This page contains examples of how the system calculates the benefit for varying account paid amounts when the Medicare safety net has been met, calculations when verification (substantiation) is required and examples when an unpaid account is claimed. It contains a description of transaction codes, examples of when a person is unable to confirm their family composition at a service centre and links to Medicare Safety Net templates and standard letter templates. There are also links to Medicare Safety Net user help guides.
Example of system calculated benefit on fully paid accounts
Table 1: This table provides an example of how the system calculates the benefit on fully paid accounts when the Medicare Safety Net has been met.
|
Billing scenario |
Amount paid |
|
Doctor’s charge |
$55.00 |
|
Patient payment |
$55.00 |
|
Standard Medicare benefit |
$31.45 |
|
Benefit to patient (Standard benefit + Additional benefit)
Note: where an extended Medicare Safety Net (EMSN) benefit cap applies, the additional benefit may be less than the 80% out-of-pocket expense. |
$50.30 |
|
Pay doctor via claimant (PDVC) |
NIL |
Example of an account where 20% has been paid and the Medicare Safety Net met
Table 2: This table provides an example of the calculation of an account where 20% has been paid.
|
Billing scenario |
Amount paid |
|
Doctor’s charge |
$55.00 |
|
Patient payment |
$4.70 |
|
Standard Medicare benefit |
$31.45 |
|
Benefit to patient |
NIL |
|
Pay doctor via claimant (PDVC) |
$50.30 |
Example of an account where less than 20% has been paid and the Medicare Safety Net met
Table 3: This table provides an example of the calculation of an account where less than 20% has been paid.
|
Billing scenario |
Amount paid |
|
Doctor’s charge |
$55.00 |
|
Patient payment |
$4.00 |
|
Standard Medicare benefit |
$31.45 |
|
Benefit to patient |
NIL |
|
Pay doctor via claimant (PDVC) |
$31.45 |
Example of an account where less than 20% has been paid and substantiation is required
Table 4: This table provides an example of the calculation of an account where less than 20% has been paid and substantiation is required for a further benefit to be paid.
|
Billing scenario |
Amount paid |
|
Doctor’s charge |
$55.00 |
|
Initial patient payment |
$4.00 |
|
Standard Medicare benefit |
$31.45 |
|
Benefit to patient |
NIL |
|
Pay doctor via claimant (PDVC) |
$31.45 |
|
Additional patient payment |
$19.55 |
|
Benefit to patient (Standard benefit + Additional benefit)
Note: where an extended Medicare Safety Net (ESMN) benefit cap applies, the additional benefit may be less than the 80% out-of-pocket (OOP) expense. |
$18.85 |
Example of an account where more than 20% has been paid and the Medicare Safety Net met
Table 5: This table provides an example of the calculation of an account where more than 20% has been paid.
|
Billing scenario |
Amount paid |
|
Doctor’s charge |
$55.00 |
|
Patient payment |
$10.00 |
|
Standard Medicare benefit |
$31.45 |
|
Benefit to patient |
$5.30 |
|
Pay doctor via claimant (PDVC) |
$45.00 |
Example of unpaid accounts when Medicare Safety Net met
Table 6: This table provides an example of the calculation when an unpaid account is claimed.
|
Billing scenario |
Amount paid |
|
Doctor’s charge |
$55.00 |
|
Patient payment |
NIL |
|
Standard Medicare benefit |
$31.45 |
|
Benefit to patient |
NIL |
|
Pay doctor via claimant (PDVC) |
$31.45 |
Description of transaction codes and modifiers for Medicare Safety Net
Table 7: This table provides a description of the control lines and modifiers for the Medicare Safety Net Family Registration and Enquiry system.
|
Transaction |
Consumer Directory Maintenance System (CDMS) |
Description |
|
Inquire on a Safety Net record |
Inquire on Consumer Details link on CDMS
|
Service Officers see:
-
Registration summary
-
Consumer details
-
Family Safety Net Registration details
-
Threshold details
-
Confirmation details
-
Letter details
-
Comments
|
|
Amend a Safety Net registration |
Amend on Consumer Details link on the CDMS home page
|
Service Officers can:
-
Amend consumer details
-
Amend family member type
-
Remove a family member
-
Add a family member
-
End date a family
-
Request a letter
-
Add comments
|
|
Register a Safety Net family |
Register New Consumer link on the CDMS home page
|
Service Officers can register a new Medicare Safety Net family.
|
|
Confirm a registered safety net family |
|
Service Officers can:
-
confirm a family composition
-
print a confirmation form
|
Person unable to verify their family composition at a service centre
Table 8: This table provides examples of when a person is unable to verify their family composition at a service centre.
|
If the patient and claimant are on… |
and are… |
then… |
|
the same Medicare card |
able to be contacted |
confirm the Medicare Safety Net family composition over the phone:
-
complete a security check
-
check safety net registration details
-
make any required adjustments
-
confirm safety net registration
-
process claim
|
|
the same Medicare card |
not able to be contacted |
Manual claim:
-
return the claim to the claimant with both a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit if they confirm their family composition prior to the claim being processed
Express Plus Medicare app claim:
-
send the claimant a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed
Online claim:
-
[F9] to acknowledge the 8-CONFIRM message and continue to process the claim
|
|
different Medicare cards |
on the same Safety Net registration and able to be contacted |
confirm the Medicare Safety Net over the phone:
-
complete a security check
-
check safety net details
-
make any required adjustments
-
confirm safety net
-
confirm the family composition over the phone
-
process claim
|
|
different Medicare cards |
on the same Safety Net registration and not able to be contacted |
Manual claim:
-
return the claim to the claimant with both a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed
Express Plus Medicare app claim:
-
send the claimant a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed
Online claim:
-
[F9] to acknowledge the 8-CONFIRM message and continue to process the claim
|
|
different Medicare cards |
not on the same Safety Net registration and able to contact the patient |
confirm the Medicare Safety Net with the patient over the phone:
-
complete a security check
-
check safety net details
-
make any required adjustments
-
confirm safety net
-
confirm the family composition over the phone
-
process claim
|
|
different Medicare cards |
not on the same Safety Net registration and unable to contact the patient |
Manual claim:
-
return the claim to the claimant with both a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed
Express Plus Medicare app claim:
-
send the claimant a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed
Online claim:
-
[F9] to acknowledge the 8-CONFIRM message and continue to process the claim
|
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