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.

If the return messages 1-EXP>28, 2-AFT EXP, or 8-EXP 28DY show, see Table 9 in Medicare online claiming.

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

Does the address on the claim form match the address recorded on the system?

• 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.

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

• 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]
• If processing in a service centre, keep a copy of the claim documents in batch work (which shows the change in address) if the address change is permanent
• Update the address in CDMS as well

If a permanent address change is reversed while processing the claim due to an incorrect claimant card number:

• return the address in the CDMS to the original address
• add notes in the Group Comment tab in CDMS to say address reversed due to incorrect Medicare card number

Key one of the following values in the EFT field on line 6 of the screen to add, amend or confirm the claimant 's 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. Claimant has marked this on the Medicare claim form
• P - EFT details keyed are permanently stored for this claimant. Use this to:
• overwrite any previously supplied banking details
• add new EFT details where none were previously supplied
• N - EFT details unavailable:
• used if the claimant cannot provide bank account details at time of lodgement
• allows validation of the EFT details to be bypassed and claim assessment to continue
• Medicare benefit is held until bank account details are provided
• once provided, payment is 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.

The date of lodgement is the date the agency got the claim for Medicare benefits.

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

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 does not show, press [F2]
• PROVIDER field, key the provider number for recipient provider/ locum
• Go to Step 10
• No, go to Step 10

Check the details on the account/invoice match the claim form and that both documents contain all required information.

Do the details on the account/invoice and the claim form match and both are complete?

• Yes, go to Step 11
• No,
• If there is original paperwork, photocopy the documents to keep onsite for future reference
• Create an appropriate letter to send to the customer. The Resources page contains links to letter templates
• Attach a copy of the document to the letter. This will either be a photocopy of the document, or one printed from the uploaded copy in PaNDA
• Send the letter and attached document to the customer
• Go to Step 17 to reject the claim

See also:

• Patient claim requirements for payment of Medicare benefits
• Incomplete or incorrect Medicare claim forms
• Account and receipt documents for Medicare claims processing

Key all the service details, in the:

• PATIENT field, key the patient's name
• ITEM field, key the item number (if service 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 charge amount
• 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 13
• No, go to Step 14

• 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
• More details can be viewed by placing the cursor at the beginning of the return message and pressing [F1]

For ‘1-INVEST’ messages and how to proceed see Suspected Medicare fraud and Business Integrity (BI) flags. If a claim is confirmed as fraudulent, do not pay the claim:

• For claims lodged using MS014 reject with reason code 108
• For claims submitted using Medicare Online Accounts (MOA), see Process digital self service claims for how to finalise the claim

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

Where the claim is a Medicare Two-way claim:

• Key 'Y' in the FUND field if a gap statement is 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 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:
• 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
• Status: Completed
• Complete Reason: Request Rejected, 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 claimant’s Medicare card number
• Claimant field: key the claimants Medicare card number
• Press [Enter]
• REF field: key the claimant’s reference number as per their Medicare card
• Confirm if the claim is paid (Y) or Unpaid (N)
• Press [Enter]

Does the address on the claim form match what is recorded on the system?

• 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

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

• 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. Use this to:
• overwrite any previously supplied banking details
• add new EFT details where none were previously supplied
• N - EFT details unavailable:
• used if the claimant cannot provide bank account details at time of lodgement
• allows validation of the EFT details to be bypassed and claim assessment to continue
• Medicare benefit is held until bank account details are provided
• once provided, payment is 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.

The date of lodgement is the date the agency got the claim for Medicare benefits.

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

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 the NO line does not show, press [F2]
• PROVIDER field, key the provider number for recipient provider/ locum
• Go to Step 10
• No, go to Step 10

Key all the service details, in the:

• PATIENT field, key the patient's name
• ITEM field, key the item number (if service 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 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
• More details 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 if a gap statement is 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 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:
• 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
• Status: Completed, Pended
• Complete Reason: Request Rejected, 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]
• a 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]

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

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

In the EFT field, key T - EFT details keyed are temporary and used for this claim only.

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 claim been paid?

• Yes, if the bank account details have not been provided on the claim form:
• key 'N' - EFT details unavailable
• used if the claimant cannot provide bank account details at time of lodgement
• allows validation of the EFT details to be bypassed and claim assessment to continue
• Medicare benefit is held until bank account details are provided
• once provided, payment is automatically released overnight
• No, as the claim is unpaid:
• a cheque will be issued to the Business/Organisation
• bank details are not 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 the agency got 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 charge amount
• 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 Table 1 > Step 11
• 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
• More details can be 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, advise the customer to call back during business hours the following business day

If the customer identifies as at risk of family or 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 with a customer:

• add a Sensitive Information Indicator for Family and Domestic Violence in the CDMS in Personal

See also:

• Family and domestic violence
• Sensitive information indicators in the CDMS

Procedure ends here.

• Contact Local Peer Support (LPS)
• Service Officer must 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 may be a training benefit
• If the customer identifies as at risk of family or domestic violence:
• Add a Sensitive Information Indicator for an Urgent Medicare benefit paid in CDMS in Personal
• Add a Sensitive Information Indicator for Family and Domestic Violence

See also:

• Family and domestic violence
• Sensitive information indicators in the CDMS

Is the MS014 correct and complete?

• Yes, go to Step 2
• No,
• Write a comment in CDMS and PaNDA - Incomplete/incorrect details on the claim form, unable to contact customer. RHCA customer left country
• Complete work in PaNDA
• Procedure ends here

In CDMS:

• Select Amend Consumer Details link
• The Amendment Search screen will show
• Conduct a Customer search to identify the customer
• Select Group
• The Amend Medicare Card Details screen will show

• Select Card Requests tab
• Note the current Group eligibility end date (this is needed for Step 6 below)
• Amend the Group eligibility end date to the date that the claim is being processed

Once the date has been amended:

• Scroll down and select Validate [Alt+V]
• A message appears that states whether the requests were acceptable or not:
• Select OK to acknowledge the message
• If the requests were not acceptable, change the requests as required
• Scroll down and select Validate [Alt+V]
• The Confirm Amended Medicare Card Details screen shows the updated details
• Select Update [Alt+U]
• A message will appear with the details that have been changed. Select OK to close the message

Using the details on the claim form, in Mainframe:

• Key NPSI
• Key Medicare card number
• Press [Enter]
• Blank claimant identification fields will show
• See Table 1 > Step 2 to process the claim

Once completed, go to Step 6

Once the claim has been processed:

• The group eligibility end date must be changed back to the date noted in Step 3
• Go to Step 2 and follow process to amend group eligibility end date back to original date
• Procedure ends here

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'
• When 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 account/invoice
• 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 assess 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 locate the date the patient’s Medicare history was culled.

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

The cull history line shows the date the patient’s Medicare history was culled. This will show as CULL against the patient’s name and the date.

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

• If date of service is after the ‘Culled’ date in history, claim can be processed without reference to culled history
• If date of service is prior to the ‘Culled’ date in history, culled history should be retrieved from ‘SAS Information Delivery Portal’

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 messages GT-2YR and 6-REJ/PEND will show for claims with a date of service greater than 2 years ago.

• 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 Assessing Pathology claims
• Key 'P' to pay claim
• Warning messages must be actioned in order from left to right
• More details 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.

The Service Officer can process the claim where there is no evidence of a duplicate payment made after the cull history date.

Is the Service Officer skilled to process claims over 2 years old and have access to the 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
• Corresponding receipts (if needed)

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

Service Officers are required to have access to the SAS Portal.

Access the SAS Information Delivery Portal:

• Select Parameter Based Reporting
• Select Medicare Patient History
• Consumer Details- key the patient’s PIN minus the last letter
• 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
• 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.

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

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

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

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

Follow the prompts:

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

Confirming address:

• Check 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 used for this claim only:
• For example, a claimant requests a one-off EFT payment into a different bank account to the details stored. Claimant has marked this on the Medicare claim form
• P - EFT details keyed are permanently stored for this claimant. Use this to:
• overwrite any previously supplied banking details
• add new EFT details where none were previously supplied
• N - EFT details unavailable:
• used if the claimant cannot provide bank account details at time of lodgement
• allows validation of the EFT details to be bypassed and claim assessment to continue
• Medicare benefit is held until bank account details are provided
• once provided, payment is 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 the agency got the claim.

Keying claim details that have been previously paid

When services appear on SAS history report and there is no note to say 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 note to say 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
• More details 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
• process and pay claims between 2-5 years before escalating
• add a note to the work item in PaNDA to say 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.

Service Officers 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
• 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.

To get a patient’s PIN number:

• Key NHSI, Medicare Number, Patient Ref
• Press [F9] to get the PIN number of the patient
• Copy the patient's PIN number

Service Officers are required to have access to the SAS Portal - Medicare GT 5 Year.

Go to the SAS Information Delivery Portal:

• Select Medicare GT 5 Year
• Select MCGT5Y_Extraction_Request_IT (Note: the SAS Portal over 5 years has 2 selections, select the top one)

• Select New Patient Request
• Key PIN number minus the alpha
• Reference Date from (start of the calendar year for claims more than 7 years old)
• Reference Date to (end of calendar year, for claims more than 7 years old)
• 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.

It may take up to 3 weeks to access the culled history report. Culled history can only be viewed when the report is available.

Once the claims history report has been requested, the Service Officer must add a note to the work item stating the:

• report has been requested
• date range requested
• estimated available date

Take a snip of confirmation of request page and upload it to PaNDA. Save the snip to their team's Customer Information secure folder. The file name must include the Service Officer's logon ID, or P Number. For example: P11111.PaNDAWID

The Service Officer must 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 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_IT (Note: the SAS Portal over 5 years has 2 selections, select the top one)

To filter the reports:

• 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

If the report does not appear, check the date range. 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 are 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 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.

In the event the original requestor is unable to retrieve the report, another service officer can retrieve the report.

• Select Produce Report tab
• Select Request Search Type Requestor P# ID
• Search Text key P number or Login
• Request Date From key date requested
• Request Date To key date requested

In the event more than one report is returned, as the report will return all reports requested for that date, narrow your search to customers PIN and select Email Reports.

Note: save SAS report to their team's secure folder Customer Information under Staff member. The file name must include the Service Officer's logon ID, or P Number. For example: P11111.PaNDAWID.

• NPOI, Medicare card number
• Press [Enter]. See Table 1

Claims previously paid

Where services appear on SAS history report and there is no note to say 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 note to say a 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 claims 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
• More details 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'

Confirm from the SAS (culled history report) that the service(s) has not previously been paid.

Log on to Mainframe:

• Key:
• QITI
• item number
• date of service (DOS)
• if the service is in-patient add ‘M01H’ in the Table field
• Press [Enter]
• [F5] to display the schedule fee and benefit amount for the date of service

This screen also displays, Greatest Permissible Gap, Standard percent, Standard benefit, whether EMSN Cap applies, Maximum cap amount and the Safety Net threshold amounts.

Check all assessing rules in Qiti, and gender at DOS in CDMS.

Note: assessing rules may have changed from the date of service to the date of claim. Some assessing rules are not retroactive.

Determine if the claim has Safety Net benefit payment considerations.

Open CDMS and check if safety net balances. Are safety net balances available for the relevant year?

• Yes, this claim can be processed on Mainframe. See Table 10
• No, go to Step 4

Services Australia does not process Extended Medicare Safety Net payments for patients in previous years where they had not taken steps to register as a family. In cases where CDMS does not display the safety net threshold amounts, Services Australia are unable to calculate family level out of pocket (OOP) expenses. As a result, the calculation should consider the below assumptions:

• The claim will be assessed considering the patient eligibility for the individual general threshold only
• If SAS report indicates customer has received higher Medicare benefits, then:
• The EMSN calculation will be applied and an additional EMSN benefit paid to any new claims processed for that calendar year
• As service is over 7 years, the claim cannot be processed in Mainframe. A manual EFT is requested and comment is recorded in CDMS of payment amount. See Table 12
• If SAS indicates customer has not received higher Medicare benefits, Service Officer is to manually calculate the out of pocket (OOP) amounts on the SAS report for the relevant year. Take into consideration the OOP for the claim being processed. If the total OOP exceeds the general threshold amount as an individual, then:
• The EMSN calculation will be applied and an additional EMSN benefit paid
• As service is over 7 years, claim cannot be processed in Mainframe. A manual EFT is requested and comment is recorded in CDMS of payment amount. See Table 12
• If SAS indicates customer did not exceed general threshold as an individual, and current claim OOP does not exceed general threshold as an individual, then:
• Current claim over 7 years process followed – no additional EMSN payment required. Pay as per QITI for that date of service. See Table 12

• SAS indicates that the patient has received higher rebate: EMSN benefit to be paid for all non-duplicate claims processed, or
• the current claim takes the patient over the individual general threshold then the patient is eligible for EMSN benefits

This can be calculated as below.

Safety Net calculation example

Item, DOS and charge: 13200, 01 Jan 2015, $6000.00

General Safety Net threshold amount from QITI for the calendar year 2015 = $2000.00

Standard benefit (from QITI for DOS): $ 3032.35

OOP from this service = $ 6000 - $3032.35 = $2967.65

OOP after SafetyNet threshold for the year 2015 reached = $2967.65 – $2000.00 = $967.65

EMSN benefit to be paid @80% (with cap amount as per QITI $1675.50) = $967.65 * 0.8 = $774.12 (check for capping amount or %capping if applicable)

Total Benefit paid after all calculations = $3032.35 + $774.12 = $3806.50. (rounded to nearest 5 cent)

Amount to be entered on Z2261 and requested as manual EFT for this claim = $3806.50

• The following order is used in addition to the above equation when 2 or more patient’s claims have been received on the same day the EMSN threshold is reached

Patient DOB (oldest to youngest) - Paid/Unpaid account – DOS (earliest to latest) – Capped/Uncapped items.

See also, the Resources page in Extended Medicare Safety Net (EMSN). for examples on processing a patient claim for a multiple operation where the EMSN cap is less than 80% of out-of-pocket expenses.

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

Are valid bank account details stored?

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

If no banking details are stored:

• Contact the claimant and advise them the Medicare benefit will not be paid until bank account details (either temporary or permanent) are provided. See Store, confirm and end date bank account details for Medicare EFT payments
• If details are not provided, or contact is unsuccessful
• Return the claim documents to the claimant with the Z0828 standard letter template
• Complete the PaNDA work item. Leave notes in both CDMS and PaNDA

Complete the Your statement of Medicare Benefits template (Z2261). See Table 16.

Your statement of Medicare Benefits template (Z2261). See Table 16. As these claims cannot be keyed and paid in Mainframe, the manual statement of benefit must be completed with great care and attention to detail while calculating the benefits to be paid.

Save and attach a copy to the PaNDA work item.

Complete the statement of benefits table with the following details:

Addressee and Signatory tab

• Claimant’s 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 there are multiple services for the same health professional/patient, 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: charge amount for item as per the account/invoice
• SCH Fee: schedule fee for that item on that date of service
• Benefit: Medicare rebate for that item on date of service, including any assessing rules and modifiers as per QITI (for most of the claims this will be ‘standard benefit’ in QITI for the DOS)

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 also:

• Family registration and confirmation for Medicare Safety Net
• Medicare Safety Net thresholds
• Multiple operations assessing rules in Medicare
• Process Medicare Safety Net claims
• See resources page for examples : Extended Medicare Safety Net (EMSN)

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.

• 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, including:
• the total benefit amount for all the items that is automatically calculated
• an explanation of the reason codes
• Save a copy of the statement as a PDF, using 'Save As Adobe PDF':
• Select Yes on the pop-up
• Save the document to the Customer Information folder located on your team’s shared drive. Customer information must not be saved to desktops or personal H drives

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.

Save the completed Manual EFT payment Request form as a PDF as it is an interactive form:

• Select Print
• Change the Printer to 'Microsoft Print to PDF'
• Save the document to the Customer Information Folder located on your team’s shared drive and attach a copy to the PaNDA work item
• Add a comment in the claimant’s personal tab in CDMS under personal and in PaNDA including the manual EFT amount and the service details
• Send the work item for quality checking by selecting the ‘Send for Delegation’ button in PaNDA
• Once the work item has been quality checked and the manual EFT payment released to the claimant, the work will then be returned to the originating PaNDA folder with the remittance advice and allocated to the next available Service Officer. The Service Officer is to print and post both the manual Statement of Benefit and the remittance advice and mark the PaNDA work item as complete

• Check the claim has been completed correctly
• Confirm the details keyed on the Manual EFT Payment Request form are correct and match the statement of benefit
• Check the Manual Statement of Benefit has been completed and is correct
• Check the benefit amounts are the same on both the Manual EFT Payment Request form and the Manual Statement of Benefit
• Check comments were added in both CDMS and PaNDA
• If errors are identified, correct the errors and submit feedback via the Staff Feedback Tool
• Add a comment to PaNDA advising the work has been quality checked
• Recategorise the PaNDA work item to Medicare Payments MC_SDST

Manual EFT payment requests are received in Medicare Payments MC SDST PaNDA.

Add the request to both the Vendor Bulk Upload and Payment Run templates.

Refer to resources tab on how to complete these.

To obtain a vendor maintenance number:

• Forward the vendor request template from the Medicare Customer email box
• Use subject heading ‘Patient claim payments - Vendor requests - Medicare Customer Services’ - PNTC
• Send to the Accounting Operations (AO) team

The AO team will create a new vendor maintenance number.

Add the allocated vendor number to the Vendor Request spreadsheet.

Access the Payment Run Request Template.

Update the following:

• Copy the claimant’s name and paste to column N ‘Line Item Text’
• Copy the vendor number from the allocated vendor number to column A ‘Vendor’

Once the templates have been completed:

• Add the total amount of benefits to be paid onto the Payment Run Request template
• Save the email from the AO team, the newly created Vendor Bulk Upload template and the Payment Run template into a new email.
• Email the template to the appropriate delegate from the Medicare Customer Services email box with the following details:
• Subject: Patient Claim Payments - Manual EFT Payment Run - Medicare Customer PNTC
• 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 templates to the Accounting Operations (AO) team.

Use the following details:

• Subject: Patient Claim Payments - Manual EFT Payment Run - Medicare Customer - PNTC
• 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 the remittance advice once payment has been processed and released to the RBA.

Once confirmation of the payment has been received:

• Upload a copy of the remittance advice to the PaNDA work item
• Add a processing note advising that the Manual EFT Payment has been made to the claimant e.g. Manual EFT Payment has been released. Post both the uploaded remittance advice and the manual Statement of Benefit to the claimant and finalise work item
• Recategorise the PaNDA work item back to the originating PaNDA folder

• 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 done or the claim is for an amount over $9,999.00, duplicate statements cannot be issued. See Table 16 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 will show

Does the statement have 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 same 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 correct 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.

To print:

• In control line, over key '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 show and the Service Officer must press [Ctrl] + [Alt] + [P].

Check details of the services to be included in the manual Statement of Benefit (Z2261):

• NHSI,Medicare number,patient name or IRN,DOS/DDMMYY check date of processing (DOP) for each claim to be included on the manual Statement of Benefit
• 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 Patient History (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.

To prepare a manual Statement of Benefits:

• 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 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. This must be sent with an Unable to transmit two-way claim letter (Z3112). See Medicare Two-way 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:

• Key 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, 104, 225 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
• Key the item numbers in the exact order as they appear in NHSI
• 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 of Benefit
• For a service over $9,999.99, do not key the 0000 line. The total charge for the service as shown on the invoice and the relevant item number should be included in the statement, as one line
• Outpatient: the total charge for the service and the relevant item number(s) should be included in the statement. Key the 0000 line with the charge as $0.00 and the schedule fee as $0.00. Key the total amount of the Manual EFT payment in the benefit field. Key reason code 255: Patient contribution substantiated-additional benefit paid
• 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 $9,999.99) for Medicare patient claims.

The reason code usually shows in Mainframe. However, if an adjustment has been made where the MOR or MSR rule(s) have been applied, the original code will not show. The Service Officer must 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 because:

• 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.

Note: save the document to the Customer Information folder located on the team’s shared drive. Customer information must not be saved to desktops or personal H drives.

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 Preparing, quality and peer to peer checking of Medicare external mail.

Service Officers in service centres

Service Officers in service centres must follow their branch’s quality assurance process before handing out the manual Statement of Benefit to the customer.

See Preparing, quality and peer to peer checking of Medicare external mail.

Service Officers must upload a copy of the manual Statement of Benefit and attach it to the PaNDA work item.

Add a processing comment in PaNDA.

Add a note:

• selecting Comments tab in Personal
• record 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."