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Account and receipt documents for Medicare claims processing 011-43010030

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This page contains details on how to process account and receipt documents for Medicare processing.

On this page:

Certify a copy of account/invoice documents

Record correct referral details where they have been obtained

Single service on account/invoice or receipt

Processing multiple services or multiple accounts/invoices or receipts

Processing an account/invoice with a non-referred service

Processing an account/invoice where service cannot be verified as non-referred

Processing of unconditional discounts or paid conditions discounts

Processing accounts/invoices with miscellaneous items

Accounts/invoices and receipts requiring additional information

Certify a copy of account/invoice documents

Table 1: this table describes how to certify a copy of account/invoice documents when returning the originals.

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Step

Action

1

Photocopy original account/invoice documents

Photocopy the original account/invoice documents.

2

Endorse the photocopy

Use the following notations to endorse the photocopy:

  • Date stamp the copy
  • Signature and logon ID
  • All of the following words:
    • benefit paid
    • this is a true copy of the original document
    • original documents returned to claimant after photocopying
    • benefit paid (if the claim is processed in the service centre before returning to the claimant)

Record correct referral details where they have been obtained

Table 2: this table describes how to record the correct referral details where they are obtained on the account/invoice. Note: this process is mandatory.

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Step

Action

1

Record referral details

Request an amended account/invoice to be faxed from the surgery, or record a processing note by:

  • filling out a VG4 form (face to face services), or
  • making a processing note on the PaNDA file and placing a comment in CDMS personal

The Resources page contains a link to the VG4 form.

2

Process claim

Process the claim.


Single service on account/invoice or receipt

Table 3: this table describes how to action a claim where the referral details cannot be obtained and the claim is for a single service. See also: Services not claimable for Medicare benefits section in Account/invoice documents.

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Step

Action

1

Claimant present in a service centre

Is the claimant present in the service centre?

  • Yes, go to Step 2
  • No, contact the claimant using the Z0828 - Medicare claim needs more information letter

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

2

Claimant present in service centre

Advise the claimant that:

  • the referring health professional details are incorrect, invalid, or missing and in order to process the claim, there must be a valid referral
  • an attempt to contact the health professional's surgery has been made to get the details, but was unsuccessful

Return the claim to the claimant and ask them to seek correct referral details from their health professional.


Processing multiple services or multiple accounts/invoices or receipts

Table 4: this table outlines different scenarios and instructions for processing multiple services or multiple account/invoice receipts claims.

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Item

Description

1

Claim is for multiple services and has 1 account/invoice or receipt

Service Officers must:

  • reject the services that require a valid referral with the appropriate reason code
  • process all other services as usual
  • contact the claimant using the Z0828 - Medicare claim needs more information letter

See also: Certify a copy of account/invoice documents.

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

2

Claim is for multiple account/invoice or receipts and has a single claim form

Service Officers must:

  • attach the claim form to the accounts/invoices or receipts that were processed
  • photocopy or print the account/invoice, notate it is a copy and return the accounts/invoices or receipts that require a valid referral to the claimant with the appropriate letter and a blank Medicare Claim form (MS014)

See also: Certify a copy of account/invoice documents.

The Resources page contains a link to the Standard Letter Templates.

3

Claim is for multiple accounts/invoices or receipts and has multiple services on each account/invoice or receipt

Service Officers must:

  • reject the services that require a valid referral with the appropriate reason code
  • process all other services as usual
  • photocopy or print the accounts/invoices that were not processed, notate that it is a scanned copy and return to the claimant with the appropriate standard letter and a blank Medicare Claim form (MS014)

See also: Certify a copy of account/invoices documents.

The Resources page contains a link to the Standard Letter Templates.


Processing an account/invoice with a non-referred service

Table 5: this table describes how to process a non-referred service that is submitted using a referred item number.

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Step

Action

1

2

3


Processing an account/invoice where service cannot be verified as non-referred

Table 6: this table describes how to action an account/invoice where the health professional cannot be contacted or cannot verify the service was non-referred.

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Step

Action

1

2

3


Processing of unconditional discounts or paid conditions discounts

Table 7: this table describes how to process accounts/invoices with unconditional discounts or paid conditional discounts.

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Step

Action

1

Discount conditional or unconditional

If the discount is:

2

Conditional discount (specified amount and percentage of total charge)

Subtract the discounted amount from the total charge.

Raise the discounted amount as a notional charge.

Example: an account/invoice states that a $150 discount applies if payment is made before a specified date. If the total charge is $3,085 for a number of services and the account/invoice has been paid by the required date, the discounted amount of $2,935 becomes the notional charge.

3

Unconditional discount (Medicare benefit is accepted as full payment)

Process the claim by either:

  • changing the charge for each item to match the benefit after initially entering the claim onto the system
  • after initially keying the claim details onto the system, add the benefits for all items together and use the end figure as a notional charge

Note: unconditional discounts only apply to out-of-hospital services.


Processing accounts/invoices with miscellaneous items

Table 8: this table describes how to process an account/invoice or receipt submitted for payment of a Medicare benefit and there is a miscellaneous item listed.

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Step

Action

1

Determine item type

If there is:

  • only a miscellaneous item listed, go to Step 2
  • a valid Medicare Benefits Schedule (MBS) item and a miscellaneous items, go to Step 3
  • a notional charge present (including a service or goods that does not attract a Medicare benefit), see the Background page for details about notional charges

2

Only a miscellaneous item listed

If the claimant is:

  • at a service centre:
    • return the account/invoice or receipt to the claimant
    • tell the claimant that no Medicare benefits are payable
  • not present at a service centre, no benefits are payable. Notify the claimant using the Z0829 - Your claim for Medicare Benefit - not paid/already paid/paid-partially letter.

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

3

Valid Medicare Benefits Schedule (MBS) item and a miscellaneous item

Is the claimant present?

  • Yes:
    • process the valid MBS item(s)
    • ask the claimant if a copy is required. If so, photocopy the account/invoice or receipt and stamp 'Medicare rebate paid'. If not, endorse the back of the account/invoice 'copy not required'
  • No:
    • process the valid MBS item(s)
    • notify the claimant, use the Z0829 - Your claim for Medicare Benefit - not paid/already paid/paid-partially letter

See also: Certify a copy of account/invoice documents.

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


Accounts/invoices and receipts requiring additional information

Table 9: this table describes the process where an account/invoice or receipt submitted needs more details.

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Step

Action

1

Determine claim type

2

Manual patient claim

Attempt to contact the health professional, request either:

  • a faxed amended account/invoice, or
  • the required details over the phone and complete processing notes verifying information

Record a processing note by:

  • filling out a VG4 form (face to face services), or
  • making a processing note on the PaNDA file and placing a comment in CDMS personal

If contact cannot be made with the health professional, contact the claimant using the Z0828 - Medicare claim needs more information letter.

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

Note: copies of letters must be uploaded into PaNDA. See Preparing, quality and peer to peer checking of Medicare external mail.

3

Digital self-service claim

Attempt to contact the health professional to request the details over the phone.

If the contact was:

  • Successful:
    • Process the claim and record a processing note on the PaNDA work item
  • Unsuccessful:
    • Reject the claim
    • Use reason code 454 (resubmit claim for service - some details not shown on image)
    • Record a processing note in the comments tab of CDMS personal

Note: if the account/invoice or receipt was not submitted, reject the claim with reason code 455 (resubmit claim for this service - include account and receipt).