy', where there is evidence either on the patient's mainframe history or PaNDA that the claim was payable at the time of the original submission

Note: this only applies where there has not been a change to the original details of the claim (for example. item number or date of service (DOS)).

Resubmission of a previously rejected claim for a different service

The assignor must sign a new assignment of benefit agreement that reflects the correct service, if:

• an online bulk bill claim is rejected, and
• the practice must resubmit the claim for a different service to the original

If agreement is obtained from the patient for the correct service, the practice can resubmit the claim for the service electronically.

Where the practice cannot submit the claim electronically, they must provide Medicare with the following documents:

• a completed header, signed by the servicing health professional and witness
• a completed assignment of benefit agreement signed by the assignor

Resubmission of a previously rejected Easyclaim bulk bill claim

For a resubmission of an Easyclaim, the following documents are required:

• a completed header, signed by the servicing health professional and witness
• copies of the Easyclaim printout/slip, and
• a signed letter on a practice letterhead stating that the original claim was submitted through the Easyclaim channel

Service Officers must determine if the claim received is for the same service as the original or if the resubmission is for a different service if:

• a manual claim has been rejected, and
• the practitioner is required to resubmit the claim

Resubmission of a previously rejected claim for the same service:

• a completed header, signed by the servicing health professional and witness
• assignment of benefit agreement accompanied with either:
  • a patient signature or agreement
  • a notation that the 'assignor has signed the Medicare copy', where there is evidence either on the patient's mainframe history or PaNDA that the claim was payable at the time of the original submission

Note: copies of the original forms are acceptable where the claim is resubmitted for the same service.

Resubmission of a previously rejected claim for a different service:

• a completed header, signed by the servicing health professional and witness
• a completed assignment of benefit form signed by the patient

Health professionals must retain a copy of the assignment of benefit agreement for 2 years from the date the claim is made. See Assignment of benefit in Medicare bulk billing.

Services Australia retains bulk bill claim forms that have been submitted for a period of 2 years, where a benefit is paid to the health professional.

All assignment of benefit agreements, accounts or account receipts for processed claims must be retained by the agency for audit purposes. These documents provide the only reliable audit evidence in support of the payment of Medicare benefits.

See also:

• Account and receipt documents for Medicare claims processing
• Archiving and document retrieval for Medicare
• Assignment of benefit in Medicare bulk billing

When a bulk bill claim is received for initial assessment (that is, a bulk bill claim not previously processed by Services Australia) and details on the assignment of benefit form have been altered, the health professional is required to have either:

• the patient's initials endorsing the alternations to indicate they are aware of and agree to the alterations, or
• complete a new assignment of benefit form with the correct details and have the patient sign the new form before submitting to Medicare for processing

Bulk bill statements are mailed to the payee provider at their current preferred mailing address, as per their stem details in the Provider Directory System (PDS). Manually requested statements are printed daily and should be received within 10 working days.

Health professionals can subscribe to the HPOS Mail Centre to receive copies of statements or reports, including Medicare bulk bill (manual claiming) reports. Health professionals subscribed to the above statements on HPOS, or who lodged the claim through HPOS, do not receive paper statements from Services Australia. They must access their statements through HPOS.

For more details, see Requests for provider statements for eBusiness/eServices.

Staff may need to complete a manual EFT payment when they cannot process a claim or adjustment in the mainframe system.

For example:

• Claims resubmitted after a non-compliance audit, where:
  • the date of service is more than 5 years ago, and
  • the claim cannot be entered into the mainframe
• Adjustments that result in an underpayment and cannot be processed in the mainframe

In these cases:

• a delegate approves the request
• payment is made via manual EFT

The Process page contains more information about how to process these.

During the Covid-19 pandemic, the Department of Health, Disability and Ageing (DHDA) introduced a temporary policy change for how health professionals obtained patients agreement for an assignment of benefit for face-to-face services.

This temporary policy was in effect from 13 March 2020 to 21 September 2023 and applied only to claims for services provided during this time.

Where a patient was seen face to face and the health professional chose to bulk bill, reasonable steps were to be taken to get a signature agreement. For example:

• Written signature
• Medicare easy claim, patient selected either the OK or Yes button on the EFTPOS terminal
• Email agreement, or
• Signature of a responsible third party

However, if the patient refused to sign the form, that is, did not want to touch the pen or paper, the health professional could get the agreement verbally. To do this the health professional was required to:

• identify on the form that the patient was unable to sign the assignment of benefit and include the reason. For example, COVID-19, risk of exposure to COVID-19, verbal agreement given
• note the verbal agreement of assignment of benefit in the patient's clinical notes

Manual bulk bill claims

To support the temporary policy, bulk bill manual claims received with a date of service from 13 March 2020 to 21 September 2023 are accepted, where the following has been provided:

• A completed header, signed by the health professional and witness
• An assignment of benefit form with the reason why the patient is unable to sign the assignment of benefit form, for example, COVID-19, risk of exposure to COVID-19

Note: this temporary policy only applied if the patient refused to sign because they did not want to touch the pen and/or paper. The above details do not replace existing policy for all other unable to sign/blank signature' scenarios during this time.