Patient claims processing in Medicare 011-43010000

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Medicare > Public > Claims

Service Officers can start the following letter from CDMS or DMC. See Digital Messaging Capability (DMC) - Health to create and send letters.

Z0828 - Medicare claim needs more information
Z2261 - Your statement of Medicare benefits

Contact details

Medicare Claims and Assessment

Cash Management section

Medicare claims helpdesk

Medicare EFT manual payments

Medicare and Aged Care - Local Peer Support (LPS)

Services Australia website

Medicare claims

Multiple processing rules and adjacent statement of benefit reason (RSN) codes

Table 1

Reason Code (RSN)	Statement reason	Corresponding Mainframe column	Mainframe reason codes	Mainframe rule applied
104	Balance of benefit due to claimant
105	Benefit paid to provider as requested
154	Diagnostic Imaging Multiple Service Rule (DIMSR) applied to service	DIMS	All DIMS	DIMSR has been applied
225	Patient contribution substantiated additional benefit paid
241	Total charge and benefit for multiple procedure	MO	A	MOP rule A has been applied
242	Service is part of a multiple procedure	MO	B or C	MOP rule B or MOP rule C has been applied
440	Multiple Echocardiogram Services rule applied	ME	All ME	MESR rule has been applied
441	Multiple Echocardiogram and DI Services rule apply	ME, DIMS	Any combination of ME and DIMS	MESR and DIMSR rules have been applied
512	Multiple Musculoskeletal MRI Service rule applied	MMRI	All MMRI	MMRISR rule has been applied
513	Multiple Musculoskeletal MRI and DI Services rule applied	MMRI, DIMS	Any combination of MMRI and DIMS	MMRISR and DIMSR rules have been applied
564	Multiple Vascular Ultrasound Service rule applied	VU	All VU	MVUSSR rule has been applied
565	Multiple DI and Vascular Ultrasound rules applied	DIMS, VU	Any combination of DIMS and VU	DIMSR and MVUSSR rules have been applied

Control lines for processing patient claims

Table 2: control lines for processing patient claims in Mainframe. Search the list using Ctrl+F.

Control line	Topic	Function
MQAI	Online PC or BB	Online patient claims or bulk bill claims lodged by the health professional
NABI	Patient claims electronic funds transfer (EFT) reversal	Returns all failed EFT payments with a status of REJECT: NABI,card number,DOP/ddmmyy NABI,card number,DOP/ddmmyy,time/hhmmss
NAOI	Same day adjustment	Used to do the same day reversal of claims. Returns up to 10 item lines processed on the day. SDL to delete SDR to reverse NAOI,cardnumber
NAQI	Cheque cancellation enquiry	Cheque reversal
NASI	Same day adjustment	Same day reversal supervisor screen
NCHI	History enquiry	Used to recall culled history lines
NDCI	Statement enquiry	Supervisor duplicate statement screen
NDFI	Statement of benefit	Request statement of benefit for same day claim NDFI,card number
NDSI	Statement enquiry	Duplicate statement screen. Issue duplicate statement. DDMMYY is DOP. P to request print, or M to print manually. NDSI,card number,ddmmy NDSI,card number,ddmmyy,<modifier> PROV CASH CLAIMANT HOSP BANK EFTPOS
NEBI	PC Electronic Pend	Browse mode
NEPI	PC Electronic Pend	Displays a claim according to the modifier: NEPI,card number,ddmmyy,mmhhss,seq no NEPI,claim ID,seq no
NERI	PC Electronic same day reversal	Used with modifiers: NERI,card number - one record only NERI,card number,ddmmyy,mmhhss,seq no - More than one record NERI,claim ID,seq no - More than one record
NESI	PC Electronic Pend	Payment claims supervisor access
NHCI	History enquiry	Supervisor restricted access
NHDI	Latter day adjustment	Same Day delete transaction
NHHI	Latter day adjustment	Suppress and transfer
NHOI	History enquiry	Used with modifier - up to the last 6 months
NHRI	Latter day adjustment	History recall transaction
NHSI	History enquiry	Supervisor access - up to 2 full years history
NPBI	Claims payments	EFT mode
NPDI	Pend	Delete pended claims or view operator that pended the claim. NPDI,card number
NPEI	Pend	Delete pend screen
NPFI	Claims payments	Full-format Medical claims payment screen
NPID	Pend	Re-pend by investigations
MPII	Pend	Returns a full-format screen for investigations
NPND	Pend	Pend claims according to the modifiers: NPND,RSN - over key NPOC or NPFC with NPND and RSN, then press [Enter] to pend the entire claim with the reason code NPND,card number - over key NPOC or NPFC with NPND, then press [Enter] to pend the entire claims screen
NPOI	Claims payments	payment screen NPOI,card number
NPRI	Pend	Recalls item lines that have been pended. NPRI,card number NPRI,card number,<modifier> OPER/NNNNN DATE/DDMMYY OPER/NNNNN,DATE/DDMMYY CLNO/(1.9 ALPHANUM) SORC/AAAA BANK CHQ CASH EFTPOS DOL DOP
NPSI	Claims payments/Statement enquiry	Full-format Medical claims payment screen - Supervisor only
NQAI	PC Electronic Claiming	Browse mode
NQEI	PC Electronic Claiming	Action mode Review online claim NQEI,Claim ID,Oper/P number,DOP/DDMMYY Review online claims - F11 on column to sort NQEI,claim ID,SORC/source code,paid Same day reversal of Online claims NQEI,claim id,card number - (type R to select, then R. Claim ID is DA for Provider Online claims, HC for MOA claims and AC for APP claims)
N-R	Claims payments	Use R on the end of a control line after payment to recall the same card
NSCI	Substantiation	Substantiate patient contribution screen
NSQD	Cheque cancellation enquiry	Online transaction which produces an offline job
NSVI	Substantiation	Substantiation of claims - requested by Supervisor

Control lines for processing cheque enquiries

Table 3: control lines for processing cheque enquiries in Mainframe. Search the list using Ctrl+F.

Control line	Topic	Function
BATI	Cheque enquiry	Used to get Medicare number BATI,NB?R,cheque number Replace ? with state of issue
BBCI	Cheque status enquiry	Cheque information screen - check status or STOP a cheque with S or lift a STOP with L (same day only) BBCI,NB?R,cheque number Replace ? with state of issue
BBEI	Cheque enquiry	Cheque enquiry screen BBEI,card number
BILI	Stop Cheque Status	Check a STOP cheque status BILI,NB?R,STOP Replace ? with state of issue

Control lines for general processing and enquiries

Table 4: control lines for general processing and enquiries in Mainframe. Search the list using Ctrl+F.

Control line	Topic	Function
BRNA	EFT details	Check or change EFT details
CESN and CESF	Mainframe	Login/Logout
EPCI	Postcodes/locations	Returns locations with that postcode EPCI,postcode Returns locations with the postcode EPCI,locale,state initial
FPGI	Provider enquiry	Shows all doctors for that provider group
FPRX	Provider exemption file	Updates and holds the details of providers eligible for either remove area or grandparent exemptions
FPVI	Provider enquiry	Shows provider details
FRSI	Source Office Enquiry	Used to define and display source office code details: FRSI,source code
INSERT	Mainframe	Use to insert into a control line
MCDS	Report	Online claims processing report
MQSI	Supervisor screen	Supervisor screen for online claims processing
OPOQ	Mainframe	Used to login to source office code OPOQ,source code
PAGE UP	Mainframe	Use to change screens on Mainframe
PHEB	Two way claim	Process a Two-way claim - [F3] to transmit
QITI	Item enquiry	Medicare item details QITI,item,DOS
QPLI	Provider enquiry	Accesses the qualification file for provider classifications
QPRX	Provider exemption file	Provider exemption file enquiry screen
QPVI	Provider enquiry	Displays details for the provider requested. Can be used with search key if the provider number is not known QPVI,State code 4 letters of last name First initial of name First three letters of the street name
QVRE	Provider enquiry	Vocationally registered provider enquiry screen
QVRL	Provider enquiry	Vocationally registered provider listing screen
RHMI	Header mode	Display in header mode: RHMI,OFF - Exit from header mode RHMI,ON - Access header mode
ROMI	Claims list	List all claims submitted that day

Control lines for common patient history searches

Table 5: control lines for common patient history searches in Mainframe. Search the list using Ctrl+F.

Control line	Topic	Function
NHSI,Card No,Patient Name	View history	View Claims History, [F9] to get PIN number
NHSI,Card No,patient,DENT/ALL	CDBS	For all CDBS Items
NHSI,Card No,patient,DENT	CDBS Caps	Shows cap amount, benefit paid and remaining balance
NHSI,Card No,patient,DENT/YY	CDBS eligibility period	YY for year of enquiry, 2 years of eligibility period info
NHSI,Card No,PEND/ONLY	Pends	Lists all Pended claims under the Card
NHSI,Card No	Safety Net	F6 for EGSN and SHIFT F6 for MSN and shows verified/unverified amounts for individuals
NSCI,Card No	Safety Net	Substantiation for current year
NSCI,Card No,to/3112YY	Safety Net	Substantiation for previous year
NLTI,Card No,YY	Safety Net	Individual Safety Net eligibility

Patient claim history (NHSI/NHOI) shortcut keys

Table 6

Key	Function
F1	Help screen
F2	Claim ID and operator number
SHIFT+F2	Claim type PCM -Manual Claim PCO - Online or Easyclaim lodged by provider PCW - Webclaim APP - Online claim through the APP D* - Bulk Bill Claims V* - Veterans' claims SB* - Simplified Billing claims MOA - Online claim through MyGov '*' will have additional letter e.g. 'E' for electronic claim
SHIFT+F1	Provider classification
F3/ESC Key	Exit/clear screen
F4	Schedule fee, Office source code
SHIFT+F4	Processing Rule applied
F6	Substantiation and EMSN details
SHIFT+F6	OMSN details
F7	Page backward
F8	Page forwards
F9	PIN number
F10	CHQ/EFT details
F11	Specimen Collection Point (SCP)
SHIFT+F11	Location specific practice number (LSPN)
F12	Cancel

GPO box capital city postcodes

Table 7

Postcode	City	State
0801	Darwin	NT
2001	Sydney	NSW
2601	Canberra	ACT
3001	Melbourne	VIC
4001	Brisbane	QLD
5001	Adelaide	SA
6000	Perth	WA
7001	Hobart	TAS

Date of service more than 2 years old

Table 8: categorising patient claims over 2 years old from the date of services.

Patient claim…

Action

over 2 years old (including over 5 years old)

If lodged manually at a service centre, scan into PaNDA:

Program: Patient Claims
Work Type: Patient Claim
Primary Index: MEDICARE CARD NUMBER
Secondary Index: SURNAMEFIRSTNAME

Claim is in PaNDA and cannot process the claim. Claims with date of service:

2-5 years - re-categorise into PC_CLAIM_2TO5YEARS category for assessment
over 5 years - re-categorise to the PC_PCLL5 (claims over 5 years) category for assessment

How to update vendor request spreadsheet for creation of MBS vendors

Table 9

Column ID	Name of Field	Details
A	VENDOR FIELD	Leave blank, this will be completed by the Accounting Operations (AO) team
B	NAME 1	Key name of recipient Maximum 35 characters (no titles for example Mr)
C	NAME 2	Leave blank
D	SEARCH TERM	Usually Medicare number No spaces Maximum 10 characters
E	SEARCH TERM 2	Leave blank
F	ADDRESS 1	Key address of recipient (symbols accepted) Maximum 35 characters Must contain number/name and type for example, Road, Crescent, Place Abbreviations are accepted (for example Rd) Include PO box if relevant
G	ADDRESS 2	Leave blank
H	POST CODE	Set column to Text 4 numbers only (include PO box if relevant)
I	CITY	Key suburb or town (include PO box if relevant) No symbols (only name), maximum 35 characters
J	STATE	Key state in capitals Maximum 3 characters
K	K -PO BOX	Leave blank
L	PO BOX POST CODE	Leave blank
M	PO BOX CITY	Leave blank
N	PO BOX STATE	Leave blank
O	EMAIL	Leave blank
P	COMMUNICATION METHOD	Leave blank
Q	1ST TELEPHONE	Leave blank
R	1ST FAX	Leave blank
S	AUTH GROUP	Leave blank
T	ABN	Leave blank
U	BANK COUNTRY	Key 'AU.' Two characters allowed
V	BSB	Set column to Text Key 6 digit number only No spaces
W	BANK A/C NUMBER	Set column to Text key numbers only Maximum 18 characters No spaces
X	A/C NAME	Key name No titles or symbols Spaces allowed Maximum 50 characters
Y	PMT TERMS	Set column to Text Key'0001' 4 numbers allowed
Z	PMT METHOD	Key 'J' (direct deposit only for upload payments) One character allowed
AA	A/C GROUP	Key 'MBS1'
AB	SHORT KEY HSE BANK	Key 'ADMIN'
AC	GL RECO A/C	Set column to Text Key '21101' 10 characters allowed
AD	SORTING KEY	Key '001'
AE	PLANNING GROUP	Key 'VANSN'
All Remaining		Leave blank

How to update payment run request spreadsheet for creation of MBS payments

Table 10

Column ID	Name of Field	Details
A	VENDOR FIELD	Key customer's name
B	INV DATE	Date the template is being completed Must be in the format DD.MM.YY No hyphens or slashes
C	HEADER TEXT	Patient Claims: PC/SOURCE OFFICE CODE OPERATOR NUMBER EG PC/ABCD12345 Where ABCD is the office code and 12345 is the operator number (do not include P from operator number) Bulk Bill Claims: BB/SOURCE OFFICE CODE OPERATOR NUMBER EG BB/ABCD12345
D	REFERENCE	MCAREBENEFITS
E	GL ACCOUNT	51201
F	COST CTR	Cost Centre allocated to the Service Officer's state NSW - N1511 VIC - V1511 QLD - Q1500 SA - S1511 TAS - S1511 WA - W0279
G		Leave blank
H	TAX CODE	P5 for GST free services
I	ORDER	Leave blank
J	QTY	Leave blank
K	QTY UNIT	Leave blank
L	AMT	The total benefit amount to be paid to recipient, example 37.05 Only a full stop (.) can be used, no other symbols are accepted, for example ($)
M	BLINE DATE	Leave blank
N	LINE ITEM TEXT	MEDICARE PCM for Patient Claims Payments MEDICARE BB for Bulk Bill Payments

Forms

Manual EFT Payment Request form (PP048)

Medicare Claim form (MS014)

Provider registration for Electronic Funds Transfer payments form (HW029)

Do not share these attachments externally. See Freedom of Information - Information Publication Scheme.
Use 'Save As' workaround to download/use attachments.

VG4 form

Medicare Claims Enquires Escalation form

Medicare Claims File Fix Escalation form

Manual EFT payment request form

Manual Cheque Request form

Operational Information

Patient claims processing in Medicare 011-43010000