Incomplete or incorrect Medicare claims forms 011-43010050
Expand allThis page contains information on the process Service Officers must complete when no Medicare card number has been supplied on the claim form. It also contains information on what to do when the claimant address details supplied on the claim form differ from the group contact address, and what to do when there is no claimant signature on the claim form or it has been supplied in the wrong section of the claim form.
On this page:
Claimant or patient can be uniquely identified, and Medicare number is missing from claim
Claimant or patient cannot be uniquely identified, and Medicare number is missing from claim
Patient not enrolled on Medicare card quoted on claim form
No claimant details supplied on claim form
Claimant is group contact and address recorded is different to claim form
Signature missing or in the wrong section of the claim form
Claimant or patient can be uniquely identified, and Medicare number is missing from claim
Table 1: this table describes what to do when the claimant or patient can be uniquely identified from the claim form or patient invoice, and Medicare number has not been supplied on the claim form.
|
Step |
Action |
|
1 |
Search CDMS + Read more ... Log on to Consumer Directory Maintenance System (CDMS). Search for the Medicare card using the details provided on the claim form. See Register a customer for Medicare in the Consumer Directory Maintenance System (CDMS). |
|
2 |
Process claim + Read more ... Process the claim using the correct card number. |
Claimant or patient cannot be uniquely identified, and Medicare number is missing from claim
Table 2: this table describes what to do when the claimant or patient cannot be uniquely identified from the information supplied on the claim form, and the Medicare number is missing. There are claimant contact details are listed on the claim form.
|
Step |
Action |
|
1 |
Contact claimant + Read more ... Attempt to contact the claimant using the details provided on the claim form. See Telephone standards for Medicare and Health Delivery Was contact made with the customer?
|
|
2 |
Unable to contact customer + Read more ... Where contact was not made:
Procedure ends here. |
|
3 |
Phone contact was made + Read more ... Conduct a security check to confirm their identity. See Authenticating a Medicare customer. Tell the claimant that no Medicare card number was supplied on the claim form. |
|
4 |
Record Medicare card number + Read more ... Record the Medicare card number given on a Customer details verified by phone. This is to be actioned using either a VG4 form or updating PaNDA notes with details of information verified. The Resources page contains a link to the VG4 form. |
|
5 |
Process claim + Read more ... Process the claim with the correct Medicare card number. |
Patient not enrolled on Medicare card quoted on claim form
Table 3: This table describes what to do when a patient is not enrolled on the Medicare card number quoted.
|
Item |
Situation and action |
|
1 |
Where the patient can be uniquely identified + Read more ... Search for the Medicare card number in the Consumer Directory Maintenance System (CDMS) and process the claim using the correct card number. |
|
2 |
Where the patient cannot be uniquely identified + Read more ... Return the claim to the claimant with a standard letter attached. Add comments in both CDMS and PaNDA stating “PC DOL DDMMYY, Letter sent because XYZ (insert reason here), PaNDA ID 1234567890”. |
|
3 |
Where the card number is flagged as lost or stolen + Read more ... Return the claim to the claimant with a standard letter attached. Add comments in both CDMS and PaNDA stating “PC DOL DDMMYY, Letter sent because XYZ (insert reason here), PaNDA ID 1234567890” |
|
4 |
Where the issue number is more than 12 months old + Read more ... Return the claim to the claimant with a standard letter attached. Add comments in both CDMS and PaNDA stating “PC DOL DDMMYY, Letter sent because XYZ (insert reason here), PaNDA ID 1234567890” Note:
|
No claimant details supplied on claim form
Table 4: this table describes what to do when a claimant provides a Medicare number only on the Medicare claim form and no personal details have been supplied.
|
Step |
Action |
|
1 |
Contact claimant + Read more ... Contact the claimant using details stored in the Consumer Directory Maintenance System (CDMS). See Telephone standards for Medicare and Health Delivery. Note: where contact is unable to be made with the claimant, process the claim using the address stored in CDMS. |
|
2 |
Confirm details + Read more ... Ask the claimant to confirm their details. When checking their address, verify if it is a permanent (p) address or a temporary (t) address. Update address details if required. Note: Service Officers must not in any circumstances release the address stored in CDMS to the claimant. |
|
3 |
Record address details + Read more ... Record the address details supplied on a VG4 form and attach to the claim or update PaNDA notes with details of information verified. The Resources page contains a link to the VG4 form. |
|
4 |
Process claim + Read more ... Process the claim. |
Claimant is group contact and address recorded is different to claim form
Table 5: this table describes what to do when the claimant is group contact and the address details supplied on the claim form is different to recorded details in CDMS.
|
Step |
Action |
|
1 |
Contact claimant + Read more ... Contact claimant to verify permanent address change applies to all persons on the card. Claimant contacted and confirmed applies to all, go to Step 2. Claimant contacted and does not apply to all, go to Step 3. Claimant not contactable, go to Step 3. Note: if the Yes or No box on the claim form has not been checked, record the address as temporary (t). |
|
2 |
Record address details as permanent + Read more ... Record address details as permanent (p). Pay the claim. See Patient claims processing in Medicare when reversing the claim due to incorrect claimant card number. |
|
3 |
Record address details as temporary + Read more ... Record address details as temporary (t). Pay the claim. |
Signature missing or in the wrong section of the claim form
Table 6: this table describes what to do when there is no claimant signature on the claim form or it has been supplied in the wrong section of the claim form.
|
Step |
Action |
|
1 |
Where contact details are available, contact the claimant + Read more ... Note:
|
|
2 |
Conduct security check + Read more ... Conduct a security check to confirm their identity. Note: where the claimant’s identity cannot be confirmed, return the claim to the claimant with the appropriate standard letter, requesting missing details or information to be updated. See: |
|
3 |
Confirm details with claimant + Read more ... Tell the claimant they are being contacted regarding the claim they submitted with the below details:
Confirm with the claimant that they either:
Read out to the customer the Claimant Declaration. The Resources page the Claimant Declaration text to read to the customer. Note: where the claimant cannot verify that they forgot to sign the claim form, or signed in the wrong place, return the claim to the claimant with the appropriate standard letter attached, requesting missing details or information to be updated. Add comments in both CDMS and PaNDA stating “PC DOL DDMMYY, Letter sent because XYZ (insert reason here), PaNDA ID 1234567890”. |
|
4 |
Note conversation + Read more ... Note this conversation on either a VG4 form or by updating PaNDA note with details of information verified, including that the claimant declaration was read out to the claimant and the claimant agreed to the declaration. The Resources page contains a link to the VG4 form. |
|
5 |
Process claim + Read more ... Process the claim accordingly. |