Patient claims processing in Medicare 011-43010000

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

The Medicare benefit is paid to the person who incurs the cost (has fully paid the account/invoice) and is known as the claimant.

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

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

Customer contacts Services Australia

When a customer contacts the agency by phone about their claim, suitably skilled Service Officers must attempt first contact resolution.

Note: Service Officers must not process Medicare online account (MOA) claims on the same day they are lodged (day zero) if the total Medicare benefit amount of the claim is greater than or equal to $100.

If the customer is in financial hardship and insisting the claim is paid on day zero, Service Officers must call the clinic to confirm the account/invoice is valid. See Suspected Medicare fraud and Business Integrity (BI) flags.

Service Officers not skilled in this work type must escalate to Medicare and Aged Care Local Peer Support (LPS) for help.

Patient and claimant

The following descriptions are provided to differentiate between patient and claimant:

• Patient - the person to whom a medical service has been provided
  Note: the patient is identified on the health professional's invoice
• Claimant - the person who incurred, or is liable for, costs associated with the medical service rendered

As the claimant:

• has paid for the service provided to themselves or another person, they are entitled to get the Medicare benefit
• may also be a business or organisation and, if on behalf of the patient, they have incurred the cost, they are entitled to get the Medicare benefit. For example, a sporting body, The Process page contains details on how to process a claim for a business or organisation

An organisation funded for the provisions of medical services under section 19(2) of the Health Insurance Act 1973 is unable to claim a Medicare benefit.

Medicare benefits for Patient claims can be submitted by:

• post
• in person at a service centre
• digitally
• phone, or
• using an Access Point

Medicare benefits can be paid by:

• Electronic Funds Transfer (EFT) for fully paid accounts
• At point of service, credit EFTPOS via Medicare Easyclaim using a debit card, or
• PDVC cheque

If claims are lodged digitally via self-service channels, the patient must be on the same Medicare card as the claimant.

Progress of Medicare claim lodged

Service Officers must:

• confirm receipt of the claim and status (received/paid/rejected etc.), where the claimant calls or enquires about the progress of a patient claim lodged in the relevant timeframe
• not process the claim, tell the claimant the agency will assess and pay any Medicare benefit owing as quickly as possible

The Process page contains details of the process to follow If a customer indicates they are in financial hardship.

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

• Medicare online account, or
• Express Plus Medicare mobile app

Services Officers must tell customers about this option when they get enquiries about the progress of an online patient claim.

See Track Medicare claims online.

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:

• via online or through the 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

Manual EFT payment

Manual EFT payments are needed in the following instances:

• Safety Net payments for outpatients with individual charges over $9,999.99
• Safety Net partial payments
• Stale Safety Net cheques
• Stale cheques that cannot be processed on the system
• Stop on a cheque but BILI is not actioned and cheque goes stale
• Patient claim late lodgement over 7 years
• Cheques manually cancelled by finance operator number 08448

All manual EFT payment requests are prepared by Medicare Provider Services (MPS) and actioned by Accounting Operations.

The Process page contains details on how to request a manual EFT payment for MPS Service Officers.

Same Day Delete

Where a claim has been identified as submitted/ processed incorrectly, an adjustment can be performed/ requested on the same day as the claim was processed. This is limited to certain claiming channels.

For more details see Delete electronic Medicare claims for eBusiness Service Centre.

A statement of benefit (printed in service centres, or a system generated receipt) provides customers with a summary of their claims and the total Medicare benefits paid. It is also confirmation of payment.

Service Officers must only issue a statement of benefit when processing claims. This applies to all Medicare claiming channels.

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

Note: Service Officers must be aware when:

• a transfer of history has occurred, details about the original patient is not to be included on the manual statement
• Medicare Online Account (MOA) claims are rejected using RSN 151, these lines are omitted on the manual statement of benefit as they are deemed as a separate claim

Statement of benefits for accounts/invoices processed via Simplified Billing

A duplicate statement of benefit cannot be issued to the patient if the service was billed to Medicare via 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 is requesting a statement of benefit see, Statement of benefit for Simplified Billing in Medicare.

Manual statement of benefit

A manual statement of benefit is a letter Z2261 manually completed by Service Officers and can be issued to customers for claims:

• with a service date over 7 years
• adjustments that cannot be actioned in mainframe or result in an overpayment
• Safety Net adjustments
• Safety Net payments for claims over $9,999.99
• for claims where a manual payment has been made

A requested manual statement of benefit letter is to be addressed to the claimant/patient.

The letter contains a field where the applicable reason code is entered.

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 of any type, then place details from the previous assessment lines with RSN 888 and the revised adjusted lines.

If this is for an inpatient service, a manual statement of benefit must be issued. If eligible, the claimant can forward this statement to their Private Health Fund to claim more gap benefits.

Service Officers:

• can issue a statement of benefit to the claimant where outstanding overpayments are recorded on a patient's history related to this service
• must not withhold the statement until the overpayment has been repaid or, contact debt recovery to enquire on the status of the overpayment

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

The account/invoice is the main element when processing patient claims. These documents contain the essential details that allow a Medicare benefit to be paid.

For a claim to be processed, the account/invoice and/or the receipt must be provided. The account/invoice can be:

• paid or partially paid (confirmation of payment must be included either by receipt or noted on the account/invoice), or
• unpaid (only the account/invoice is needed)

For details on what is needed on an account/invoice or receipt for the claim to be processed, see Account and receipt documents for Medicare claims processing.

If an MS014 claim is received to process and the Organ donor registration section is completed, Service Officer must refer to Register a new organ donor in the Australian Organ Donor Register (AODR), to follow and action accordingly.

Following the Australian Government announcement in the 2015-16 Budget, payment of Medicare benefits to claimants by cheque stopped from 1 July 2016. Pay doctor via claimant (PDVC) cheques will continue as legislated in the Health Insurance Act 1973.

Payment of benefits for paid accounts/invoices will be deposited into the claimant’s nominated bank account. For a processed claim where the claimant has not provided a bank account, the payment for the claim will be held until EFT details have been provided.

If a claim is processed at a service centre and the account/invoice is paid in full or via phone claiming, the claimant does not need to complete and sign a claim form. See Patient claims requirements for payment of Medicare benefits.

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

If a health professional submits a claim online and selects a child under 14 years of age as the claimant and no EFT details are recorded, the benefit will be held. The Service Officer is to decide who the correct claimant is.

If a customer (other than the child) contacts Medicare and claims to be the claimant, the Service Officer is to decide if the customer is the actual claimant and the health professional has transmitted the child as the claimant incorrectly.

To decide if the customer is the claimant, the Service Officer must ask the customer the following questions (following a security check):

• what was the date of service
• who was the health professional
• how much was paid for the service

If the customer successfully answers these questions, the claim should be adjusted to reflect the correct claimant.

Unpaid or partially paid accounts/invoices

Medicare benefits for unpaid or partially paid accounts/invoices can only be paid by cheque. The claimant must present both:

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

Medicare benefits for unpaid or partially paid accounts/invoices are paid via a computer generated Pay Doctor via Claimant (PDVC) cheque drawn in favour of the health professional who is entitled to the Medicare benefit.

The PDVC cheque is posted to the claimant at the address recorded against the claimant or on the claim form (when the claimant nominates a temporary address), together with a statement of benefit for retention by the claimant and the health professional.

The claimant is responsible for forwarding the benefit cheque to the health professional, together with the balance of the account/invoice, if applicable. They can then present the account/invoice receipt at a service centre to show the service has been paid in full. The claim can then be substantiated and will accumulate towards the Medicare Safety Net threshold for all out of hospital services.

See also: Verify services for Medicare Safety Net.

These requirements cannot be varied as they are supported by the Health Insurance Act 1973, Section 20(2).

See also: 90 Day Pay Doctor Cheque Scheme

The details supplied on the account/invoice or receipt should be used to uniquely identify both the patient and the claimant.

When identification is not possible, return the original document to the customer, together with the appropriate letter. Photocopy the original account/invoice documents and keep onsite for future reference attached to a photocopy of the letter.

The Resources page contains links to letter templates.

See also:

• Patient claim requirements for payment of Medicare benefits
• Incomplete or incorrect Medicare claim forms

If a permanent address change is actioned during claims processing, by Medicare Claim form (MS014), telephone claiming or in person at a Medicare Service Centre, and the claim is later reversed, the amended address must not be reversed with the claim. The claimant's address must remain updated in CDMS.

There is a minimum turn-around time for Medicare benefits to be paid. These minimum payment times vary according to the claim type and relate to the number of days (including weekends) the benefit is held by Services Australia before release for payment to the claimant or health professional.

This detail is for situations where the Medicare system mainframe is not available in service centres. Customers should not be penalised when the Medicare system is not available.

Service Officers should tell customers that the system is down and they can either:

• fill in a Medicare Claim form (MS014) and the claim will be processed as soon as the system is available into their nominated back account by electronic funds transfer (EFT)
• lodge the claim through their myGov account if applicable or on the Express Plus Medicare mobile app

Medicare benefits for fully paid accounts/invoices can only be paid by EFT with funds deposited into a nominated bank account. Where the claimant does not have valid EFT details stored in the CDMS or cannot provide valid temporary or permanent EFT details at the time the claim is submitted, the payment for the claim will be held until EFT details have been provided.

See Standards for helping customers complete claims and forms.

The Process page contains a table outlining the situations and the action needed when patient claims submitted for payment are over 2 years old from the date of service.

Contact Local Peer Support (LPS) for help with processing a patient claim when:

• claim is received via the PaNDA work tool
• claimant has an RHCA entitlement, and
• has already left the country

Processing radiation oncology can be complex, Service Officer must take extra care when processing these accounts.

Service Officer must check the patient account/invoice and or transmitted claims have all the relevant details provided, to assess the claim according to legislation.

If any errors are keyed during the processing:

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

Only experienced Service Officers can process radiation oncology claims. If a Service Officer is not suitably skilled to process radiation oncology claims:

• proficiency raise the claim in PaNDA, and/or
• escalate to the Claims interpreter (CI) queue

See Processing radiation oncology.