Patient claims processing in Medicare 011-43010000

Using the details on the Medicare claim form (MS014):

• In Mainframe, key 'NPOI', Medicare card number
• Press [Enter], blank claimant identification fields are displayed
• Check if patient claim is using a previously issued card number

For claims where the patient is using a previously issued card number, see Patient claim requirements for payment of Medicare benefits.

Where return message 1-EXP>28, 2-AFT EXP, 8-EXP 28DY is returned, see Table 9 in Medicare online claiming.

• Identify the claimant (REF)
• Confirm if the claim is paid (Y) or Unpaid (N)
• Press [Enter]

Is the address on the claim form the same as what is recorded on the system?

If the claimant's address needs updating, place curser under the return message 8-ADDR CK, select [F1] and action per message.

• Yes, go to Step 4
• No, go to Step 5

• Key the first 2 letters of the street name in the ADR field line (for a PO Box key the first 2 letters of the suburb
• Press [Enter]

Go to Step 6.

• Key the postal address of the claimant in the ADR field
• Key 'T' for temporary use of address or 'P' for permanent updating
• Press [Enter]

Key one of the following values in the EFT field on line 6 of the screen to add, amend or confirm the claimant 's Electronic Funds Transfer (EFT) details:

• C - claimant has confirmed the use of EFT details previously stored as per claim form
• T - EFT details keyed are temporary and used for this claim only. For example, a claimant requests a one-off EFT payment into a different bank account to the details stored and the claimant has indicated this on the Medicare claim form
• P - EFT details keyed are permanently stored for this claimant. Using this indicator results in overwriting of any previously supplied banking details or the addition of EFT details where none were previously supplied
• N - EFT details unavailable, if the claimant cannot provide bank account details at time of lodgement this will allow validation of the EFT details to be bypassed, and for the assessment of the claim to continue. The Medicare benefit will be held until bank account details are provided. Once bank account details are provided, the payment will be automatically released overnight.

Key 'P' in the STM field to issue a statement to the claimant.

For claims processed in a Service Centre, key ‘R’ in the STM field to print a receipt for the customer to verify bank details and sign.

• Key date of lodgement in the DOL field
• Press [Enter]

The date of lodgement is the date Services Australia received the claim for Medicare benefits.

Is there a Recipient Provider or Locum on the claim?

• Yes, on the first line in the:
• PATIENT field, key the patient's name
• ITEM field, key PAYP
• NO field, key number of services, e.g. 01. If NO line is not displayed, press [F2]
• PROVIDER field, key the provider number for recipient provider/ locum
• No, go to Step 10

Note: for details of what to key in the second line, go to Step 10.

Key all the service details, in the:

• PATIENT field, key the patient's name
• ITEM field, key the item number
• FST DT field, key the date of service
• PROVIDER field, key the provider number
• Payee code, for example, 2 for unpaid claim and 9 for a paid claim
• CHARGE field, key the amount charge
• Press [Enter]

The Medicare system correctly calculates the maximum amount of the Medicare benefit payable to the claimant

If the account or invoice is incomplete, see Incomplete claim forms or incorrect details section in the Background page.

Does the account/invoice include referral details?

• Yes, go to Step 12
• No, go to Step 13

• PATIENT field, key the patient's name
• ITEM field, key the appropriate referral code:
• SR - Specialist referral
• AH - Allied health referral
• DI - Diagnostic Imaging
• PA - Pathology
• FST DT field, key the date the referral was written/ issued
• If the referral period is for:
• 12 months, the Service Officer does not need to key this field. The system will decide the end date of the referral
• a period other than 12 months. For example, 3 months, 24 months or indefinite
  LAST DT field, key the number of months on the referral line. For example, where the referral is 3 months, key '3', for 24 months key '24'
  For indefinite referrals, key '99'. The system will decide the end date of the referral
• PROVIDER field, key the referring provider number

• Review and apply assessing restrictions by following warning messages
• Warning messages must be actioned in order from left to right and more explanation can be viewed by placing the cursor at the beginning of the return message and pressing [F1]

Note: if RSN 8-CONFIRM displays, see Process Medicare Safety Net claims and action accordingly.

Where the claim is a Medicare Two-way claim:

• key 'Y' in the FUND field to get the gap statement, if needed
• key 'N' in the FUND field if no gap statement is needed

If in-hospital items are keyed, Service Officers will be prompted to complete the FUND field.

See Medicare Two-way and claims processing for more details.

• Press [Enter]
• Key 'P' to pay claim

• Add processing notes where needed
• On Work Item and Document details page complete the following:
• Medicare Number field - claimant's Medicare number, if not included already
• Surname First Name: this is the claimant’s surname and first name with no spaces
• Case ID: this is the Work ID number
• Status: Completed, Pended
• Complete Reason: Requested Reject, Request Approved, Already Completed
• Press Save
• Process ends here

Note: see Work Optimiser for staff for more details using PaNDA.

Using details on the Medicare claim form (MS014):

• In Mainframe key 'NPOI', Medicare card number of the patient
• Press [Enter], blank claimant identification fields will show

• Identify the claimants Medicare card number
• Claimant field, key the claimants Medicare card number
• Press [Enter]
• REF field, key the claimants reference number as per their Medicare card
• Confirm if the claim is paid (Y) or Unpaid (N)
• Press [Enter]

Is the address on the claim form the same as what is recorded on the system?

If the claimant's address needs updating, place curser under the return message 8-ADDR CK, select [F1] and action per message.

• Yes, go to Step 4
• No, go to Step 5

• Key the first 2 letters of the street name in the ADR field line (for a PO Box key the first 2 letters of the suburb
• Press [Enter]
• Go to Step 6

• Key the postal address of the claimant in the ADR field
• Key 'T' for temporary use of address or 'P' for permanent updating
• Press [Enter]

Key one of the following values in the EFT field on line 6 of the screen to add, amend or confirm the claimant 's Electronic Funds Transfer (EFT) details:

• C - claimant has confirmed the use of EFT details previously stored as per claim form
• T - EFT details keyed are temporary and used for this claim only. For example, a claimant requests a one-off EFT payment into a different bank account to the details stored and the claimant has indicated this on the Medicare claim form
• P - EFT details keyed are permanently stored for this claimant. Using this indicator results in overwriting of any previously supplied banking details or the addition of EFT details where none were previously supplied
• N - EFT details unavailable, if the claimant cannot provide bank account details at time of lodgement this will allow validation of the EFT details to be bypassed, and for the assessment of the claim to continue. The Medicare benefit will be held until bank account details are provided. Once bank account details are provided, the payment will be automatically released overnight

Key (P) in the STM field to issue a statement to the claimant.

For claims processed in a Service Centre, key ‘R’ in the STM field to print a receipt for the customer to verify bank details and sign.

• Key date of lodgement in the DOL field
• Press [Enter]

The date of lodgement is the date Services Australia received the claim for Medicare benefits.

Is there a Recipient Provider or Locum on the claim?

• Yes, on the first line in the:
• PATIENT field, key the patient's name
• ITEM field, key PAYP
• NO field, key number of services, for example, 01. If NO line is not displayed, press [F2]
• PROVIDER field, key the provider number for recipient provider/ locum
• No, go to Step 10

Note: for details of what to key in the second line, go to Step 10.

Key all the service details, in the:

• PATIENT field, key the patient's name
• ITEM field, key the item number
• FST DT field, key the date of service
• PROVIDER field, key the provider number
• Payee code, for example, 2 for unpaid claim and 9 for a paid claim
• CHARGE field, key the amount charge
• Press [Enter]

The Medicare system correctly calculates the maximum amount of the Medicare benefit payable to the claimant.

Does the account/invoice include referral details?

• Yes, go to Step 12
• No, go to Step 13

• PATIENT field, key the patient's name
• ITEM field, key the appropriate referral code:
• SR - Specialist referral
• AH - Allied health referral
• DI - Diagnostic Imaging
• PA - Pathology
• FST DT field, key the date the referral was written/ issued
• If the referral period is for:
• 12 months, the Service Officer does not need to key this field. The system will decide the end date of the referral
• a period other than 12 months, for example, 3 months, 24 months or indefinite
• LAST DT field, key the number of months on the referral line. For example, where the referral is 3 months, key '3', for 24 months key '24'.
  For indefinite referrals, key '99'. The system will decide the end date of the referral
• PROVIDER field, key the referring provider number

• Review and apply assessing restrictions by following warning messages
• Warning messages must be actioned in order from left to right and more explanation can be viewed by placing the cursor at the beginning of the return message and pressing [F1]

Where the claim is a Medicare Two-way claim:

• key 'Y' in the FUND field to get the gap statement, if needed
• key 'N' in the FUND field if no gap statement is needed

If in-hospital items are keyed, Service Officers will be prompted to complete the FUND field.

See Medicare Two-way and claims processing for more details.

• Press [Enter]
• Key 'P' to pay claim
• Press [Enter]

• Add processing notes where needed
• On Work Item and Document details page complete the following:
• Medicare Number field – claimant’s Medicare number if not included already
• Surname First Name: this is the claimant’s surname and first name with no spaces
• Case ID: this is the Work ID number
• Status: Completed, Pended
• Complete Reason: Requested Reject, Request Approved, Already Completed
• Press Save
• Procedure ends here

Note: see Work Optimiser for staff for more details using PaNDA.

Using the details on the Medicare claim form:

• In Mainframe, key 'NPOI', Medicare card number (MS014)
• Press [Enter], blank claimant identification fields will show

• Identify the claimant is a business or organisation
• CTYPE field key 'B' (business/organisation)
• Press [Enter]
• POSTAL NAME key the name of the organisation followed by a comma
• Confirm if the claim is paid (Y) or Unpaid (N)
• Press [Enter]

• Key the postal address of the claimant (business or organisation) in the ADR field
• Key 'T' for temporary storage of address in the last field after the postcode
• Press [Enter]

Note: Businesses and organisations cannot have banking details stored permanently in CDMS, unless the customer is under financial management or other guardianship order. See, Power of Attorney, Guardianship, Administrative Orders and Authorised Representative for Medicare.

Has the business or organisation provided bank account details on the claim form?

• Yes, go to Step 5
• No, go to Step 6

Key the following values in the EFT field to add the claimant's Electronic Funds Transfer (EFT) details.

T - EFT details keyed are temporary and used for this claim only.

Is the claim paid?

• Yes:
• if the bank account details have not been provided on the claim form, Service Officers must key 'N' - EFT details unavailable. If the claimant cannot provide bank account details at time of lodgement this allows validation of the EFT details to be bypassed, and for the assessment of the claim to continue. The Medicare benefit is held until bank account details are provided. Once bank account details are provided, the payment releases automatically overnight
• procedure ends here
• No, as the claim is unpaid, a cheque will be issued to the Business/Organisation. Bank details will not be needed, go to Step 7

Key 'P' in the STM field to issue a statement to the claimant.

Note: a statement must be issued when the claimant is a business or organisation.

• Key date of lodgement in the DOL field
• Press [Enter]

The date of lodgement is the date Services Australia received the claim for Medicare benefits.

Key all of the following items:

• PATIENT field, key the patient's name
• ITEM field, key the item number (if item is in-hospital, key 'H' after the item)
• FST DT field, key the date of service
• PROVIDER field, key the provider number
• Payee code, for example, 2 for unpaid claim and 9 for a paid claim
• CHARGE field, key the amount charged
• Press [Enter]

Repeat this step for each service being claimed.

Has the Medicare system calculated the maximum amount of the Medicare benefit payable to the claimant without returning any restriction or warning messages?

• Yes, see Step 11 in Table 1
• No, go to Step 10

Note: for Locum-tenens see Professional services related to Medicare patient claims.

• Review and apply assessing restrictions by following warning messages
• Warning messages must be actioned in order from left to right and more explanation viewed by placing the cursor at the beginning of the return message and pressing [F1]
• For more details on pathology items, see Assessing Pathology claims

• Press [Enter]
• Key ‘P’ to pay claim
• Press [Enter]

Is the Service Officer proficient in processing the claim?

• Yes, go to Step 2
• No, go to Step 3

Tell the customer the agency minimum standard processing times.

If the customer states that they need their money as soon as possible, are experiencing hardship and the benefit amount of the claim is:

• under $100, process the claim regardless of the date of lodgement
• greater than or equal to $100 and on day zero:
• Service Officer must call the clinic to confirm the account is valid. See Suspected Medicare fraud and Business Integrity (BI) flags
• if after hours, tell the customer that due to the claim being lodged at a service centre it will not show in the system until overnight. Tell the customer to call back during business hours the following business day

If the customer identifies as at risk of family or domestic violence see Family and domestic violence.

• Add a Sensitive Information Indicator for an Urgent Medicare benefit paid in the CDMS in Personal
• If Service Officer identifies family and domestic violence concerns, add a Sensitive Information Indicator for Family and Domestic Violence
• See Sensitive information indicators in the CDMS for more details.

Procedure ends here.

• Contact Local Peer Support (LPS)
• Service Officer should tell LPS they are not proficient in completing work for customers identified as experiencing financial hardship
• Process ends here

• Process the claim as soon as possible. LPS may use a conference call if there is a perceived training benefit
• If the customer identifies as at risk of family or domestic violence see Family and domestic violence
• Add a Sensitive Information Indicator for an Urgent Medicare benefit paid in CDMS in Personal
• If Service Officer identifies family and domestic violence concerns, add a Sensitive Information Indicator for Family and Domestic Violence

See Sensitive information indicators in the CDMS for more details.

Offer to process the claim using a claim form completed by the unauthorised agent or carer and if:

• bank account details - the claimant has bank account details recorded, pay the Medicare benefit into the claimant's bank account via Electronic Funds Transfer (EFT)
• no bank account details - if the claimant does not have bank account details recorded, update the CDMS or key bank account details in the NPBI screen whilst processing the claim and to pay the claimant via EFT
• cannot provide valid EFT - where the claimant cannot provide valid EFT details, the payment of the claim will be held until EFT details can be provided

A statement of benefit (printed receipt) must be issued.

Add a processing note in PaNDA to describe the circumstances. For example, 'Assistance required as per Providing assistance to claimants with a disability'.

If the claim form is signed by a carer, leave a processing note in PaNDA to state that the claim form is signed by a carer and not the claimant.

Claim must be supported by:

• an original
• duplicate account/invoice, or
• receipt for payment

Sort claims into date order for each patient.

Medicare benefits for fully paid accounts/invoices can only be paid by Electronic Funds Transfer (EFT). If no EFT details are provided or stored in CDMS for the claimant the payment will be ‘held’ until EFT details are provided.

• Key QITI, item number, DOS
• Press [Enter]
• Press [F5], schedule fee and benefit amount will display for that date of service

If the Medicare benefit is less than $100 (for all patients for one Medicare card number), the claim can be processed and paid without reference to culled history.

Service Officers will need to complete the above steps for each item and DOS in question, to decide each benefit amount and then the total benefit for all items.

Is the total Medicare benefit less than $100?

• Yes, go to Step 3
• No, see Table 7, Step 2

If the Medicare benefit is less than $100, the claim can be processed and paid.

See Table 1 for how to process a Medicare patient claim.

The return message GT-2YR will display for claims with a date of service greater than 2 years, 6-REJ/PEND is also displayed.

• Over key NPBC with 'NPSC'
• Press [Enter]
• Key '17' in the PI line
• Press [Enter]

Review and apply assessing restrictions by following warning messages.

• Key 'P' to pay claim
• Press [Enter]
• Warning messages must be actioned in order from left to right and more explanation can be viewed by placing the cursor at the beginning of the return message and pressing [F1]

Claim must be supported by:

• an original
• duplicate account/invoice, or
• receipt for payment

Sort claims into date order for each patient.

Medicare benefits for fully paid accounts/invoices can only be paid by Electronic Funds Transfer (EFT). If no EFT details are provided or stored in CDMS for the claimant, the payment will be ‘held’ until EFT details are provided

Check the patient history to decide if the claim has been processed after the cull history date.

Is there evidence of a duplicate payment on the history?

• Yes, reject the claim with RSN 162
• No, go to Step 2

Check the patient history to decide the date the patients Medicare history was culled.

• Key NHSI, Medicare card number
• Press [Enter]

The Cull history line indicates the date the patients Medicare history was culled. This is displayed against the patient’s name, CULL, and the date.

Medicare mainframe system maintains about 2 years of claimed treatment history.

Does the claim have a date of service after or before the cull history date?

• after the cull history date, go to Step 3
• before the cull history date, go to Step 6

If there is no evidence of a duplicate payment on the history, the claim can be processed and paid. See Table 1.

The return message GT-2YR will display for claims with a date of service greater than 2 years before, 6-REJ/PEND is also displayed.

• Over key NPBC with ‘NPSC’
• Press [Enter]
• Key '17' in the PI line
• Press [Enter]

Review and apply assessing restrictions by following warning messages.

• For more details on pathology items, see Assessment of pathology claims
• Key 'P' to pay claim
• Warning messages must be actioned in order from left to right. More explanation can be viewed by placing the cursor at the beginning of the return message and pressing [F1]
• Procedure ends here

Search the claims history for each date of service by keying 'DOS/DDMMYY' at the end of the NHSI control line.

Where there is no evidence of a duplicate payment already made after the cull history date, the Service Officer can proceed with the claim.

Is the Service Officer skilled to process claims over 2 years old and have access to use SAS Portal?

• Yes, see Table 8
• No, go to Step 7

• select the work item in the Worklist
• select Unassign to raise proficiency
• select Proficiency Raised as the reason
• select Submit
• Add a processing note explaining the reason for raising proficiency

Make sure all relevant paperwork has been received - claim form, accounts/invoices and corresponding receipts if needed.

• Key NHSI, Medicare Number, Patient name or IRN (Individual Reference Number)
• Press [F9] to obtain the PIN number of the patient
• Copy the patient's PIN number

Access the SAS Information Delivery Portal, and:

• Select Parameter Based Reporting
• Select Medicare Patient History
• Under Consumer Details- enter the patients PIN minus the last letter
• Under Date of Service- enter the date range, ensuring it includes any time dependency periods for the specific item(s), using format of DD/MM/YYYY
• Under Report Format Options:
• change the Output Type to PDF
• select Yes for 'results in New Window'
• select Submit Request

Service Officers need to save a copy of the report and attach it to the PaNDA work item.

Verify accounts/invoices:

• check all account/invoice details against the culled history for confirmation of payment, and for any other restrictive services, based on the item requirements
• decide if claim has been previously paid, or that there are restrictive items previously paid
• Go to Step 5

Anaesthetic services displayed on the SAS Patient history report may not show all item numbers.

Using the details on the Medicare claim form (MS014):

• In Mainframe, key NPOI, Medicare card number
• Press [Enter] - blank claimant identification fields are displayed

Follow the prompts:

• Identify the claimant (REF)
• Confirm if the claim is paid (Y) or Unpaid (N)
• Press [Enter]

Confirming address:

• Confirm the address of the claimant
• Key the first 2 letters of the street name in the ADR field line. For a PO Box, key the first 2 letters of the suburb

Key one of the following values in the EFT field:

• C - Claimant has confirmed the use of EFT details previously stored as per the claim form
• T - EFT details keyed are temporary and to be used for this claim only. For example, a claimant requests a one-off EFT payment into a different bank account to the details stored and the claimant has indicated this on the claim form
• P - EFT details keyed are permanently stored for this claimant. Using this indicator results in overwriting of any previously supplied banking details or the addition of EFT details where none were previously supplied
• N - EFT details unavailable. If the claimant cannot provide bank account details at time of lodgement this will allow validation of the EFT details to be bypassed and for the assessment of the claim to continue. The Medicare Benefit will be held until bank account details are provided. Once provided the payment will be automatically released overnight

Key 'P' in the STM field to issue a statement to the claimant.

• Key date of lodgement in the DOL field
• Press [Enter]

The date of lodgement is the date Services Australia received the claim.

Keying claim details that have been previously paid

When services appear on SAS history report and there is no notation to indicate a second service is payable:

• Reject service with RSN 162 - SUS DUP in reason field, and:
• For fully paid (payee code 9) claims, key 'E' in P field
• Unpaid/partially paid (Payee code 2) claims, key 'R' in P field and 162 in reason field
• Go to Step 9

Keying claim details where restrictive items have been previously paid

Where restrictive services appear on SAS history report and there is no notation to indicate a second service is payable:

• Reject service with an appropriate code in reason field, as per the Reason Codes list, and:
• For fully paid (Payee code 9) claims, key 'E' in P field
• Unpaid/ partially paid (Payee code 2) claims, key 'R' in P field
• Go to Step 9

Keying claim details that have not been previously paid

Where services are not appearing on SAS history, the Medicare benefit is payable.

See Table 1.

The return message GT-2YR will display for claims with a date of service greater than 2 years, 6-REJ/PEND is also displayed.

• Over key NPBC with 'NPSC'
• Press [Enter]
• Key '17' in the PI line
• Press [Enter]

• Review and apply assessing restrictions by following warning messages
• Warning messages must be actioned in order from left to right and more explanation can be viewed by placing the cursor at the beginning of the return message and pressing [F1]
• When assessment of the claim is completed and warning messages actioned, Press [Enter]
• Key 'P' to pay claim
• Press [Enter]
• Attach any SAS reports to the work item in PaNDA, add relevant notes, and mark the work item as 'Complete'
• For more details on pathology items, see Assessing Pathology claims

Claim must be supported by:

• an original
• duplicate account/invoice, or
• receipt for payment

Service Officers should pay any claim under 2 years old. Claims between 2-5 years should be processed and paid before escalating. Add a note to the work item in PaNDA to indicate what services the Service Officer has processed and that the item will be re-categorised to over 5 years.

Medicare benefits for fully paid accounts/invoices can only be paid by Electronic Funds Transfer (EFT). If no EFT details are provided or stored in CDMS for the claimant, the payment will be ‘held’ until EFT details are provided.

Select the Reassign button.

Users may be prompted to enter additional work item details. If so, enter as per standard process for the work type being re-categorised and press Reassign again.

• In the Assign pop up window, enter your own User ID and select Re-categorised as the reason from the Reason field
• Select the Re-categorise to field. A dropdown menu will display a list of work types. Search and select the relevant work type:
• PaNDA system work type program - Patient Claims
• PaNDA work type process - Claims
• PaNDA work type name - PC_CLAIM_OVER_5YEARS
• Once the work item has been moved to the correct category, make sure the card and name details are correct on the work item, save any changes, then Unassign the work item as User Unavailable

The work item will then be processed in date of lodgement order.

Check all accounts/invoices and receipts are sorted into order with earliest date to latest date for each patient.

Enter all services in mainframe and then key and pend the claim (NPND)

See Table 1.

• key NHSI, Medicare Number, Patient Ref
• press [F9] to obtain the PIN number of the patient
• copy the patient's PIN number

• Select Medicare GT 5 Year
• Select MCGT5Y_Extraction_Request

• Select New Patient Request
• Key PIN number minus the alpha
• Reference Date from
• Reference Date to
• Once all details have been keyed, select Validate Request

Feedback will be displayed in a new window.

• Delete unwanted patients by selecting the check box next to the patient
• Select Submit Request to save and submit the request

The system will display the confirmation page with the Request and Report date available.

To make sure no time restrictions, the time range requested must reflect the time dependency of the item claimed. For example, item 2715 can only be claimed once every 12 months. The report needs to cover the 12 months before and post item being claimed.

Culled history report may take up to 3 weeks before being assessable. Culled history can only be viewed when the report is available.

Once the claims history report has been requested, the Service Officer should add a note to the work item stating that the report has been requested, the date range requested, and the estimated available date. Once this has been done, the Service Officer should Pend the work item to themselves:

• Pend reason 'Previous Work in Progress Extended'
• Save the work item
• Select Assign to Me so the item is now pended to the Service Officer

If the situation occurs where a second report is requested for the same patient within the same 2 week cycle, the system will not allow Service Officers to proceed.

• Delete the first request by going to the Manage Current requests tab
• Select View request
• Tick the box to remove the request
• Select Remove Selected Requests

The system will then state Request Removed and a new report can be re-ordered within an expanded date range to include all dates of service for the relevant claim/s.

On the date the report is available:

• access the SAS Information Delivery Portal
• select Medicare GT 5 Year
• select MCGT5Y_Extraction_Request

• Select Produce Report tab
• Search report parameters by selecting PIN in search type and placing the PIN number in Search text box
• Select View Request

This will narrow down reports produced to only include the patient being actioned and not all available reports requested by the Service Officer.

If the report does not appear, make sure the date range is correct. The system will only display a date range 2 weeks from the current date. If the report was ordered before the 2 weeks, expand the date range to include the date the report was ordered.

All available reports matching the search criteria will be listed in the new window.

• Scroll to bottom of the page
• On the results page, reports can be retrieved by selecting Email Reports

The system will email all reports displayed on this page to the requesting Service Officers email address.

Reports are only accessible by the original requestor. If no report is available, check the View Requests tab and enter the customers PIN to check if a report has been ordered.

Recall claim from pend

• NPRI, Medicare card number
• Press [Enter], recalls item lines that have been pended

Claims previously paid

Where services appear on SAS history report and there is no notation to indicate a second service is payable:

• Reject service with RSN 162 - SUS DUP in reason field, and:
• For fully paid (Payee code 9) claims, key 'E' in P field
• Unpaid/ partially paid (Payee code 2) claims, key 'R' in P field
• Go to Step 11

Claims over 7 years can be keyed and rejected with RSN 162.

Claims where restrictive items have been previously paid.

Where restrictive services appear on SAS history report and there is no notation to indicate a second service is payable:

• Reject service with an appropriate code in reason field, as per the Reason Codes list, and:
• For fully paid (Payee code 9) claims, key 'E' in P field
• Unpaid/ partially paid (Payee code 2) claims, key 'R' in P field
• Go to Step 11

Claims not previously paid

Where services are not appearing on SAS history then the benefit is payable.

• For claim over 5 years but under 7 years old, these can be paid via mainframe, go to Step 11
• For claims over 7 years old, See Table 11

• Review and apply assessing restrictions by following warning messages
• Warning messages must be actioned in order from left to right and more explanation can be viewed by placing the cursor at the beginning of the return message and pressing [F1]
• When assessment of the claim is completed and warning messages actioned, Press [Enter]
• Key 'P' to pay claim
• Press [Enter]
• Attach any SAS reports to the work item in PaNDA, add relevant notes, and mark the work item as 'Complete'

Decide from SAS (culled history report) the service(s) was not previously paid.

Log on to Mainframe:

• Key QITI, item number, date of service (DOS)
• Press [Enter]
• [F5] to display the schedule fee and benefit amount for the date of service

Check all assessing rules, as these must be manually calculated. Assessing rules may have changed from the date of service to the date of claim. Some assessing rules are not retroactive.

View CDMS (for Claimants) to confirm valid bank account details are stored.

Are valid bank account details stored?

• Yes, go to Step 5
• No, go to Step 4

Complete the following:

• Contact claimant and tell if a bank account (either temporary or permanent) is not provided the Medicare benefit will not be paid until bank account details are supplied. See Store, confirm and end date bank account details for Medicare EFT payments
• If claimant cannot be contacted, return the claim documentation to the claimant with the appropriate standard letter template

Has the claimant given bank account details?

• Yes, go to Step 5
• No, procedure ends here

Complete the Your statement of Medicare Benefits template (Z2261).

Complete the statement of benefits table with the following details:

Addressee and Signatory tab

• Claimants full name and address details as per CDMS, unless the claimant is a Business or organisation, then enter the details as per the claim form
• Our reference: your Source Office code/your P number or universal login/10 digit PaNDA work item ID

Benefits details tab

For each separate item and DOS:

• Key health professional’s title, first name, surname, and provider number
• If multiple services for the same health professional/patient are involved, tick 'retain provider' and 'retain patient' fields
• Key patient’s full name, item number, and the date of service
• Select if the service is fully paid or unpaid- for unpaid RSN code 001 will auto-populate
• If the service was in-hospital tick the Inpatient box- RSN code 000 will auto-populate
• Explanation: Key any relevant RSN code (for example, 241,242,154,179 etc.)
• CHARGE: amount charged for item as per the account/invoice
• SCH FEE: schedule fee for that item at that date of service
• BENEFIT: Medicare rebate for that item at date of service, including any assessing rules and modifiers as per QITI

If multiple service rules (MSR) apply, manually calculate the correct schedule fees and benefits. Enter the correct schedule fee and benefit amounts on the manual statement.

Notional charges where the Multiple Operation Rule (MOR) has been applied, these must be keyed for the first item only, along with the total derived schedule fee and total benefit amounts. The rest of the related MBS Items will have a ‘0’ value for charge, schedule fee and benefit.

See the Resources for multiple processing rules and adjacent statement of benefit reason (RSN) codes to decide the reason code to be included in the Z2261.

• Once the details for an item are keyed and correct, select Add, which adds the details to the list of items to be included on the statement, and clears the fields so that the next item can be keyed
• Repeat these steps on the benefits details tab for each individual item performed

There are also Remove and Edit Information buttons in the Z2261 template if a line needs to be amended or removed.

Once all items have been keyed correctly:

• Select OK. The full statement will then show, and will include the total benefit amount for all the items that is automatically calculated, and the Explanation of the reason codes will be visible
• Save a copy of the statement as a PDF, using 'Save As Adobe PDF':
• Select 'Yes' on the pop-up that appears
• Select a location to save it to, and
• Change the 'Save as Type' from 'Word Macro-Enabled Document' to 'PDF' using the dropdown list

Open the Manual EFT Payment Request form (PP048) template and complete the relevant fields.

Make sure the completed Manual EFT payment Request form is saved as a PDF as it is an interactive form. Service Officers will need to do this by selecting ‘Print,’ then changing the Printer to 'Microsoft Print to PDF'.

• Combine the Manual EFT request form (PP048) and the Manual Statement of Benefits (Z2261) to a single PDF, named in the format of:
• Date of lodgement YYYYMMDD.claimantsurnamefirstname.PCLL5.yourloginID, and
• add that combined document to the claim, and update notes in PaNDA
• Add a comment to CDMS in personal (claimant) indicating the manual EFT amount and the Service details
• Save the combined PDF version of the documents to R:\NAT\HLTHSERDEL\DELSUPPORT\MPS-National\MPS_Claims_&_Assessing\1. Manual EFT Payment Requests\insert state from list below \4. FORMS PCBB (week ending accordingly)

The state codes are as follows:

• 01. NSW
• 02. QLD
• 03. VIC
• 04. WA

The Vendor Request Template is on the National MPS drive:
R:\NAT\HLTHSERDEL\DELSUPPORT\MPS-National\MPS_Claims_&_Assessing

The templates are weekly, so add the details to the form for the current week.

If the template is marked as closed, meaning it has already been sent for payment/ Add the details to the template dated for the following week.

Note:

• The spreadsheet can have up to 200 vendor lines only. Make multiple files if needed
• Capitalise appropriately (for example, First and Surname should be capitalised)
• Do not remove any columns even if blank
• File must contain only numbers and letters
• Hyphens (-) are accepted in the name or address columns only
• Backslash (/) is accepted in the address column only
• No other symbols are permitted including:
• Commas (,)
• Colons (:)(;)
• And (&)
• Full stop (.)x

See the Resources page for How to update vendor request spreadsheet for creation of MBS vendors.

The Payment Run Request Template on the National MPS drive:
R:\NAT\HLTHSERDEL\DELSUPPORT\MPS-National\MPS_Claims_&_Assessing

The templates are weekly, so add the details to the form for the current week, which should be the same period as the Vendor Request template the details were added to.

If the template is marked as closed, meaning it has already been sent for payment, add the details to the template dated for the following week.

See Resources for how to update the Payment run spreadsheet for creation of MBS Payments.

Once all forms and templates have been completed:

• Email the combined version of the PP048 and the Z2261 to the quality checking team leader, with Subject field as 'Manual EFT Payment Request form<CLAIMANT NAME>'
• Tell the claim is in PaNDA awaiting manual EFT payment

When the payment by the RBA has been confirmed, the Team Leader will contact the requesting Service Officer to tell them to add updated comments to PaNDA and CDMS indicating payment has been made and the statement sent.

The process for the Service Officer ends here.

The Team leader checks the Vendor Request Template, which is on the National MPS drive:
R:\NAT\HLTHSERDEL\DELSUPPORT\MPS-National\MPS_Claims_&_Assessing

Make sure the template complies with the following rules:

• The spreadsheet can have up to 200 vendor lines only. Make multiple files if needed
• Capitalise appropriately (for example, First and Surname should be capitalised)
• Do not remove any columns even if blank
• File must contain only numbers and letters
• Hyphens (-) are accepted in the name or address columns only
• Backslash (/) is accepted in the address column only
• No other symbols are permitted including:
• Commas (,)
• Colons (:)(;)
• And (&)
• Full stop (.)x`

Make sure the template has been completed correctly so all the details match the related Manual EFT Payment request forms.

See the Resources page for details to update vendor request spreadsheet for creation of MBS vendors.

The Team Leader also checks the Payment Run Request Template, which is on the National MPS drive:
R:\NAT\HLTHSERDEL\DELSUPPORT\MPS-National\MPS_Claims_&_Assessing.

See Resources for how to update the Payment run spreadsheet for creation of MBS Payments.

Complete the following checks for each entry on the templates:

• Locate the claim/s
• Confirm the details keyed on the Manual EFT Payment Request form are correct and match the statement of benefit (as well as the details on the request templates)
• Check statement of benefits has been actioned and is correct
• Check comments were added in CDMS and PaNDA
• Add notes in PaNDA to the file indicating the form has been checked

Once per week, after the Team Leader has checked the templates, they email copies of both templates to Provider Services.

When the payment by the RBA has been confirmed by the Team Leader, they:

• retrieve the remittance advice from the folder on the National MPS drive:
  R:\NAT\HLTHSERDEL\DELSUPPORT\MPS-National\MPS_Claims_&_Assessing
• confirm the amount is correct
• print and mail the statement of benefit and the remittance advice to the claimant
• arrange for the Service Officer to add updated comments to PaNDA and CDMS indicating payment made and statement sent

Save the remittance advice on the National MPS drive:
R:\NAT\HLTHSERDEL\DELSUPPORT\MPS-National\MPS_Claims_&_Assessing

To obtain a vendor maintenance number, forward the vendor request template from the Provider Services email box with subject heading ‘Patient claim payments - Vendor requests - Medicare Provider Services’ to the Accounting Operations (AO) team.

The AO team will create a new vendor maintenance number.

The spreadsheet will be updated with the new vendor number and returned to the requesting officer.

When the Vendor maintenance number has been received, access the Payment Run Request Template, and complete the following field:
A - VENDOR: key vendor number assigned to the claimant/health professional

Once the template has been completed, delegate approval is needed before payment can be made. Add the total amount of benefits to be paid.

Email the template to the appropriate delegate from the Provider Services email box with the subject line and body of the email as follows:

• Subject: Patient Claim Payments - Manual EFT Payment Run - Medicare Provider Services
• Body of email: Please find attached for your approval, a request for <insert number of payments> manual EFT payments for the total amount of $<insert total amount>

Once approval is received by the delegate, email the request template to:

• Medicare Cash Management
• National Accounting Operations

Use the following details for the subject line and body of the email:

• Subject: Patient Claim Payments - Manual EFT Payment Run - Medicare Provider Services
• Body of email: Please find attached the spreadsheet for <Insert number of payments> payments for the total amount of $<Insert Total amount> which has been approved for payment as per delegation limit of <Insert Delegate name>

Accounting Operations will email once payment has been processed and released to the RBA.

Once confirmation of the payment has been received, email MPS Claims and Assessing Team Leaders with the following:

• Payment has been made
• Service Officers must now issue the claimant/health professional with a manual statement of benefit

• Key NHSI, card number, patient name in Mainframe
• Press [Enter]
• Medicare Patient History screen will display, locate the claim
• Note the date of processing in PRC DT column
• to identify the claimant, place the cursor on the CHARGE for that date of claim and press [F1]- the claimants details will display at the bottom of the screen

If a Latter Day Adjustment (LDA) has been undertaken or the claim is for an amount over $9,999.00, duplicate statements cannot be issued. See Table 15 to issue a manual statement of benefit. The date of processing of the claim is needed for issuing a duplicate statement of benefit.

Is the patient/claimant requesting the duplicate statement the group contact?

• Yes, go to Step 4
• No, go to Step 3

• Key NDSI, card number, date of processing (DDMMYY)
• Press [Enter]
• Duplicate Statement screen displays

If the person requesting the duplicate statement is not the group contact (for example, a business organisation is the claimant):

• Over-type the following contact details:
• CONTACT field key surname, title first name
• ADR field key address details

Check the NDSI screen:

• key NDSI, card number, date of processing (DDMMYY)
• press [Enter]
• Duplicate Statement screen displays

Is the statement displaying with the correct processing date, patient, and health professional?

• Yes, go to Step 6
• No, go to Step 5

If multiple claims are processed on the one day, the system lists a separate statement for each health professional.

Use the [F2] and [F3] keys to move from statement to statement until the needed one is located.

Each screen displays up to 8 services. If there are more than 8 services, use [F7] and [F8] function keys to view all the services for that health professional.

In control line, over-type 'I' with either 'P' to post or 'M' to print statement in a service centre.

Press [Enter].

When printing statement on site, an additional screen will present and the Service Officer will need to press [Ctrl] + [Alt] + [P].

• NHSI,Medicare number,patient name or IRN,Dos/DDMMYY check date of processing for each claim to be included on the manual statement
• Change control line to NHSI, Medicare number, patient name or IRN,DOP/DDMMYY, for each claim to be included on the manual statement
• DOP screen shows all lines processed on that DOP

Are there any adjustment codes (888 or 816)?

• Yes, go to Step 2
• No, go to Step 3

Change control line to NHSI, Medicare number, patient name or IRN,ADJ/PC.

The NHSI screen shows all the adjusted payments including original and revised lines.

The Service Officer must check each claim/ adjustment to be included on the manual statement.

• Open the Your Statement of Medicare benefits (Z2261) template. See Medicare letters
• On the Address and Signatory tab enter the following details:
• Recipient’s name and address as listed in the CDMS. This can only be the claimant or patient.
• Our Reference (PaNDA work ID or Source Code and Logon ID, where work type is not completed in PaNDA)
• Patient's Medicare card number

Note:

• key the full name of the recipient as there may be another person with the same initials on that Medicare card.
• a Z2261 should only be issued to the claimant or the patient. The only exception to this is where a two-way claim form has been provided and a copy of the statement issued in the name of the claimant or patient can be forwarded to the health fund with an accompanying ‘unable to transmit two-way claim’ letter (HW038). See Medicare Two-way and claims processing for more details.

For each claim to be included on the statement, select Benefits Details tab, and then for each individual item and service:

• Enter the health professional’s title, first name, surname, and provider number
• If multiple services for the same health professional/patient are involved, select ‘retain provider’ and ‘retain patient’ fields
• Key patient’s full name, item number, date of service
• Select if the service is fully paid or unpaid
• Key the relevant RSN code (for example, 888, 816, 242,179 etc.)
• If the service was in-hospital tick the Inpatient box- RSN code 000 will auto populate.

Service Officers must:

• Key in the service line exactly as it appears in mainframe
• Press [F1] under the RSN code on patient history and only include reason codes which display a ‘Statement message’
• Referral and service request lines (SR, DI, PA, and AH) and UPAY/OPAY lines as a result of LDA’s must not be placed on the manual statement
• For a service over $9999.99, it is not necessary to key the '0000' line. The total charge for the service and the relevant item number should be included in the statement, as one line
• The Z2261 should include item numbers and reason codes for any rejected services

Any previous assessing RSN codes will be overwritten if a Latter Day Adjustment has been actioned.

See Charges $10,000 or more (greater than $999.99) for Medicare patient claims.

The reason code will generally display in mainframe. However, if an adjustment has been made where the MOR or MSR rule(s) have been applied, the original code will not display. The Service Officer will need to check the MOR/MSR and identify the reason code to be used in the letter.

Press [Shift] + [F4] on history screen to find out if an MOR and/or MSR has been applied.

Has a MOR and/or MSR been applied?

• Yes, go to Step 6
• No, go to Step 7

See the Resources page for multiple processing rules and adjacent statement of benefit reason (RSN) codes to decide the reason code to be included in the Z2261.

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

• Key in charge and benefit amounts as per NHSI screen
• For schedule fee, in mainframe on the NHSI screen press [F4] to display the schedule fee displayed under the ‘fee’ field
• Select Add, to add the service line to the list to be included on the statement.
• Repeat these steps for each service line to be included on the manual statement

Do not refer to the QITI for schedule fees as there may be derived fees for operations with more than one item, or where there have been multiple services performed, and multiple service rules such as the Multiple Operation Rule (MOR) or Diagnostic Imaging Multiple Service Rule (DIMSR) have applied.

Notional charges must be placed for the first item only with the derived schedule fee and benefit where the MOR has been applied. The rest of the MBS Items will have a ‘0’ value for charge, schedule fee and benefit.

If there are any remaining items, enter them individually and add to the statement.

There are also REMOVE and Edit Information buttons in the Z2261 template.

Service Officers in telephony

Service Officers in telephony must follow the quality assurance process before mailing out the manual statement of benefit to the customer.

See Quality assurance and quality checking for external mail in Medicare

Service Officers in Services Australia service centres

Service Officers in service centres should follow their branch quality assurance process before handing out the manual statement of benefit to the customer.

See Quality assurance and quality checking for external mail in Medicare.

Service Officers are to upload a copy of the manual statement of benefit and attach it to the PaNDA work item.

Add a processing comment in PaNDA.

Record a comment against the claimant advising that a manual statement of benefit has been issued by:

• selecting Comments tab in Personal
• recording comment that the manual statement of benefit has been issued including for which patient and date of service

For example - "Manual statement of benefit issued for DOS DD/MM/YY patient FULL NAME."

Service Officers must keep:

• the new address details in the CDMS
• a photocopy of the claim documentation in batch work (which shows the change in address)

Service Officers must keep the new address details in the CDMS.

The claim documentation held in the batch work is a sufficient audit trail of address changes.

The exception if a permanent address change is reversed during claims processing is when the reason for reversal was incorrect claimant card number.

If this occurs, Service Officers must:

• return the address in the CDMS to the original address
• add notes in the group comment tab in CDMS to explain why the address was reversed