Bulk bill late lodgement claims in Medicare 011-43030020

Section 20B(2)(b) of the Health Insurance Act 1973 (the Act) states that a Medicare bulk bill claim must be lodged with Services Australia within 2 years from the date of service.

Section 20B(3A) of the Act enables the Chief Executive Medicare (or their delegate) to consider applications from health professionals to extend this period, having regard to all matters considered relevant, including any hardship that may be caused to the claimant if a longer period is not allowed.

An application to extend the 2-year lodgement period is known as a late lodgement.

Where the health professional is incapacitated or deceased, then the person who holds their legal authority, such as their power of attorney or executor, can apply for late lodgement.

The decision of the Chief Executive Medicare or their delegate is final.

When a claim is lodged with Services Australia within the 2-year period, but it is not processed until after 2 years from the date or service, the claim is not considered a late lodgement. This is because the claim was submitted before the 2-year allowable period.

Approving the late lodgement application means Services Australia will accept the claim for processing outside of the 2-year claiming period. Late lodgement claims are assessed in the same way as any other claim.

Note: the late lodgement policy does not apply to claims that are submitted late as a result of compliance activity. These claims will contain a case number issued by the Department of Health and Aged Care. Health professionals must include the case number on the form when applying for late lodgement.

Services Australia will not approve applications due to administrative errors.

Administrative errors include but are not limited to:

• poor book keeping
• inadequate staffing/resources/training
• an issue with software, system or computer malfunctions

The following are some examples of what may or may not be acceptable.

Acceptable

• hospitalisation or serious long term medical condition and an extensive period of recovery (however it would not be acceptable if the health professional was still practising during this period)
• evidence to demonstrate that if a longer period is not allowed, there will be impact on the ongoing viability of the practice, such as certified copies of bank statements or tax returns
• a compliance audit on the health professional carried out by Services Australia that has resulted in the health professional needing to resubmit claims
• a natural disaster (for example, major fire/flood, cyclone etc.)

Not acceptable

• a private account has been previously raised and not paid (debt collecting)
• a declined work cover application

The References page contains a link to the Health Insurance Act 1973.

Health professionals can only submit adjustments to previously lodged bulk bill claims over 2 years old where the servicing health professional can demonstrate that not adjusting the initial claim will affect the patient's My Health Record.

The Resources page contains a link to the required form Application for late lodgement of a claim for assigned Medicare benefits (DB019).

To apply for late lodgement of a bulk bill claim, the health professional must submit the following:

• An application for late lodgement of a claim for assigned Medicare benefits form (DB019). Note: to obtain this form health professionals must contact the Medicare provider enquiries line
• A correctly completed original ‘Claim for Assigned Benefits’ (DB1N/DB1H) form signed by the treating health professional and co-signed by a witness
• A correctly completed original Assignment of benefit form(s), signed by the patient, and
• Evidence to demonstrate the circumstances preventing lodgement within the 2 years, or evidence to demonstrate that if a longer period is not allowed, there will be impact on the ongoing viability of the practice, such as certified copies of bank statements or tax returns

Late lodgement applications must be sent to the Medicare Provider Services. See Bulk bill claims for contact details.

Note: applications for late lodgement cannot be accepted electronically as the date of service is over 2 years.

The Resources page contains a link to the required form ‘Application for late lodgement of a claim for assigned Medicare benefits (DB019)’.

An authorised delegate must approve all bulk bill late lodgement applications prior to processing. The delegate for bulk bill late lodgement applications is an APS6 Team Leader.

Medicare Provider Services assess late lodgement applications.

See the Process page for information on how to seek delegate approval.

The health professional will receive a letter advising if their application is successful or not.

Bulk bill incentive and Patient Episode Initiation (PEI) items are not service items. This is because they are not patient assigned and can only be claimed in association with an appropriately assigned service item. Omitting or amending these items from the original claim is an administrative error.

Omitted or incorrect bulk bill incentive or PEI items with a date of service that is over 2 years old are not accepted for processing.

As bulk bill incentive and PEI items are not service items, they will not impact the patient's My Health Record.

Prior to assessing and processing a late lodgement claim, Service Officers must verify the patient history to ensure a Medicare benefit has not previously been paid.

For most services, Mainframe keeps items visible on patient history for a period of 2 years. Once the item reaches the cull period, they are no longer visible in Mainframe and Service Officers will need to recall these from Cull history.

SAS® Portal allows access to culled history reports:

• up to 5 years (available upon request)
• over 5 years are submitted to the Department of Health and Aged Care via the portal

Note: the Department of Health and Aged Care can take up to 6 weeks to return over 5 year culled history.

It is an offence under section 128A, 128B and 129 of the Health Insurance Act 1973 for a servicing health professional to make a false or misleading statement in relation to a Medicare claim. The servicing health professional must not, under any circumstances, amend details, for example, an item number, because Services Australia rejected the original claim.