Medicare - Claims - Your Health 011-43000000

This document contains information about the policies and process for Medicare claims.

Government intent

Medicare provides access to medical, allied health and hospital services for all Australian residents, including permanent residents of Norfolk Island and certain categories of visitors to Australia. Services Australia administers the payment of Medicare benefits.

Under Medicare, benefits are paid for professional services listed in the Medicare Benefits Schedule (MBS) that are provided to eligible patients in and out of hospital.

Medicare benefits are payable only for 'clinically relevant' services rendered by an appropriate health practitioner. A 'clinically relevant' service is one that is generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.

When a service is not clinically relevant, the fee and payment arrangements are a private matter between the practitioner and the patient.

Medical practitioners are free to set own fees for their professional service.

Medicare Benefits Schedule

The Medicare Benefits Schedule (MBS) is a listing of the professional services that attract a Medicare benefit.

Each service includes a unique item number, a description, the Schedule fee and Medicare benefit, together with a reference to an explanatory note relating to the item (if applicable).

The MBS is not a legal document. It operates under the Health Insurance Act 1973 (as amended) and, in cases of discrepancy, the legislation is the source for payments of Medicare benefits.

Medicare benefits

In general, the Medicare benefit is 85% of the fee listed in the Medicare Benefits Schedule (MBS) for the service (known as the Schedule fee).

For attendances provided by general practitioners (GP) (or on behalf of a GP) to out of hospital patients, the Medicare benefit is 100% of the listed Schedule fee.

For professional services provided to private hospital patients (admitted to either a private or public hospital) the Medicare benefit is 75% of the listed Schedule fee.

Public patients admitted to public hospitals, receive free medical and hospital treatment funded under state/territory arrangements, therefore are not entitled to Medicare benefits.

The Resources page contains Medicare claims helpdesk and Medicare Benefits Schedule (MBS) contact details.

Claims processing in Medicare

Indicators, codes, modifiers and control lines for claims processing in Medicare

Bulk bill claims in Medicare

Bulk bill latter day adjustment (LDA) claims in Medicare

Latter day adjustments (LDA) and HELD payments in for patient claims

Simplified billing claims in Medicare

Simplified billing latter day adjustment (LDA) claims in Medicare

Location Specific Practice Number (LSPN) for Medicare

Medicare Safety Net

Cheque processing in Medicare

Medicare Two-way and claims processing