Process Medicare Safety Net claims 011-43080040

Where a fully paid account is claimed, the claim is processed as paid and the claimant is reimbursed the appropriate Medicare benefit plus 80% of the remaining out-of-pocket (OOP) expenses or the Extended Medicare Safety Net (EMSN) benefit cap, when the claimant has reached their relevant Medicare Safety Net threshold.

Service Officers must check to ensure that there are no outstanding balances on the account. The system then calculates the benefit automatically without any Service Officers intervention.

The Resources page contains an example of how the system calculates the benefit on fully paid accounts when the Medicare Safety Net has been met.

Legislation states that where an individual has met their Safety Net threshold, they need only pay a maximum of 20% of the out-of-pocket (OOP) expenses.

This means that Services Australia (the agency) accepts partially paid accounts (where at least 20% of the OOP has been paid) as well as fully paid and unpaid accounts.

This also means that some health professionals may only charge claimants 20% of the OOP who they believe or know have reached the Safety Net threshold. In this case, claimants only incur 20% of the OOP expense and health professionals are reimbursed the Medicare benefit plus 80% of the OOP or the Extended Medicare Safety Net (EMSN) benefit cap via a pay doctor via claimant (PDVC) cheque.

Note: where the item is subject to an Extended Medicare Safety Net (EMSN) benefit cap the 20% of the OOP expense paid by the claimant may not be sufficient to pay the account in full and the account is treated as an unpaid account.

The agency automatically processes partially paid accounts where the claimant has paid exactly 20% of the out-of-pocket (OOP).

When processing a claim where 20% of the OOP has been paid, the system prompts Service Officers to enter the amount paid by the claimant and it then calculates the benefit payable automatically.

The Resources page contains an example of when 20% of the OOP has been paid.

Where a claimant has paid less than 20% of the out-of-pocket (OOP), the system asks for the partial payment to be keyed because it does not know the calculation until all figures are entered.

When the system recognises that the partial payment is less than 20% of the OOP, the message '8-PPMT<20%' displays.

Where the claimant is:

• Present or contacted via telephone:
• Service Officers should advise that this claim will be processed as unpaid, only paying the standard Medicare benefit. Alternatively, when the claimant pays the account, an additional benefit would be payable
• Not present, for example, claims lodged by post or digitally:
• The claim is to be processed as unpaid

Note:

• Where the claim is processed as unpaid, the system disregards the partial payment entered and the claim is processed as unpaid. The pay doctor via claimant (PDVC) cheque is for the Medicare benefit only
• Verification is required for a further benefit to be paid. The message 'Extra benefits may be paid with proof of payment to Medicare' on the PDVC cheque statement advises this

The Resources page contains an example of when less than 20% of the OOP has been paid and verification is required for a further benefit.

Claimants may sometimes pay more than 20% of the out-of-pocket (OOP) due to health professionals not knowing what is exactly 20% of the OOP.

In this situation, the benefit payable from the claim must be split between the health professionals and the claimant.

When the claimant has paid more than the 20% OOP, but less than the health professionals charge on the account, process the claim recording the amount of partial payment where prompted.

A message displays advising that the claim cannot be finalised at this stage because payment must be split between the health professional and the claimant. The claim must be pended and forwarded to MPS Assessing for full assessment and payment of benefit.

The Resources page contains an example of when more than 20% of the OOP has been paid.

When the claimant has paid more than 100% of the out-of-pocket (OOP), Service Officers are prompted to enter the partial payment amount and should process the claim as more than 20% of OOP paid.

The Resources page contains an example of when more than 20% of the OOP has been paid.

Health professionals must provide the following details on an account:

• date
• amount charged
• total amount paid
• amount outstanding

This assists Service Officers in identifying where an account is unpaid, fully paid or partially paid.

The amount a claimant has paid towards the account, as well as the amount still outstanding, is recorded on all accounts.

When this information is not included on the account the claim is to be treated as unpaid and processed as a pay doctor via claimant (PDVC) for the standard benefit only, and the claimant advised to pay the balance as per current procedure.

When the amount paid is less than 20% of the out-of-pocket (OOP).

The Resources page contains an example of when less than 20% of the OOP has been paid.

Where an unpaid account is claimed, the system generates a pay doctor via claimant (PDVC) cheque for the appropriate Medicare benefit.

Service Officers are prompted to key a partial payment when a threshold has been reached which will be 0 (zero).

The message 'Extra benefits may be paid with proof of payment to Medicare' is inserted on the statement of benefit to advise the claimant that additional benefits may be payable when the account is paid and verified by Medicare.

To claim the additional Safety Net benefit, the claimant must provide proof of payment to the agency so that verification (substantiation) can be processed. When this is done the system calculates and pays the 80% out-of-pocket (OOP) benefit or the Extended Medicare Safety Net (EMSN) benefit cap, whichever is less, to the claimant.

The Resources page contains an example of when an unpaid account is claimed.

It is possible for a dependant to be enrolled on more than one Medicare card. These dependants can also be registered with more than one Safety Net family.

When processing a claim Service Officers must ensure they allocate the Safety Net benefit to the family who incurred the cost of the service. The Process page contains processes for selecting the correct Safety Net family when processing claims and adjustments.

Note: dependants can be registered on a maximum of two Safety Net family registrations.

See also:

Medicare Safety Net

Incomplete or incorrect Medicare claims forms

This document outlines the procedures to follow when the 8-CONFIRM message is displayed when processing a claim. It applies to out of hospital claims where the account is either paid in full or where the gap has been paid. Claims for unpaid or in-patient service accounts are to be processed as normal.

Claimant in a service centre

Where the 8-CONFIRM message is displayed and the person is in the service centre, they must confirm their current family Safety Net composition by either:

• signing the CDMS printed family confirmation, see the Print a confirmation form table in Family registration and confirmation for Medicare Safety Net, or
• completing a Family Safety Net confirmation form

Once the family composition has been confirmed the claim can be processed.

Note: for quality control purposes, it is considered an error when a Service Officer has confirmed a family composition and has not included the signed confirmation in their work.

Claimant not in a service centre

When a claim for a fully paid or partially paid account returns an 8-CONFIRM message and the person is not in the service centre, only continue to process the claim when it can be determined that the Safety Net threshold will not be exceeded. See Family registration and confirmation for Medicare Safety Net.

When processing a claim that will take the family over the Safety Net threshold, confirming a registered safety net family can be done over the phone.

Service Officers are to attempt to call the family contact or the claimant (who is over 14 years of age). Service Officers are required to make 2 attempts by telephone before returning the claim to the claimant. Where the claimant is unable to be contacted by phone, the claim must be returned to them with a family Safety Net confirmation form and letter.

Any individual who is part of the registered Safety Net family and aged 14 years of age or older can confirm the family composition.

See also: Family registration and confirmation for Medicare Safety Net.

When it is necessary to return the claim to an individual with a letter informing them that they may be entitled to higher benefits once they verify their family composition, the following must occur, the:

• Standard letter template is used for each letter. This decreases the chances of incorrect information being sent. Note: do not under any circumstances, overtype information saved from a previous letter sent to a different person
• Correct claim is attached to the letter that is to be sent

Note: when this policy is not adhered to, it is considered a breach of the privacy and secrecy provisions.

See also: Preparing, quality and peer to peer checking of Medicare external mail.

A claim can be adjusted after receiving verification of the family composition in the following circumstances:

• all online claims
• an individual or family identifies that they were entitled to a higher benefit
• a Service Officer identifies that the individual or family was entitled to a higher benefit
• a Service Officer has made an error

When processing an adjustment where a dependant is registered with more than one Safety Net family, Service Officers must ensure they select the correct Safety Net family who incurred the cost of the initial service.

See the Select correct Safety Net family for Medicare patient claim adjustment table on the Process page.

Note: take extreme care when performing adjustments. Once an adjustment has been performed, the affected service lines cannot be altered.