Concession Entitlement Validation Online Enquiry 101-06060040

Medicare is responsible for determining eligibility to the Pharmaceutical Benefits Scheme (PBS) and the Medicare Safety Net (MSN). The aim of these schemes is to provide access to low cost pharmaceutical items and bulk doctors services to the Australian community via Commonwealth subsidies.

To assist Medicare with the administration of these programs, Centrelink is responsible for providing data to Medicare about customers' identity, concession status and details of any Family Tax Benefit (FTB) Part A payments.

Concession providers, such as pharmacists, are required to satisfy themselves that the customer has a current concession entitlement (for example: sight the customer's Centrelink concession card).

Any checking of a customer's concession status for PBS purposes is done by Medicare following a request for payment by the pharmacist. The check is conducted against a database maintained by Medicare with updates provided by Centrelink. For the pharmacists who have adopted PBS on-line this checking is done at the time of the actual service. All other pharmacies will continue to provide claims to Medicare after the date of supply. These claims will be assessed with Medicare receiving confirmation of the customer's entitlement in real time at the date of supply, as the entitlement is known at the date and time of the enquiry.

PBS Online offers an online claiming system by allowing pharmacies to submit a claim to Medicare each time a PBS funded prescription medicine is purchased by a customer. A pharmacy using PBS Online will be able to receive confirmation of the customer's entitlement as at the date and time of the enquiry. Access to limited historical data is also available, if required.

Customers presenting receipts at a Medicare Shop front will be able to receive confirmation of their entitlement at the date of supply, as it is known at the date and time of the enquiry.

This procedure is primarily concerned with Phase 1 of the Concession Entitlement Validation (CEV) Online Enquiry project. Further phased enhancements were respectively scheduled for December 2006 and June 2007 releases.

The Phase 1 online enquiry encompasses two separate processes, these are:

• matching the citizen's identity information between Medicare and Centrelink, at the point in time the citizen becomes entitled to a concession
• responding to a query from a pharmacy regarding a citizen's concessional entitlement

Medicare determines the PBS eligibility for the individual based on the individual's concession entitlement.