Incomplete or incorrect Medicare claims forms 011-43010050

Where a Medicare Claim form (MS014) is submitted and it is incomplete or incorrect details have been supplied, Service Officers must adhere to the policy and procedures detailed in this document.

A claim form is considered incomplete if:

• claimant or patient cannot be uniquely identified and the Medicare number is missing or incorrect on the claim form
• claimant details not provided
• claimant signature is missing

A claim form is considered incorrect if:

• patient is not enrolled on the Medicare number quoted
• claimant signature provided is in wrong section

The Process page contains steps to follow when a Medicare form is incomplete or incorrect

Where a Medicare claim form (MS014) is submitted and is either incomplete or incorrect details have been supplied the Service Officer needs to contact the claimant to process the claim. Service Officers must attempt to contact the claimant at least once to get the necessary information in order to process the claim.

The Process page provides situations where a claimant must be contacted for incomplete or incorrect forms submitted.

If the claimant is unable to be contacted by phone, or the required information is unable to be obtained, the claim must be sent back to the claimant accompanied by the appropriate standard letter. Claimant details such as their postal address, phone number, EFT details and organ donor registration must be recorded before sending the claim back to the claimant. Note: Service Officers must not update any details if the claimant has not signed the Medicare claim form.

Service Officers must make sure that a copy of the MS014 form, invoice and Standard Letter has been uploaded to the PaNDA work ID where they have updated any information in Consumer Directory Maintenance System (CDMS) including adding a comment in the personal section under the claimant in CDMS that they are returning the paperwork to the claimant.

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

Note: if at any time Service Officers are in doubt about the validity of a claim being processed, they should escalate the matter to their supervisor.

Afterhours Service Officers

If you are processing outside of customer contact hours (before 8am and or after 8pm), see Telephone standards for Medicare and Health Delivery

See System functionality of the Consumer Directory Maintenance System (CDMS) for Medicare and Amend customer details in the Consumer Directory Maintenance System (CDMS) for Medicare

Patient claims submitted for payment using a previously issued Medicare card can only be processed if:

• the name, date of birth and address details are an exact match to those contained on Consumer Directory Maintenance System (CDMS)
• a current Medicare card number has been issued within the last 12 months
• the claimant has paid the invoice in full

Note: claims quoting a previously issued Medicare number flagged as lost or stolen are not to be paid.

See the 'Paying patient claims using a Medicare card with a previously issued number' section in Patient claim requirements for payment of Medicare benefits.

Where a claimant's signature differs from the claimant details, see the 'Signature requirements for Medicare claim forms (MS014)' section in Patient claim requirements for payment of Medicare benefits.

Organ donor registration completed

Where the organ donor registration section of MS014 form has been completed on forms that are incomplete or contain incorrect details, the registration must be actioned.

For instruction on how to process the registration, see Register new organ donor.

Overseas address on claim form

For instruction on how to process claim forms with an overseas address, see Cheque processing in Medicare.