Bulk bill latter day adjustment (LDA) claims in Medicare 011-43040000

Bulk bill LDA documentation requirements

Table 1: documents required to be submitted by health professionals for a Bulk Bill adjustment to be processed.

Note: All adjustment types listed below are for previously paid claim(s) – where the original claim was less than 2 years from the date of service. For services over 2 years, see Bulk bill late lodgement claims in Medicare.

Adjustment type

Documents required

Example of adjustment

Amendment to original:

Item number(s)

Date of service or

Add additional item number(s)

Application for bulk bill claim adjustment form (DB018)

New signed assignment of benefit form (by the patient) with the correct information

The health professional originally:

Billed an item 23 however meant to bill item 2715
Billed item 732 x 1, however meant to bill 732 x 3
Billed an item for DOS 11/07/2023, however the service was performed on 10/07/2023

Deletion of previously paid claim(s)

Application for Bulk Bill claim adjustment form (DB018) with all claim information present on the form, that is:

Patient's Medicare Number and Name
DOS
Item Number(s) etc. or

A letter using the practice letterhead which includes all claim information and signed by the health professional

The health professional:

Bulk billed the patient, however the patient was meant to be privately billed
Bulk billed the patient, however the service did not occur
Bulk billed the patient, however the claim was meant to be submitted via Simplified Billing
Submitted the claim using the incorrect provider number

Amendment to:

The date of referral (DOR)

Referral period validity

Application for bulk bill claim adjustment form (DB018)
Copy of referral with correct date details

The health professional:

Lodged the DOR as 13/02/2023, however it was meant to be 13/05/2023
Lodged the referral as being valid for 12 months, however they have received an indefinite referral

Omitted bulk bill incentive or patient episode initiation (PEI) item(s)

This also includes omitted telehealth incentive items.

Application for Bulk Bill claim adjustment form (DB018)
A spreadsheet outlining service details (patient name, Medicare number, DOS etc.)

Note: a new signed assignment of benefit form is not required if this is the only change being requested

The health professional:

lodged the Bulk Bill claim without any incentive items, however they are entitled to bill these items to Medicare i.e. item 10990 was not billed to the patients record

Adjustment to originally claimed bulk bill incentive or patient episode initiation (PEI) item(s)

Application for Bulk Bill claim adjustment form (DB018)
A spreadsheet outlining service details (patient name, Medicare number, DOS etc.)

Note: a new signed assignment of benefit form is not required if this is the only change being requested

The health professional:

lodged the claim using item 10990, but meant to use item 75855

DHSC screen

Fields on a restated line can be corrected at any time throughout the DHSC stage. The [Enter] key must be pressed to accept any changes.

Note: whenever a line is protected the system removes the dashes in all fields that are empty and the colour changes to blue.

Table 2

DHSC screen features	Description
Original line	All field are protected, except the A field which contains an O to indicate the Original line.
Reinstated line with corrected details	All keying fields are unprotected and an R is displayed in the A field to indicate the Reinstated line.
Zero in the FEE and BENEFIT fields	Restates PI's, IE, IL, IS and 11. Any other PI's and all reason codes are not reinstated, allowing the adjustment line to be completely re-assessed.
Error messages	Relating to the accuracy of the new details.
Service lines	Nine service lines can be displayed. If I is entered on the A field on the ninth line, the new line is positioned on the next DHSC screen. Note: press [F8]-Forward to scroll forward to the next screen.

Adjustment action codes for bulk bill LDA claims

Adjustments can be actioned on lines that have:

not already been adjusted (the A fields or these lines contain '-')
restated lines (the A fields contain R)
new lines (the A fields contain N)
I may be entered (to insert a line) in the A field if over keying an R or N

Table 3

Action code	Description
T	Delete a line and reinstate the original (D was previously used to delete line)
I	Insert a line
N	New line
R	Restated line
O	Original line
H	Suppress a line
M	Suppress a line identified through Medicare online
F	Suppress a line identified through fraud
X	Cancel a restarted line or new line
A	Adjust
P	Patient Transfer

DCEI reason codes

Table 4: This table describes the codes that can be entered into the DCEI RSN field when an overpayment has been raised when processing a bulk bill LDA.

Code	Description	Explanation
DRD	Debt Received	Applies if the health professional has indicated that they have paid the overpayment and Medicare Debt Recovery can confirm that the amount has been received.
DRI	Doctor Refund Initiated	Applies if the recovery action needs to be pursued as monies are owed to Services Australia as a result of the overpayment.
EFT	Medicare Provider EFT returned	Applies if the agency's banking details were stored on the provider's records. An overpayment is then processed, and EFT is entered to advise debt recovery that the agency is in receipt of the overpayment amount.
VRC	Voluntary Recovery	Applies if the health professional submits a cheque or money order in relation to a Bulk Bill overpayment.

DCEI enquiry claims

The status of an updated claim on DCEI depends on the result of all adjustments processed.

Examples of claim status depending on adjustment amount.

Table 5: This table shows examples of claim status depending on the sum of the adjustment.

If the sum of all adjustments results in:	Then claim status is:
Either no change to benefit paid or an underpayment of less than $1.00	ADJ PAID
An underpayment of $1.00 or more	ADJ HIST
An overpayment (regardless of amount)	ADJ OPAY

Examples of claim status depending on adjustment amount

Table 5: This table shows examples of claim status depending on the sum of the adjustment

If the sum of all adjustments results in:	Then claim status is:
Either no change to benefit paid or an underpayment of less than $1.00	ADJ PAID
An underpayment of $1.00 or more	ADJ HIST
An overpayment (regardless of amount)	ADJ OPAY

Enter adjustment details

Table 6: This table shows how to enter specific adjustment types for bulk bill LDA claims

Adjustment type	Action:
Overkey	Key: Item DOS BN ASG Referring/requesting details
Transfer	Overkey: Card number and/or Patient's name
Suppress	Action codes: H - suppress HIC internal reasons M - suppress Medicare Online (MOL) F - suppress fraud
Delete total overpayment	Use action code T Note: this has replaced action code D.
Insert	In the A field key action code I over: R or N
Original Line (System generated codes)	Action codes: O - replaced the action code entered by the Service Officer R - must have a matching O line. Can be overtyped with X or I action codes
Adjust	Action code: A - can only be used on an unadjusted line
Patient transfer	Action code: P - allows Service Officer to adjust a patient transfer

Reason codes displayed - underpayment

Table 7: This table describes the system generated reason codes for an underpayment of benefits previously paid

Reason code	Line type
888	Original line
816	Restated line
861 and item of UPAY	Result line

Reason codes displayed - overpayment

Table 8: This table describes the system generated reason codes for an underpayment of benefits previously paid

Reason code	Line type
888	Original line
818	Restated line
819 and item of OPAY	Result line

Reason codes displayed - no change to benefit

Table 9: This table describes the system generated reason codes when there is no change to benefits previously paid

Reason code	Line type
888	Original line
821	Restated line
	Result line

Reason codes displayed - transfer of services - underpayment

Table 10: This table describes the system generated codes when a service has been transferred from another patient's record, and the adjustment results in an underpayment

Reason code	Line type
889	Original line
821	Restated line
881 and item of UPAY	Result line

Reason codes displayed - transfer of services - overpayment

Table 11: This table describes the system generated codes when a service has been transferred from another patient's record, and the adjustment results in an overpayment

Reason code	Line type
889	Original line
841	Restated line
	Result line

Reason codes displayed - transfer of services – no change to benefit

Table 12: This table describes the system generated codes when a service has been transferred from another patient's record, and the adjustment results in no change to benefit

Reason code	Line type
889	Original line
841	Restated line
	Result line

Reason codes displayed - suppress history – Medicare internal

Table 13: This table describes the system generated codes when a service has been suppressed using the 'H' action

Reason code	Line type
898	Original line
890	Restated line
8901 and item of OPAY	Result line

Reason codes displayed - suppress history – Medicare Online

Table 14: This table describes the system generated codes when a service has been suppressed using the 'M' action

……………………………………………………………………………………………………….	Line type
898	Original line
891	Restated line
891 and item of OPAY	Result line

Reason codes displayed - suppress history – Fraud

Table 15: This table describes the system generated codes when a service has been suppressed using the 'M' action

Reason code	Line type
898	Original line
891	Restated line
892 and item of OPAY	Result line

Contact details

Debt and Compensation Program (DCP) Branch and Payment Assurance Operations (PAO) contacts > Medicare Debt Recovery

Department of Health, Disability and Ageing

Medicare claims helpdesk

Medicare Provider Enquiries

Medicare Provider Services (MPS)

1-PREV CON escalation template

Do not share this attachment externally. See Freedom of Information - Information Publication Scheme.

$\\INTERNAL.DEPT.LOCAL\Shared\NAT\SERDELEXCEL\WORKPRODIMP\Operation Blueprint Migration\RDT Release Icons\32w\icon-hidden-attachment.png$ Escalation template