Bulk bill latter day adjustment (LDA) claims in Medicare 011-43040000

The Department of Care Health and Aged (DoHAC) have provided updated policy advice on how a health professional can obtain agreement from their patient for an assignment of benefit for face-to-face services that are bulk billed during the COVID-19 pandemic.

See Bulk bill claims in Medicare for more details.

For information specific to COVID-19 services, see Temporary Medicare Benefits Schedule (MBS) items in response to Coronavirus (COVID-19).

If health professionals cannot get patient agreement in writing or by email for telehealth services, they can get verbal agreement from their patient during the telehealth consultation.

See Bulk bill claims in Medicare for more details.

An LDA is needed when any details of a previously processed claim needs amending with new or altered information.

A bulk bill LDA (BBADJ) can only be actioned if the service details are present on the patient's history.

Service Officers should always check PaNDA to see if a compliance schedule has been submitted before actioning any adjustments. A search can be performed using the health professional’s stem.

The processes outlined in this document are for users experienced with bulk bill processing concepts, methods and transactions.

All adjustment processing functions available in the DL** transaction suite are also operational in the DH** transaction suite.

Five types of adjustments can be processed on the DHSC screen:

• correcting service details for the patient
• transfer service(s) from one patient to another
• delete service(s)
• insert service(s)
• suppress service(s

When the system displays an original claim for adjustment processing, all claim lines (vouchers) for a Personal Identification Number (PIN) in that claim are grouped together. If there are 2 or more vouchers (each with a different date of service) for the same patient, this grouping will result only in lines for a patient with the same dates of service.

If a line is inserted or a DOS field over keyed with a different date of service, the system returns the warning message 8-CHCK DOS.

Lines with a different date of service than the existing lines should not be inserted. As such, the date of service for each claim line for a patient should be the same.

Note: new vouchers for patients not initially within the original bulk bill claim cannot be inserted in an adjustment claim. The DUP key is not available.

If a health professional contacts Services Australia (the agency) asking for an adjustment to a transmitted bulk bill claim:

• for that same day, the Medicare Provider line must be contacted. Request a same day deletion
• on a previous day, a manual request for adjustment must be submitted by the health professional

Note: if a claim has been transmitted or keyed on a previous day but has not been finalised (pended), this can still be adjusted as part of the same day delete process.

See also, Delete electronic Medicare claims for eBusiness Service Centre.

Health professionals can submit adjustments to previously lodged bulk bill claims where there was incorrect information. For example, item 23 was claimed but it should have been item 5023 and the original claim's date of service is less than 2 years old.

If the claim has already been processed, has a date of service under 2 years old and an item number needs to be changed, a manual request must be submitted for adjustment and the health professional must submit:

• an Application for bulk bill claim adjustment form (DB018) signed by the health professional, and
• a new Assignment of benefit form completed with the correct information and signed by the patient

If a payee provider received the payment:

• questions 8 and 9 must be completed on the DB018, and
• the payee provider details are required on the debt advice notice (DAN)

For any changes to an item number on a previously paid claim, the patient must sign the Assignment of benefit form. This is because the original agreement entered into when accepting the patient's assigned benefit(s) has been changed. An adjustment cannot be assessed unless the patient or a third party (including a parent, guardian or power of attorney) signs a new Assignment of benefit form.

The Resources page contains a link to the DB018 form.

For late lodgement adjustments (over 2 years from date of service) See Bulk bill late lodgement claims in Medicare.

If an adjustment is required due to an agency error, the health professional is not required to submit an application for an adjustment. The bulk bill claim must be adjusted to reflect the original claim submitted. If the Service Officer does not have the proficiency to perform the adjustment, they are required to raise an enquiry with subject - BB LATTER DAY ADJ and email to Medicare Provider Services (MPS) Assessing to allow the adjustment to be put into the workflow for actioning.

It is a requirement from the Australian National Audit Office (ANAO) and Quality Control advice that a Service Officer records adequate comments and documents to substantiate any adjustment including any additional information or documentation requested or received. That is, amended paperwork, emails, a word doc with screenshots uploaded to PaNDA and detailed processing notes.

There are occasions when the same health professional submits services that have been performed at the same attendance in different bulk bill claims. Some of these services may be subject to varying multiple services rules, such as the multiple operation rule or the diagnostic imagining multiple services rule. When these rules apply, and additional services have been submitted in a different bulk bill claim, Mainframe will return one of the following messages to indicate that an LDA may be required:

• Sus Dup
• Multi Split
• RST Claim

If possible, the LDA process must be performed under the original Bulk Bill claim submitted to allow correct system calculation and payment of Medicare benefits. See the Process Bulk Bill LDA to include additional services in a claim table.

Wherever possible the LDA process must be performed.

There are some occasions when the LDA process is not possible, for example, if a consultation and a surgical procedure are claimed using different claiming channels, or if the service on history was claimed as an out-patient and the surgical procedure is in-patient.

If the LDA process cannot be performed, Service Officers can use PI 58 to reduce the schedule fee of the highlighted item by the schedule fee of the restricted item on history to adjust the benefit. Processing notes must be added to the PaNDA file.

Where bulk bill incentive or Patient Episode Initiation (PEI) items were omitted or incorrect from the original bulk bill claim, and the date of service is less than 2 years old, health professionals can resubmit the bulk bill claim to include the omitted or adjusted bulk bill incentive or PEI items.

Note: health professionals do not need to obtain a new signed Assignment of benefit form.

Health professionals who do not have access to electronic claiming, or if their software does not allow them to transmit claims up to 2 years, can manually submit these adjustments to the agency. The health professional must submit:

• an Application for bulk bill claim adjustment form (DB018), signed by the health professional, and
• a spreadsheet outlining:
• patient details, full name, Medicare card number and IRN
• original date of service
• correct incentive or PEI item number

Health professionals whose software can transmit claims up to 2 years should contact their software vendors for assistance.

The Resources page contains a link to the DB018 form.

See Bulk bill late lodgement claims in Medicare

Adjustment on Adjustment (ADJ on ADJ) was introduced in 2012 to allow for subsequent adjustments within Mainframe to be made to an existing LDA after the original date of processing has passed, working for both underpayments and overpayments.

Access to this procedure is limited to Service Officers fully proficient in the Bulk Billing work type. Within PaNDA, this is under the following classifications:

• Entry level - No access, Service Officer to adjust capability to NV_MCA_Bulk_Bill_Adjustment / Experienced
• Established level - No access, Service Officer to adjust capability to NV_MCA_Bulk_Bill_Adjustment / Experienced
• Experienced level - Access is granted, Service Officer expected to complete the ADJ on ADJ process

The LDA bulk bill claims system pays benefits for amounts over $2.00 via EFT to the payee provider.

Claims with a status of ADJ PAID are paid in the next overnight run. A bulk bill benefit statement and EFT payment for the amount of the underpayment is generated for the health professional.

Note: if the underpayment is under $2.00 the system will apply an RSN advising the amount raised as trivial and will not apply the underpayment.

When an adjustment results in an overpayment, any outstanding amount requires follow-up action as per the agency's debt recovery policy.

For example, if an initial adjustment results in an overpayment of $60.00 and a further adjustment results in an overpayment of $50.00, recovery of monies must be sought for the total amount of $110.00.

Note: any outstanding amount requires follow-up action as per the agency’s debt recovery policy.

If the claim has been previously paid and has a date of service under 2 years old and a health professional requests a deletion, a manual request must be submitted for adjustment. The health professional who performed the service/s must submit:

• a signed Application for Bulk Bill claim adjustment form (DB018), or
• a signed letter using the practice letterhead

All claim information must be provided, for example, patient name, Medicare number, date of service (DOS)

Co-claiming message 1-PREV CON returns when certain consultation items performed by the same health professional are on a patient’s history and restrict against a Group T8 item, with:

• a schedule fee equal to or greater than the threshold
• the same date of service

Restrictive items: 105, 116, 119, 386, 2806, 2814, 3010, 3014, 6009, 6011, 6013, 6015, 6019, 6052, 16404, 91823, 91825, 91826, 91833, 91836, 92611, 92612, 92613 and 92618.

Co-claiming threshold is $330.20 as of 1 November 2023 and is indexed annually.

Service Officers must follow the co-claiming matrix for the relevant claiming channels. For a consultation paid on history in:

• Patient Claiming channels, see Latter day adjustments (LDA) and HELD payments for patient claims
• Simplified Billing channels, see Simplified Billing Latter Day Adjustment (LDA) claims in Medicare
• Bulk Billing channels, see the Process page

Note: see the PREV CON co-claiming threshold for the consultation item in QITI PF22.

The Resources page contains:

• a list describing DHSC screen features
• a list of adjustment codes to assist with Bulk Bill LDA claims for Medicare
• Bulk Bill LDA documentation requirements
• contact details
• the 1-PREV CON escalation template, and
• links to forms

Services may be suppressed on a patient history where there is doubt the services have been recorded correctly on that patient's history.

For example, if a Compliance investigation identifies services have been claimed inappropriately, the services on the patient's history can be suppressed, indicating they were fraudulent.

Suppression is only used where:

• no other adjustment transaction applies to the adjustment, and
• investigation of the service cannot determine who the benefit was paid to, or where the service should have been allocated

The suppressed services remain on the History enquiry screens for Medicare audit trail and processing purposes.

If a patient contacts Services Australia and states that a service on their Medicare history is not theirs, the service can be suppressed where Medicare:

• has investigated to the fullest
• cannot verify how the service was recorded on the patient's history
• is unable to substantiate the error

The Department of Health and Aged Care’s (DoHAC) compliance section have created a Voluntary acknowledgement of incorrect payments form.

The Resources page contains a link to the DoHAC form.

Health professionals complete this form when a benefit has been incorrectly claimed. Health professionals making a voluntary acknowledgement of an incorrect payment helps ensure that Medicare remains sustainable by only paying legitimate claims.

If a Voluntary acknowledgement of incorrect payment form is received by Medicare, the form is not to be processed. Service Officers must forward all documentation to the Provider Benefits Integrity section of the Department of Health and Aged Care.

The Process page contains more details about where to forward documentation.