Call enquiries for pharmacy online claiming and payments in Pharmaceutical Benefits Scheme (PBS) 012-60130000

General enquiries include:

• routine queries Service Officers undertake or refer to other areas of Services Australia
• policy related queries
• prescription related queries
• payment related queries
• authority related queries

An approved supplier can be an approved pharmacist, approved medical practitioner or approved hospital authority and may contact Services Australia about:

• the status of a claim prescription
• the status of a claim payment (Claim period) enquiry by only the authorised or approved person
• duplicate statements
• reason code enquiries about a claim
• information on a PBS Authority Approval
• prescription details

Service Officers must complete the relevant security check before assisting an approved supplier with an enquiry. See Table 2 on the Process page.

Service Officers must:

• contact Local Peer Support (LPS) for status of claim payment enquiries, and
• refer all pharmacy approval enquiries to Department of Health and Aged Care

The Resources page contains:

• links to the Department of Health and Aged Care website, and
• information about general enquiry types and the usual callers from which those enquiries are received

A prescription enquiry occurs when approved supplier staff ask:

• for more details about reason codes assigned to a claim
• to confirm if details in a claim sent to Services Australia are the same as those in the approved supplier's Prescription Dispensing Software (PDS)

Service Officers can release prescription details obtained from the Prescription Details screen in the PBS Online Claims Processing System (PBS Online), to the approved supplier after completing a security check.

Note: Service Officers must not release reason codes that do not have the Notifier Indicator column ticked. See information on notify indicators in Assessment of claims in Pharmaceutical Benefits Scheme (PBS) Claims Processing System.

Supply after death enquiries in PBS

Service Officers must not disclose a patient's deceased status to any approved supplier or individual when responding to enquiries. Disclosure of this may be in breach of the secrecy provisions outlined in the National Health Act 1953 and Health Insurance Act 1973. The References page contains links to these Acts.

The Resources page contains typical questions and appropriate responses to death related enquiries in PBS.

Prescription status in the PBS online Claims Processing System (PBS Online)

The current status of a prescription is shown in the Prescription Status field as follows:

• New: the first status given to a manual claim prescription when a Service Officer has entered the claim, but it has not yet been assessed
• Assessed: the assessment engine has assessed a claim successfully
• Rejected: the assessment engine or a Service Officer (for manual claims) has assessed the claim as not valid for payment
• Re-assessed: claim details have successfully been re-transmitted to the assessment engine and re-assessed
• Cancelled: claim has been successfully cancelled

The PBS Online system:

• automatically requests payment to the Common Payments System (CPS)
• determines the approved supplier's banking details, and
• sends the request to the Reserve Bank of Australia (RBA). The RBA makes the payment directly into the approved supplier's registered bank account

Each Friday the RBA makes payments to pharmacies claiming electronically, including claims from the previous Thursday to Wednesday.

For approved suppliers:

• claiming electronically, the request for payment from PBS Online to the CPS occurs at the time of claiming. The CPS releases information to the RBA after the payment lag (minimum 2 days) is met, then sends the payment to the RBA on the following Friday
• claiming manually, the request for payment from PBS Online to the CPS occurs 30 days after the claim package is closed
• making an amendment to a claim via PBS online, the amendment may result in an adjustment to an amount previously paid. When an adjustment is made, it is offset against the next payment to the approved supplier
• if a claim period has been closed for more than 90 days, the pharmacy cannot resubmit a script. They must submit the script via a manual claim

A claim period can have multiple payments associated with it and a single payment can include multiple claim periods.

See Pharmaceutical Benefits Scheme (PBS) Safety Net processing and enquiries for PBS safety net payment enquiries.

Payment Identifiers

There are 2 unique identifiers assigned to each payment:

• PBS Payment ID - by the PBS Online system after sending the request for payment to the Common Payments System (CPS)
• CPS Payment ID - by the CPS after receiving the payment request from the PBS Online system

Having these numbers assigned to a claim/payment does not indicate the payment has been made, only that a request for payment has occurred.

PBS Online payment capping

All online claims from approved suppliers have daily capping amounts applied.

Daily capped amount

The daily capped amount is displayed in the PBS Online system. This amount determines the financial amount that can be paid to an approved supplier per day. Service Officers must not disclose this to the approved supplier, escalate to claiming support for any queries.

Default daily capped amount

The daily capped amount for each approved supplier is defaulted to $50,000.

Claims over the daily capped amount

Claims assessed in PBS Online are completed in order of receipt from the approved supplier. When a claim (prescription) takes an approved supplier's total over the daily capped amount, the full claim will be held until the next day. Partial payments are not processed.

Capping exceptions

Where an approved supplier regularly exceeds the daily capped amount, Services Australia can increase their daily capped amount.

See Table 5 on the Process page for details when an approved or authorised person from the pharmacy requests to increase the daily payment cap.

Payment requests

When an approved supplier completes entry of a prescription into Prescription Dispensing Software (PDS), a payment request transaction will automatically submit to the agency for that prescription.

Cancelling payment requests

Approved suppliers must cancel a request in PDS if they determine that a previously claimed supply was incorrect or supply did not occur. For help with cancelling a claim, refer suppliers to their software vendor.