Verify services for Medicare Safety Net 011-43080050

Paid in full services a doctor submits online are verified automatically by the system at time of processing. They do not require more verification.

Unpaid services a doctor submits online need verification. The claimant must provide proof of payment for the outstanding balance.

When processing proof of payments, if the relevant Medicare Safety Net threshold is reached and confirmed for family registrations, the system:

• calculates, and
• generates the additional Medicare Safety Net benefit

When an individual is nearing or has crossed the Medicare Safety Net threshold, a letter for unverified payments (Letter A reaching the threshold, Letter B crossing the threshold) is sent.

Individuals who get Letter A or B need to submit receipts to have unverified services processed (verified) in order to get higher benefits once the threshold is reached.

Services are only verified (substantiated) once.

Services paid by instalments must not be verified unless both the:

• last payment has been made, and
• the full amount paid for the service is notated on the account receipt

The Process page contains more details about verifying services.

If a person asks for verification details for other members of the family, tell the person that due to reasons of confidentiality it is inappropriate to:

• comment, or
• provide combined statements

If a family member is seeking sensitive and personal details about other family members, Service Officers can only provide information if:

• the family member is under the age of 14 years, and
• authentication has been completed

Other family members details cannot be discussed due to Services Australia's policy to protect the privacy of an individual's personal details.

Customers can submit their verification receipts using the following claiming channels:

• Medicare Online claiming (MOA)
• Medicare Express Plus mobile app
• Post
• Service centre

When registered family members submit their receipts, the system tallies the gap payments. When the system identifies the registration has reached the threshold and the family composition is confirmed, any future out-of-hospital services within that calendar year are paid at the higher benefit.

If the customer submits the incorrect receipts for verification, add a comment in the Consumer Directory Maintenance System (CDMS).

The Process page contains details about how to print verification receipts.

A health professional can accept a pay doctor via claimant (PDVC) cheque as full payment for services rendered. The claimant must provide proof that the health professional has accepted this as full payment. In these instances, no verification amount is registered on the Substantiate patient contribution (NSCI) screen but the service line remains.

Service Officers must key a zero ($0.00) amount for verification. The specific lines verified with a zero amount display when:

• re-accessing the NSCI screen, and
• the service details will no longer appear on Safety Net letters.

See Table 3 on the Process page for more details.

Service Officers can issue an unverified payments letter (letter U) through CDMS for any or all members of a Safety Net family registration who have unverified services.

See Medicare Safety Net letters for more details.

Family contacts (FC) and spouse/partners (SP) can view and print an unverified payments statement using their Medicare online account.

See Using Medicare self service for more details.

Verification is where the out of pocket (OOP) amount is recorded by Medicare to allow those amounts to be counted towards the Safety Net threshold.

Where the claimant has paid the out of pocket amount and the outstanding balance of the account is the Medicare benefit owed to the health professional the claim must be verified.

Service Officers must verify the services at the time of processing a claim using the:

• Claim Payment (NPOI) screen, or
• after a claim has been processed (using the Substantiate patient contribution (NSCI) screen)

Note: verification (substantiation) occurring at the time of processing reduces the inconvenience placed on the claimant. There is no need to request duplicate accounts or receipts.

The Resources page contains the methods of verifying a claim.

Claims may be submitted where the health professional is paid the Medicare benefit as a pay doctor via cheque and the claimant pays the remaining amount or just a proportion of the remaining amount.

For claims where the partial payment is less than the out of pocket amount, verification cannot be done until proof of full payment is provided.

Where the claimant pays more than the owed out of pocket (OOP) amount only the actual difference between the Medicare benefit and the health professional's charge is verified.

The system will return the warning message 8-PPMT>OOP, verification still occurs automatically on the Full-format Medical claims payment screen - Supervisor only (NPSI) screen.

The additional amount paid is a matter between the claimant and the health professional.

For example:

A claimant is charged $60 for a Level B surgery consultation (Item 23):

• the claimant pays $31.50
• the Medicare benefit is $34.30
• the health professional receives $31.50 (incorrect gap payment) and $34.30 (100% Medicare benefit)
• total monies received by the health professional is $65.80 which is $5.80 above the original charge of $60

Note: only the difference between the Medicare benefit and the total charge is verified ($25.70). This is the actual difference between the total charge ($60) and the Medicare benefit ($34.30).

When verifying a claim in the Substantiate patient contribution (NSCI) screen, the claimant pays less than the calculated out of pocket amount and it is entered in the Fee field with a P prefix, the system returns the error message 1-PPMT NOT. A zero partial payment amount must then be rekeyed.

Note: where a partial payment is made (and an outstanding balance remains for that service) then entered against an item on the NSCI screen and updated by the Service Officer (U to UPDATE/ENTER), no additional out of pocket payment can be verified against the item as it no longer appears on the NSCI screen.

The claim cannot be verified until the claimant has produced an account or account receipt indicating the full out of pocket amount has been paid or the claimant provides evidence that the health professional has accepted a reduced amount as full payment for the service and the amount outstanding is the Medicare benefit owed to the health professional.

Claims that have a partial payment may be submitted via online channels.

Online claims submitted by the doctor are verified automatically if the partial payment is equal to the out of pocket amount and does not break the Medicare Safety Net threshold.

When a claim that has a partial payment that is equal to the out of pocket amount breaks the Safety net threshold, the message 8-SUB REQ appears prompting the Service Officer to manually verify the claim.

For partially paid claims where the amount paid is less than the out of pocket amount, this amount cannot be verified until proof of payment is provided.

The Process page contains more details about how to verify claims.

See Process digital self service claims for claims received via a digital channel.

Note: Safety Net verification requests submitted via MOA are often rejected with reason 162 (duplicate service). This is because Service Officers may not know the claim has been submitted for verification. If verification is actioned via a MOA claim, reject the MOA claim with reason code 151.