Patient claims processing in Medicare 011-43010000

A patient claim is a claim submitted to Medicare for payment of a Medicare benefit after a medical service has been provided to a patient.

The Medicare benefit is paid to the claimant. The claimant is the person who paid for the service.

For a fully paid account or invoice, the Medicare benefit is paid to the claimant.

If the account or invoice is unpaid or partially paid, the Medicare benefit is paid to the health professional by cheque under Pay Doctor via Claimant (PDVC).

The patient and the claimant do not have to be the same person. They also do not have to be listed on the same Medicare card.

Patient claims can be submitted:

• through the doctor’s practice
• by mail
• in person at a service centre
• through a Medicare online account, if the claimant is the patient or is listed on the same Medicare card
• by phone
• through an Access Point

Medicare benefits can be paid by:

• electronic funds transfer (EFT) for fully paid accounts
• credit EFTPOS at the point of service using Medicare Easyclaim and a debit card
• PDVC cheque when the benefit is paid to the health professional.

If a claim is:

• submitted through a digital self-service channel, the patient must be listed on the same Medicare card as the claimant
• processed at a service centre, and the account or invoice has been paid in full; the claimant does not need to complete or sign a claim form. A claim form is also not required for phone claims

See Patient claims requirements for payment of Medicare benefits.

If a customer contacts Services Australia about their claim, suitably skilled Service Officers must follow First Contact Resolution (FCR).

For Medicare online account (MOA) claims, see Process digital self service claims.

If a Service officer is not skilled in this work type, they must escalate the claim to Medicare and Aged Care Local Peer Support (LPS) for help.

If a customer contacts the agency about the progress of their claim:

• the Service Officer must confirm the claim has been received and advise the claim's status, for example, received, paid, or rejected, if the enquiry is within the relevant timeframe
• if the Service Officer is skilled in the work type, they must apply the First Contact Resolution (FCR) principles, unless Principle One exemptions apply

If a customer indicates they are experiencing financial hardship, the Service Officer should follow the process on the Process page.

Customers can also check the status of recent Medicare claims online using their:

• Medicare online account
• myGov app

Service Officers should tell customers about this option if they ask about the progress of a patient claim.

See Track Medicare claims online for more details.

The Resources page contains a link to the Services Australia website with the relevant timeframe for claiming a Medicare benefit.

If the claim was received outside the relevant timeframe and was submitted:

• online or through the myGov app, see Enquiries received via telephone for digital self service claims
• by mail or at a service centre, process the claim, see the Process page

The patient and the claimant are not always the same person:

• Patient - the person who received the medical service. The patient is identified on the health professional's account or invoice
• Claimant- the person who incurred, or is liable for, the cost of the medical service

The claimant:

• is entitled to the Medicare benefit if they paid for the service provided to themselves or another person
• may be a business or organisation, such as a sporting body or an Aboriginal Medical Service with a section 19(2) exemption, if they incurred the cost of the service

The Process page contains details on how to process a claim for a business or organisation.

An organisation funded to provide medical services under section 19(2) of the Health Insurance Act 1973 cannot claim a Medicare benefit.

Health professionals can only receive the Medicare benefit if:

• the service is bulk billed
• there is a valid assignment of benefit in place, and
• they use the approved bulk billing form to submit the claim

The Medicare Claim form (MS014) is not an approved form for health professionals to claim assigned Medicare benefits.

See Professional services related to Medicare patient claims for details about:

• when locum arrangements apply, and
• PAYP lines

Some Medicare patient claims cannot be processed through Mainframe and may require a Manual EFT payment, including:

• Safety Net payments for outpatients with individual charges over $9,999.99
• Safety Net partial payments that are more than 2 years old
• stale cheques that cannot be processed on the system
• a stopped cheque where the BILI control line was not actioned, and the cheque becomes stale
• patient claims with a date of service more than 7 years old
• cheques manually cancelled by finance operator number 08448

All manual EFT payment requests for patient claims are prepared by the Medicare Customer Service Delivery Support Team and actioned by Accounting Operations.

These claims cannot be viewed in Mainframe, and the payment cannot be viewed on the BRNA screen.

Comments will be recorded in CDMS.

The Process page contains details on how to request a manual EFT payment.

If a claim was submitted or processed incorrectly, an adjustment can be made or requested on the same day the claim was processed. This only applies to some claiming channels.

See Delete electronic Medicare claims for Provider Tier 1 eBusiness for more details.

A statement of benefit provides customers a summary of their claims and the total Medicare benefits paid. It can be printed at a service centre or issued as a system generated receipt. It also confirms payment.

If a claimant or patient asks for a duplicate statement of benefit, the Service Officer must make sure it is only issued to the claimant or patient for that service.

Statement of benefits for accounts/invoices processed through Simplified Billing

A duplicate statement of benefit cannot be issued to the patient if the service was billed to Medicare through the Simplified Billing channel.

These statements can only be issued to the relevant health fund or billing agent that lodged the claim with Medicare.

If a health fund or billing agent asks for a statement of benefit see, Statement of benefit for Simplified Billing in Medicare.

The Z2261 - Your statement of Medicare benefits letter is completed manually by the Service Officer and can be issued for claims with:

• a service date more than 7 years old
• adjustments that cannot be actioned in Mainframe or that result in an overpayment
• Safety Net adjustments
• Safety Net payments for claims over $9,999.99
• manual EFT payments
• claims with an individual item charge greater than $9999.99
• adjusted inpatient services

The Resources page contains a link to the Digital Messaging Capability (DMC) to create and send letters.

The Z2261 letter is addressed to the claimant and contains a field for the applicable reason code.

See Indicators, codes, modifiers and control lines for claims processing in Medicare for more details on reason codes.

If the manual statement of benefit is for an adjustment, include the previous assessment lines with RSN 888 and the revised adjusted lines.

If an additional Medicare Safety Net benefit is payable for an out of hospital claim, and service line 0000 is rejected with RSN 151, do not include these lines on the manual statement of benefit. They are treated as a separate claim.

If a transfer of history has occurred, Service Officers must make sure details about the original patient are not included on the manual Statement of Benefit.

Service Officers:

• can issue a manual Statement of Benefit to the claimant if outstanding overpayments are recorded on the patient's history for that service
• must not withhold the statement until the overpayment has been repaid, or contact debt recovery to ask about the status of the overpayment

The account or invoice is the main document used to process patient claims. It contains the details needed to pay a Medicare benefit.

To process a claim, the account or invoice and, if needed, the receipt must be provided as evidence.

The account or invoice can be:

• paid or partially paid with proof of payment shown on a receipt or noted on the account or invoice
• unpaid, therefore only the account or invoice is needed

Use the details on the account, invoice or receipt to identify the patient.

See Account and receipt documents for Medicare claims processing for more details.

If a customer completes the organ donor registration section on a Medicare claim form (MS014), see Register a new organ donor in the Australian Organ Donor Register (AODR) for the steps to register their decision.

Medicare benefits for paid accounts or invoices are paid directly into the claimant's nominated bank account by electronic funds transfer (EFT).

If a claim is processed and the claimant has not provided bank account details, the payment will be held until EFT details are provided.

Cheque payments to claimants stopped on 1 July 2016. Pay Doctor via Claimant (PDVC) cheques continue under the Health Insurance Act 1973.

Held EFT payments for children under 14 years of age (health professional error)

A Medicare benefit will be held if:

• a health professional submits a claim online
• they incorrectly select a child under 14 years of age as the claimant, and
• no EFT details are recorded

The Service Officer must decide who the correct claimant is.

If a customer other than the child contacts Medicare and says they are the claimant, the Service Officer must assess whether the:

• customer is the claimant
• health professional transmitted the child as the claimant in error

To decide if the customer is the claimant, the Service Officer must authenticate the customer and ask:

• the date of service
• the name of the health professional
• how much was paid for the service
• where (location) the service was performed

If the customer answers these questions correctly, the claim should be adjusted to show the correct claimant.

For more details, see Latter day adjustments (LDA) and HELD payments for patient claims.

Unpaid or partially paid accounts/invoices

Medicare benefits for unpaid or partially paid accounts or invoices can only be paid by cheque. For claims that are not submitted online, the claimant must provide:

• the account, invoice or receipt, and
• a completed and signed Medicare Claim form (MS014)

For unpaid or partially paid accounts or invoices, the Medicare benefit is paid:

• by a system-generated PDVC cheque
• in favour of the health professional who is entitled to the Medicare benefit

The PDVC cheque is posted:

• to the claimant using the address on the:
  • claimant's record, or
  • claim form if the claimant has nominated a different address
• with 2 Statements of Benefit, one for the claimant and one for the health professional

The claimant must forward the health professional:

• the PDVC cheque and a copy of the Statement of Benefit
• any outstanding balance of the account or invoice

These requirements cannot be changed because they are set out in section 20(2) of the Health Insurance Act 1973.

See 90 Day Pay Doctor Cheque Scheme.

If the outstanding balance of the account has been paid in full, the account, invoice or receipt can be provided as evidence and verified to accumulate towards the Medicare Safety Net threshold.

See Verify services for Medicare Safety Net.

Specialists and consultant physicians cannot bill a subsequent attendance item on the same day as any item in Group T8 (Surgical Operations) with:

• a schedule fee equal to or greater than the threshold
• the same date of service
• performed by the same health professional

The threshold amount can be viewed in QITI against the subsequent consultation item number.

For more details, see Assessing MBS item restrictions.

If a claim for a surgery item returns message 1-PREV CON, the attendance item must be suppressed before the surgery can be assessed.

See, Table 20 in Latter day adjustments (LDA) and HELD payments for patient claims.

A permanent address change can be updated:

• during claim processing using a Medicare Claim form (MS014)
• during telephone claiming
• in person at a Medicare Service Centre

If the claim is later reversed, the updated address must not be reversed with the claim, unless the address is known to be incorrect.

The claimant's address must remain updated in CDMS. See the Process page for more details.

Businesses and organisations cannot have address details stored permanently in CDMS unless the customer is under financial management or another guardianship order.

See Power of Attorney, Guardianship, Administrative Orders and Authorised Representative for Medicare.

There is a minimum turn-around time for Medicare benefits to be paid. The minimum payment times vary by claim type and relate to the number of days, including weekends, that the benefit is held by Services Australia.

If Mainframe is unavailable in a service centre, Service Officers should tell customers that the system is unavailable, and they can:

• complete a Medicare Claim form (MS014), and the claim will be processed once the system is available
• submit the claim through their Medicare online account using the myGov website or the myGov app

If a claim is submitted more than 2 years after the date of service, see the Process page for the circumstances and the action required.

Contact Medicare Customer Local Peer Support (LPS) for help if the claimant has:

• an RHCA entitlement, and
• already left Australia

Radiation oncology claims can be complex. Only trained Service Officers can process these claims, and they must take extra care.

Service Officers must check that the patient account, invoice or transmitted claim includes all relevant details before assessing the claim.

If errors are keyed during processing:

• an incorrect benefit may be paid, and
• a latter day adjustment may be needed

If a Service Officer is not skilled to process radiation oncology claims they must either proficiency raise the claim in PaNDA or escalate it to the Claims interpreter (CI) queue.

See Processing radiation oncology.