Telephone claiming service for Medicare 011-43150000

Establish if the caller is the claimant by asking if they paid for the service.

Did the caller pay for the service?

• Yes, advise claimant all Medicare benefits for paid patient claims will be paid by electronic funds transfer (EFT). Complete Authenticating a Medicare customer. Where the claimant:
• Passes the security check, go to Step 2
• Does not pass the security check, advise the caller to go to their nearest service centre with acceptable identification. Procedure ends here
• No, advise the caller they must be the claimant to lodge the claim through this channel. Procedure ends here.

Obtain Medicare card number of the patient:

• Key NPOI, Medicare card number
• Press [Enter]. A blank claimant identification field is displayed
• Identify claimant by keying their Individual Reference Number (IRN) into the REF field. Note: if claimant is on a different Medicare card to the patient, key the claimant's Medicare card number in the CLAIMANT field and select their IRN
• Confirm if claim is paid 'Y' or unpaid 'N'

• Confirm the address of the claimant
• Key the first 2 letters of the street name in the ADR field. Note: for a PO BOX, key the first 2 letters of the suburb

Confirm the bank account details of the claimant. See also: Store, confirm and end date bank account details for Medicare EFT payments.

For electronic funds transfer (EFT) payment, to add, amend or confirm the claimant's banking details, key one of the following values in the EFT field:

• 'P' - EFT details keyed are permanently stored for this claimant. Note: the usage of this indicator results in overwriting of any previously supplied banking details or the addition of EFT details where none were previously supplied
• 'T' - EFT details keyed are temporary and are used for this claim only. For example, where a claimant requests a one-off EFT payment into a different bank account to the details stored and the claimant has indicated this on the back of the account/receipt lodged via telephone claims
• 'C' - claimant has confirmed the usage of EFT details previously stored. This indicator is only used where EFT details are automatically displayed on the NPBI screen (banking details are present in Consumer Directory Maintenance System (CDMS) for this claimant)
• 'N' - claimant does not have valid EFT details stored in CDMS or cannot provide valid temporary or permanent EFT details at the time the claim is submitted. Note: the EFT action indicator of 'N' allows validation of the EFT details to be bypassed and the assessment of claim to continue. The payment for the claim will be held until EFT details have been provided

Note: the EFT usage field accepts values P, T, C, N or U. The value U (unstated) must not be used under any circumstances

STM field:

• to issue statement to claimant - key 'P'
• no statement is required - key 'N'

Read the Privacy Note, Bank Declaration and Claimant Declaration to the claimant. The Resources page has link to Privacy Note, Claimant Declaration and Bank Declaration.

Note: the privacy declaration is not read by the IVR when customers contact that phone line.

Does the claimant agree to the terms and conditions of the Claimant Declaration? (The Claimant Declaration must be read out to the customer as per Step 4.)

• Yes, go to Step 6
• No, advise the claimant that the claim cannot be processed via the telephone claiming channel and they will need to attend their nearest service centre to lodge the claim. Procedure ends here

• key date of lodgement in the DOL field
• key the details of the claim:
• Patient
• Item
• Date of service (FST DT)
• Provider number
• Payee code
• Charge

Once details are correct, press [Enter]

• key '385' in the RSN field
• hit the [Home] key the cursor will move to top left hand corner
• key 'NPND'
• press [Enter]

Ask the claimant to record the details listed below on the back of the account/receipt. If there are more than 2 accounts or receipts in the claim, the claimant can list the below information on a single page and staple the page to the accounts/receipts before placing in the envelope:

• patient's Medicare card number
• claimant's Medicare card number (if different)
• Bank/State/Branch (BSB) number, bank account number and name of the account holder or noted 'as stored'
• date of lodgement
• claimant's:
• name
• phone number
• mailing address
• sign the account or receipt

Ask if a statement of benefit is required.

Advise the claimant to keep a copy of the receipt and/or account for their records and to post all original documents to Medicare. The Resources page contains a link to Medicare contact information on the Services Australia Website.

Note: Medicare does not supply reply paid envelopes except for claims lodged through the service centre's self service facility.

Assess account documents to confirm it complies with the minimum account requirements.

See also: Account and receipt documents for Medicare claims processing

Ensure the following information has been recorded by the claimant on the back of the account/receipt:

• patient's Medicare card number
• claimant's Medicare card number (if different)
• Bank/State/Branch (BSB), bank account number and name of the account holder or noted 'as stored'
• date of lodgement
• claimant 's:
• name
• phone number
• mailing address
• signature

Where the details have:

• Been completed, go to Step 4
• Not been completed, attempt to contact the claimant or provider by telephone. Go to Step 3

If the claimant or provider:

• Can be contacted, notate the required details on a Claims details verified by phone (VG4) form. The Resources page contains a link to the form. Go to Step 4
• Cannot be contacted:
• Return the account or receipt to the claimant with the appropriate standard letter attached, requesting required information
• Ensure that the option Unable to contact - no answer is selected in the Standard Letter Template
• The Resources page contains a link to the Standard Letter Templates
• Procedure ends here

See Resources page for a list of telephone source office codes

Key CESN

• Press [Enter]
• Log in with operator number
• Press [Enter]

• Key OPOQ, source office code (relevant to the processing Service Officer's site)
• Press [Enter]

A blank screen appears.

• Key NPRI, Medicare card number
• Press [Enter]

Note: the following modifiers can also be used if more than one claim is in pend:

• DOL/DDMMYY
• OPER/NNNNN
• SORC/AAAA
• BANK
• CHQ

The claims payment screen is displayed.

Key the first 2 letters of the street name in the ADR field line. Note: for a PO BOX, key the first 2 letters of the suburb.

Key one of the following values in the EFT field on line 6 of the screen to add, amend or confirm the claimant 's Electronic Funds Transfer (EFT) details:

• 'P' - EFT details keyed are permanently stored for this claimant. Using this indicator results in overwriting of any previously supplied banking details or the addition of EFT details where none were previously supplied
• 'T' - EFT details keyed are temporary and are used for this claim only. For example, a claimant requests a one-off EFT payment into a different bank account to the details stored and the claimant has indicated this on the back of the account or receipt lodged via telephone claims
• 'C' - claimant has confirmed the use of EFT details previously stored. Only used where EFT details are automatically displayed on the NPBI screen (banking details are present in CDMS for this claimant)
• 'N' - claimant does not have valid EFT details stored in CDMS or cannot provide valid temporary or permanent EFT details at the time the claim is submitted

STM field:

• to issue statement to claimant - key 'P'
• no statement is required - key 'N'

• Key date of lodgement in the DOL field
• Press [Enter]

Note: the date of lodgement is the date the claimant lodged the telephone claim

Ensure that the following information on the claims payment screen matches the information on the account submitted by the claimant:

• patient details
• correct claimant has been selected
• date of service
• servicing provider number - name and address
• item number or numbers
• referral details - referring provider number and date of referral (where appropriate)
• specimen collection point (SCP) number (where appropriate)
• Location Specific Practice Number (LSPN) (where appropriate)
• check if claim is paid or not paid: for paid accounts - ensure a receipt is attached (where applicable) and nil balance owing

Identify any discrepancies between the information on the account or receipt and the claims payment screen.

Note: the information provided by the claimant on the telephone claim is considered to be the most recent update.

Where appropriate, update any information on the claims payment screen or Consumer Directory Maintenance System (CDMS).

Review and apply assessing restrictions by following warning messages.

Warning message must be actioned in order from left to right and further explanations can be viewed by placing the cursor at the beginning of the return message and pressing [F1]

To finalise the claim:

• Press [Enter]
• Key 'P' to pay claim

Note: a statement of benefit should only be issued to the claimant if they have requested it.