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Adjustments for Medicare patient claims 011-43010100

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This document outlines information relating to electronic funds transfer (EFT) or adjustments for Medicare patient claims. Note: as at 1 July 2016 Norfolk Island is covered under Medicare provisions.

Adjustments

When performing any adjustment, check the following:

  • EFT status is PAID
  • cheque has been presented on patient history (for claims processed pre 1 July 2016 or unpaid claims - Pay Doctor via claimant (PDVC)
  • original claimant (so that the correct claimant is entered in the latter day adjustment screen)

Note:

  • only use the stored EFT details where a previous claim has been successfully paid using the stored bank details
  • Service Officers in:
    • service centres must not adjust an adjusted service (these must be forwarded to Assessing and Benefits)
    • the Assessing and Benefits team may perform an additional 2 adjustments (or 3 where a service centre has not made a previous adjustment)
  • where a fourth or further adjustment is required, it must be referred to Medicare Claims Helpdesk and Support

Adjustment to claims originally paid via a cheque

Where a processing error is detected in a processed patient claim and payment was via a cheque (PDVC or paid claims processed pre 1 July 2016), do not action any adjustments to the claim until the cheque has been presented at the financial institution or the cheque has been cancelled.

If the error is highlighted prior to the PDVC cheque being issued, request the cheque to be extracted. When the Service Officer has received the successfully extracted cheque, cancel the cheque and reprocess the claim.

If the PDVC cheque cannot be extracted, action the adjustment when the cheque has been presented at the financial institution.

In the case of an adjustment to history only, do not change the payee codes except when:

  • extra benefit is to be paid, then the payee code needs to be replaced with a 9 (if paid)
  • the services have been verified (substantiated)

For claims adjusted that were originally paid via cheque (paid accounts), the adjustment will be paid via EFT.

See also: Cheque processing in Medicare.

EFT adjustments

It is not possible to stop an EFT payment. Payments are released from Services Australia's bank account either at 6:30 pm AEST the same day or the next working day after processing.

Same day versus Latter Day adjustments

When an error is detected:

  • before 6:30 pm AEST on the day the transaction was processed, the Service Officer must perform a same day adjustment
  • after 6:30 pm AEST on the day the transaction was processed, the Service Officer must perform a Latter Day adjustment

Note:

  • where adjustments are not possible, normal debt recovery procedures must be followed
  • an adjustment to a patient claim resulting in an increase in benefit will be paid by EFT into the claimant's nominated bank account

The Resources page contains contact details for the Assessing and Benefits team and the Medicare claims helpdesk, and a link to the Adjustment for Patient Claims form.

Account and receipt documents for Medicare claims processing

Cheque processing in Medicare

Latter day adjustments (LDA) and HELD payments for patient claims