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Patient claim requirements for payment of Medicare benefits 011-43010040

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This document outlines information a claimant must provide to receive Medicare benefits. Note: as of 1 July 2016, Norfolk Island is covered under Medicare provisions.

On this page:

Patient claims using a previously issued card number - for service centre staff

Process a patient claim lodged at a service centre

Process a patient claim using previously issued card number received by mail

Process a patient claim using previously issued card number received online

Process unpaid cheque Pay Doctor via claimant (PDVC) claims using a previously issued card number

Creating a Consumer ID for not eligible claimant, cost for eligible patient

Patient claims using a previously issued card number - for service centre staff

Table 1

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Step

Action

1

Confirm claimant was issued with a new Medicare card

Access CDMS to check if a new card has been issued and confirm with the claimant if they have received the current issue card (this card must be used if in the possession of the claimant).

If the claimant has:

2

Confirm identification and reissue Medicare card
  • Sight identification
  • Establish Medicare eligibility
  • Amend any enrolment details
  • Reissue a Medicare card if the card has been issued to incorrect address or over 21 days and not received (supply the claimant with a printed receipt from the office printer), go to Step 4

See also: Medicare cards

3

Sight identification

Sight identification and confirm with claimant that the submitted account has been paid.

4

Pay the claim

Pay the claim using the current card issue number.


Process a patient claim lodged at a service centre

Table 2

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Step

Action

1

Confirm and identify claimant
  • Confirm with the customer that they are the claimant
  • Key NPBI, (patient) card number and press [Enter], or swipe the patient's Medicare card
  • Identify claimant (1-ID CLMT). Press [Enter]

2

Claimant's address

Confirm and validate claimant's address (8 -ADDR CHK).

3

Check bank details

Check bank details (6-CHK EFT) by:

  • (C) confirming details automatically displayed from the CDMS, or
  • keying bank account details on the processing screen as supplied from the claimant
  • update EFT field with:
    • C - Confirm
    • P - Permanent
    • T - Temporary
    • U - Unstated
    • N - no EFT

Note: where no EFT details are stored in CDMS for the claimant and the claimant does not supply EFT details the payment will be held due to no EFT details provided.

4

Statement request

Statement request STM is displayed for all EFT claims - (6-EFT STM):

Key 'R' in the STM field to print customer copy and office copy for customer to sign.

5

Key claim details

Key claim details and press [Enter]

6

Return messages

Are there any return messages that require action?

  • Yes, review and apply assessing restrictions by following return messages.
    Return messages must be actioned in order from left to right and further explanations can be viewed by placing the cursor at the beginning of the return message and pressing [F1]. Go to Step 7
  • No, press (P) to Pay claim. Go to Step 7

7

Print statement

Print a statement of benefit receipt for the claimant to sign:

  • Ask the claimant to verify account details and BSB number by circling the information on the statement and sign the office copy of the statement of benefit
  • Where no EFT details are stored in CDMS for the claimant and the claimant does not supply EFT details, the Service Officer must circle the declaration on the statement, explain to the claimant that the claim has been completed and the Medicare Benefit will not be paid until a valid bank account is provided. Ask the claimant to sign the office copy of the statement of benefit
  • Give the customer statement of benefits receipt
  • Attach the office copy to the documents being retained

Note: once valid bank account details have been provided in CDMS the payment will automatically be released.


Process a patient claim using previously issued card number received by mail

Table 3

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Step

Action

1

Check card issue details

Access CDMS and check card issue details.

2

Current card issue number in circulation

Is there a current card issue number in circulation that is less than 12 months old (issued in the last 12 months)?

3

EFT details on claim form

Have electronic funds transfer (EFT) details been provided on the claim form?

4

EFT details match CDMS details

Do the EFT details provided match those in the CDMS?

  • Yes, pay the claim via EFT using the current card issue number
  • No, go to Step 6

5

EFT details stored in CDMS

Are EFT details stored in CDMS?

  • Yes, pay the claims via EFT using the current card issue number
  • No, go to Step 8

6

Attempt to contact the claimant to verify the details

Can the claimant be contacted?

7

Confirm EFT details

Can the EFT details be confirmed?

  • Yes, pay the claim via EFT using the current card issue number
  • No, go to Step 8

8

Pay the claim

Pay the claim via:

  • update EFT field with ‘N’ - no EFT
  • finalise claim process as usual

Note: where the claimant does not have valid EFT details stored or did not provide valid EFT details the payment for the claim will be ‘HELD’ until EFT details have been provided.

9

Return claim to claimant

Contact the customer 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.


Process a patient claim using previously issued card number received online

Table 4

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Step

Action

1

Check card issue details

Access CDMS and check card issue details.

2

Current card issue number in circulation

Is there a current card issue number in circulation that is less than 12 months old (issued in the last 12 months)?

3

EFT details stored in CDMS

Are electronic funds transfer (EFT) details stored in CDMS?

  • Yes, pay the claims via EFT using the current card issue number
  • No, go to Step 4

4

Pay the claim

Pay the claim via:

  • update EFT field with ‘N’ - no EFT
  • finalise claim process as usual

Note: where the claimant does not have valid EFT details stored or did not provide valid EFT details the payment for the claim will be ‘HELD’ until EFT details have been provided.

5

Return claim to claimant

Contact the customer 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.


Process unpaid cheque Pay Doctor via claimant (PDVC) claims using a previously issued card number

Table 5:

Note: these claims should be processed using a PI indicator or reason code.

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Step

Action

1

Check CDMS for current card issue number

Check CDMS to see if there is a current card issue number in circulation.

2

Age of current card in circulation

Is there a current card issue number in circulation that is:

3

Less than 12 months old

Pay the claim using current card issue number.

Note: claims must not be paid if the previously issued card number has been reported as lost or stolen and should be returned with the appropriate letter.

The Resources page contains a link to letters and electronic messaging.

4

More than 12 months old

Contact the customer 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.


Creating a Consumer ID for not eligible claimant, cost for eligible patient

Table 6: this table describes how to create a consumer ID in CDMS to allow a claimant to receive a Medicare benefit if the claimant is not eligible for Medicare enrolment.

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Step

Action

1

New customer registration

Log on to CDMS. For assistance on accessing CDMS, see Consumer Directory Maintenance System (CDMS) for Medicare

  • select Register New Consumer on the CDMS Home page, the Registration Type screen is displayed
  • select New Consumer, the Search for Consumer (Register) screen is displayed

2

Search for customer

Key name search details as follows:

  • Family Name
  • Gender
  • Date of Birth
  • Leave Postcode field as default, such as 0001-9999. Do not remove
  • Select Search

Note: if the person being enrolled is greater than 12 months of age a Warning Message (01875) is displayed. Follow the instructions in the Warning Message.

To continue with the search for an existing record in CDMS, select Yes.

3

Determine possible matches to customer search

Have possible matches been found?

  • Yes, customer has:
    • been previously registered, select the customer and select Add to list, go to Step 5
    • not previously registered, go to Step 4
  • No, a message displays indicating that no records were found. Select OK to acknowledge the message. Go to Step 4.

4

Record customer details

Select New Consumer. The Record New Consumer screen is displayed. The personal details are populated with any search details previously entered.

Key or select the following details for the customer:

  • External ID (the external agency ID number of the customer)
  • External ID type (currently only Hospital Reference Number available)
  • Issuing Party (the organisation that issued the external ID)
  • Title
  • Only Name Indicator (select if the person is registering with only one name)
  • Second Name
  • Name suffix
  • Birth Date (mandatory)
  • Birth Date Accuracy (mandatory)
  • Multiple Birth Indicator (select if customer is part of a multiple birth)
  • Language spoken at home
  • Aboriginal or Torres Strait Islander Status (mandatory)

5

Record customer mailing address details

Select Address tab.

Key or select the following mailing address details:

  • Address (mandatory)
  • Locality
  • Postcode
  • State
  • Country (mandatory)

Note: both the mailing and residential address must be an Australian address.

Are the residential and mailing addresses the same?

  • Yes, select the Residential Address Indicator checkbox. Go to Step 6.
  • No, key the residential address details in the Residential Address fields. Go to Step 6.

6

Record customer's contact details

Select Contact details tab.

Key the customer's contact details that are available:

  • Business Phone Number - any comments about the business phone number (Business Comment)
  • Home Phone Number - any comments about the home phone number (Home Comment), for example, 'Only to be used between 5.00 pm and 7.00pm'

Note: key phone numbers without any spacing, for example, 0261234567.

7

Record comments for customer detail
  • Select Comments tab. Note: for registration at consumer ID level only, Service Officers must enter a reason in the Comment field
  • Select Validate (Alt+V)

Note: if any of the details are invalid, a message indicates which details are missing or invalid. Correct or enter these details as required.

8

Confirm customer registration details

When the details are correct, the Confirm New Consumer Details screen displays.

Select either:

  • Update (Alt+U) to confirm the details displayed. When Update is selected a message displays confirming that a customer record has been created. Select OK to acknowledge the message
  • Change (Alt+U) to amend the details, as required

The Registration Type screen is displayed with the customer’s details and consumer ID.

Record the consumer ID to use in Mainframe for claimant field.