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

Process any adjustment involving over keying, including transferring, the service line(s) with adjustment details.

Process any adjustments involving the insertion of service lines.

Process any deletions of service lines.

Suppression will usually be done in a separate adjustment claim.

• Key DHSI,PROVIDER NO,CLAIM ID,DOL=DDMMYY
• Press [Enter]

Note: the provider number to be entered is the provider who received payment, that is payee provider.

If the details entered are:

• Not Accepted as valid, a 1-Claim ID message will display
• correct error
• press [Enter]
• Accepted as valid, the DHSC screen shows. Follow the process tables to complete the appropriate adjustment as required.

Note when an adjustment is first accepted:

• When the DHSI control line is entered in the first instance, adjustment processing is initiated and the date of lodgement used on the control line is the DOL of the original claim
• The display will default to showing the Medicare card number/s in numerical order
• Key A at the end of the control line to display the claim in alphabetical order - the return message 'ALPHA' is displayed
• After initiation of adjustment processing, the DOL shown on the control line of the DHSC screen is the new adjustment claim DOL

• Key ‘A’ in field of the line to be amended
• Press [Enter]

Mainframe returns the message ‘ORIN DOL = DDMMYY’ and displays:

• The original line. All fields are protected and the A field contains an O
• A restated line. All fields are protected, except the A field which contains an R. All details will display the same as the original line, but the fee and benefit fields will display 0 00

Press [F3]

The system checks the claim and if background assessing is:

• Not completed - the error message 3-STATUS is returned
• Completed - the first DHAC screen for the claim is displayed

On the unlocked restated line/s, over-key:

• Item
• DOS
• BN ASG
• Referring/Requesting details

Press [Enter]

Are the details in the revised service line/s correct?

• Yes, go to Step 5
• No, correct the information by over-keying the details on DHAC screen

• Assess and apply MBS restrictions and rulings as normal
• Over-key DHAC to DHAU to ‘U’ to update
• Press [Enter]

A new service line can be added during the adjustment claim processing.

Are any restated lines displayed for the patient requiring adjustment?

• No, go to Step 3
• Yes, go to Step 4

• Position cursor in the A field where the new line is to be inserted
• Key 'A’ and press [Enter]

An ‘O’ and ‘R’ line will now display for the service/s.

• Key ‘I’ over the ‘R’ in the A field
• Press [Enter]

The system returns the message Insert, together with a new line that enables new details to be keyed.

Note: an N appears in the A field to indicate a new line. When an N line has been generated, a new line/s can then be generated from this line.

Key details in the following mandatory fields:

• Item
• DOS
• BN ASSG
• Press [Enter]

Note: When [Enter] is pressed, the ‘N’ field will lock

The system:

• Repeats the Medicare card number and patient name from the restated line. These fields are protected
• Inserts PAYEE Code 6 and zeros in the Fee and Benefit fields. These fields are protected
• Leaves the PI, RSN and TX fields blank. This information is not required when inserting a new link

Are the details in the new service line/s correct?

• Yes, go to Step 7
• No, over-key the ‘N’ with an ‘X’ in the A field and press [Enter]

A ‘REV INS OK’ message will return in Mainframe.

This action will delete the newly inserted adjustment line.

Press [F3]

The system checks the claim and if background assessing is:

• Not completed - the error message 3-STATUS is returned
• Completed - the first DHAC screen for the claim is displayed

Assess and apply MBS restrictions and rulings as normal.

Check the adjustment displayed is correct then:

• Over-key DHAC to DHAU to ‘U’ to update
• Press [Enter]

• Yes, see Table 13
• No, Procedure ends here

Locate the service line/s that require deletion.

• Key ‘T’ in the A field of the line to be deleted
• Press [Enter]

Mainframe returns the message ‘LINE DLTD’ and displays:

• The original deleted line. All fields are protected and the A field contains an O
• A restated line. All fields are protected, except the A field which contains an R. The FEE and BENEFIT fields will display zero amounts, a H is displayed in the PAYEE field and the RSN field has also been updated to display 818. This is done to indicate that the line will be recorded for history purposes only.

Note: if ‘T’ is keyed next to all service lines this will result in a total overpayment. This means that no more adjustments can be performed. Make sure that all service lines are correct prior to deletion.

Are the details in the revised service line/s correct?

• Yes, go to Step 3
• No, over-key the ‘R’ with an ‘X’ in the A field and press [Enter]

A ‘REV ADJ OK’ message will return in Mainframe.

This action will undo the deletion adjustment line.

Press [F3]

The system checks the claim and if background assessing is:

• Not completed - the error message 3-STATUS is returned
• Completed - the first DHAC screen for the claim is displayed

Assess and apply MBS restrictions and rulings as normal

Check the adjustment displayed is correct then:

• Over-key DHAC to DHAU to ‘U’ to update
• Press [Enter]

• Yes, see Table 13
• No, Procedure ends here

Locate the service line/s that require transferring.

Key ‘P’ in the A field of the line/s that are to be transferred and press [Enter]

The card number and patient name field is now unlocked.

Over-key where applicable:

• card number
• patient name
• press [Enter]

Are the details in the revised service line/s correct?

• Yes, go to step 4
• No, over-key the ‘R’ with an ‘X’ in the A field and press [Enter]

A ‘REV ADJ OK’ message will return in Mainframe.

This action will undo the previous action and enable the correction of details.

Press [F3].

The system checks the claim and if background assessing is:

• Not completed - the error message 3-STATUS is returned
• Completed - the first DHAC screen for the claim is displayed

Assess and apply MBS restrictions and rulings as normal.

Check the adjustment displayed is correct then:

• Over-key DHAC to DHAU to ‘U’ to update
• Press [Enter]

• Yes, see Table 13
• No, Procedure ends here

Face-to-face (F2F) staff, and staff who have not completed end-to-end training in adjustments, must not action adjustments. In such cases, escalate by proficiency raising the work item in PaNDA or escalating the claim to the CI queue.

All vouchers in the restrictive claim are to be assessed and processed where possible. If a service is subject to a multiple services rule, the schedule fee is not to be manually calculated using PI 58.

• Take a screen print of the service(s)/voucher(s) that require adjustment
• Reject the restrictive service(s) with Reason Code (RSN) 151
• Assess any outstanding vouchers within the claim and finalise the claim

• key NHSI,Medicare No,patient’s IRN,DOS/DDMMYY
• press [Enter]

When the relevant service has been located on the patient’s history, update the control line to filter by the date of processing. This will display any payee provider information (if appropriate).

• key NHSI,Medicare No,patient’s IRN,DOP/DDMMYY
• press [Enter]

Take note of the:

• Provider number
• Payee provider (if applicable)
• Claim ID
• Date of Lodgement

• Key DHSI,PROVIDER NO,CLAIM ID,DOL=DDMMYY
• Press [Enter]

Locate the Medicare number and patient name that requires adjusting and:

• Position cursor in the A field where the new line is to be inserted
• Key ‘A’ and press [Enter]

An ‘O’ and ‘R’ line will now display for the service/s.

• Key ‘I’ over the ‘R’ in the A field
• Press [Enter]

The system returns the message Insert, together with a new line that enables new details to be keyed.

Note: an N appears in the A field to indicate a new line. When an N line has been generated, a new line/s can then be generated from this line.

Key details of the service/s that were rejected with RSN 151 in the mandatory fields:

• Item
• DOS
• BN ASSG
• Press [Enter]

Note: when [Enter] is pressed, the ‘N’ field will lock.

The system:

• Repeats the card number and patient name from the restated line and these fields are protected
• Inserts PAYEE Code 6 and zeros in the FEE and BENEFIT fields. These fields are protected
• Leaves the PI, RSN and TX fields blank and are not needed when inserting a new line

Are the details in the new service line/s correct?

• Yes, go to Step 7
• No, over-key the ‘N’ with an ‘X’ in the A field and press [Enter]

A ‘REV INS OK’ message will return in Mainframe.

This action will delete the newly inserted adjustment line.

Press [F3].

The system checks the claim and if background assessing is:

• Not completed - the error message 3-STATUS is returned
• Completed - the first DHAC screen for the claim is displayed

Assess and apply MBS restrictions and rulings as normal.

Check the adjustment displayed is correct then:

• Over-key DHAC to DHAU to ‘U’ to update
• Press [Enter]

• Yes, see Table 13
• No, procedure ends here

Key control line  DHAI,PROVIDER NO,CLAIM ID,DOL=DDMMYY.

This will re-assess the claim.

Apply MBS restrictions and rulings as normal.

Complete adjustment and U to Update and finalise the adjustment

Key control line DHAC,PROVIDER NO, CLAIM ID,DOL=DDMMYY,RESET.

This action resets the claim to start again with the first adjustment.

Key control line DHRI,PROVIDER NO,CLAIM ID,DOL=DDMMYY

Press [Enter]

Mainframe will display the message ‘R’ to RVRSE

• Over-key ‘C’ of DHRC with ‘R’ of the control line
• Press [Enter]

Mainframe will display the message ‘REVERSED’

This action reverses the claim to the ADJUST status. The claim can then be recalled from pend (DHAI)

• Yes, see Delete a Bulk Bill LDA claim table
• No, procedure ends here

• Key control line DHRI,PROVIDER NO,CLAIM ID,DOL=DDMMYY,DELETE
• Press [Enter]

Mainframe will display the message ‘ADJ DEL OK’.

Note: DELETE can also be used with the following control lines:

• DHSC
• DHAI
• DHAC

Co-claiming 1-PREV CON warning message displays on Medicare Mainframe when certain consultation items are on a patient’s history and restrict with a Group T8 item.

• Telephony staff unable to perform overpayment or same day reversal (SDR) in Bulk Bill, go to Step 2
• Face to face staff unable to perform overpayment or same day reversal (SDR) in Bulk Bill, go to Step 3
• Service Officer able to perform overpayment, or SDR in Simplified Billing, go to Step 4

When the consultation on history has been processed via the bulk bill channel and you are unsure about processing an overpayment:

• Park Online or Pend manual surgical T8 claim
• Complete the 1 PREV CON escalation template
• Upload template and assign to BB Helpdesk in PaNDA with the title 1-PREV CON – BB OPAY – <M/C NUMBER>

When advised that overpayment has been actioned:

• select parked/pended Surgical T8 claim
• finalise claim

• Park, Pend or Action as required, the manual surgical T8 claim
• Complete the 1 PREV CON escalation template
• Email to Medicare Claims Helpdesk

When a SDR of the consultation on history is possible (DOP = today):

• complete the SDR to reverse the consultation using DSDI
• when claim is reversed, use reason code 506 to reject the consultation item
• Select parked/pended Surgical T8 claim
• process the claim

Where the SDR is not possible:

• Complete the OPAY
• Key DHSI, provider no, claim ID,DOL=DDMMYY
• Key T in the Action (A) field
• Original item line (O) and Reversed item line (R) will be displayed
• Select [F3] to display total OPAY line
• Key U to update

Complete Debt Advice Notice ‘DAN’:

• On the Health Service Delivery Division SharePoint page:
• Open the Medicare Provider Services Library
• Select the Claims and Assessing page

This page will contain a:

• PowerPoint on how to use the DAN form
• Link to the interactive DAN form
• Key the business reason on the pop-up if you need access to the DAN homepage
• Key details into the DAN form
• Select overpayment reason: From 1 November 2017, subsequent attendance items were not payable with any Group T8 surgical items with a schedule fee of equal to or greater than $330.20, provided by the same health professional on the same day
• Press Submit

When complete:

• select parked/pended Surgical T8 claim
• process to finalise the claim

For Bulk Bill Helpdesk processing, go to Step 5

• Action SDR/overpayment following the process in Step 4
• Send an email to originating telephony staff advising overpayment has been completed using below script:

Hi XX,

Please be advised that your Bulk Bill overpayment adjustment request as per attached PREV CON template for mc number XXXX has been actioned. You can now finalise your parked/pended surgical claim.

When the Bulk Bill LDA has been finalised Mainframe will change the control line to:

DPSI,PROVIDERNO,CLAIMID,DOL=DDMMYY

Note: the DOL displayed is the adjustment DOL and not the original claims DOL

• Press [Enter]
• Take screen shots/print of all pages of the adjustment statement
• Upload the statement to the PaNDA work ID

When the end of the statement has been reached Mainframe will default back to the DPSI screen.

• Key DCEI,PROVIDER NO, CLAIM ID
• press [Enter]

This will display basic information on both the original claim, and the adjusted claim.

In the RSN field of the Adjusted claim, key either:

• VRC
• DRI
• DRD. For more information about RSN codes on the DCEI screen, see the Resources page

Press [Enter].

Mainframe will then return a ‘1-U for UP’ message.

• Over-key DCEI with DCEU
• Press [Enter]

Mainframe will return a ‘UPDATE OK’ message

• Open a web browser and navigate to SharePoint
• locate the Health Service Delivery Division SharePoint page
• open the Medicare Provider Services Library
• select the Claims and Assessing page

This page will contain a:

• PowerPoint on how to use the DAN form
• link to the interactive DAN form
• manual DAN template should the interactive form not work

Select the ‘Click Here’ for the interactive form to complete the DAN.

Note: if Service Officers do not have access, the business reason will need to be entered into the pop-up field on SharePoint. A manual DAN is to be completed until access is granted to the interactive form.

• Select the ‘Medicare Bulk Bill Debt Advice Notice (DAN)’ link
• Complete all mandatory fields of the form
• Press [Save]

All documentation received from the health professional is to be scanned into PaNDA. This includes:

• Copy of the cheque or money order
• Request letter
• Claim print outs
• Any other documentation received with the payment

The documentation is to be scanned into:

• Program: Bulk Bill
• Work Type: VRC Reimbursement
• Provider Number: Number quoted on adjustment request
• Claim ID: Enter claim ID
• Date of Lodgement: date mail received

Locate and allocate the work item in PaNDA by searching under:

• Program: Bulk Bill
• Work Type: VRC Reimbursement

The work item can be located using the:

• Provider number contained on the manual paperwork
• Date of lodgement

Check Mainframe to confirm if an adjustment has been actioned

• Key NHSI,MEDICARE CARD NUMBER,ADJ/BB

Has the adjustment request been processed?

• Yes, go to Step 4
• No, see Table 2

When the Bulk Bill LDA has been finalised Mainframe will change the control line to:

• DPSI,PROVIDERNO,CLAIMID,DOL=DDMMYY

Note: The DOL displayed is the adjustment DOL and not the original claims DOL.

• Press [Enter]
• Take screen shots/print of all pages of the adjustment statement
• Upload the statement to the PaNDA work ID

When the end of the statement has been reached Mainframe will default back to the DPSI screen.

• Key DCEI,PROVIDER NO, CLAIM ID
• Press [Enter]

This will display basic information on both the original claim, and the adjusted claim.

In the RSN field of the Adjusted claim:

• Key VRC
• Press [Enter]

Mainframe will then return a ‘1-U for UP’ message.

• Over-key DCEI with DCEU
• Press [Enter]

Mainframe will return a ‘UPDATE OK’ message

When all adjustments have been actioned as per the health professionals request, make sure that the DPSI statement overpayment amount/s match total payment amount.

If the total funds received for the cheque/money order is:

• the same as the overpayment amount raised, no additional action will be required
• more than the overpayment amount raised, Medicare Debt Recovery will arrange a refund to the health professional for the difference
• less than the overpayment amount raised, Medicare Debt Recovery will arrange for the recovery of additional funds owed

Note: if the total amount of funds received is substantially different than that on Mainframe, contact the health professional to clarify the discrepancy. Record the advice received from the health professional in the PaNDA work item comments. This may include, but is not limited to, returning the payment and request paperwork to the health professional for amendment.

• print a paper copy of the DPSI adjustment statement
• all pages of the statement must be printed
• DPSI statement to be attached to the original adjustment request/payment paperwork

Using internal mail forward the following to Medicare Debt Recovery Parramatta:

• the cheque or money order
• original paperwork received
• DPSI prints

Note: a DAN entry is not required to be entered as Medicare Debt Recovery Parramatta will manually enter payment and claim details directly

Prior to registering a bulk bill Adjustment on Adjustment, experienced Service Officers must:

• Review all documents associated with the request
• Review all comments contained on the PaNDA work ID
• Review all prior adjustments made to the claim/s and/or patient/s prior to the current request
• Make sure that sufficient documentation and information has been received to progress with the adjustment on adjustment request

Note: If a work item is escalated incorrectly in PaNDA, the experienced Service Officer is to return to work item to the escalating Service Officer to request additional information. Clear comments must be left in PaNDA as the why the work item is being escalated or returned.

• Key DHSI,PROVIDER NO,CLAIM ID,DOL=DDMMYY,MODIFIER

The adjustment date of lodgement is to be entered, rather than the original claims date of lodgement.

• Press [Enter]

Note: Service Officers who are assessed as fully proficient, experienced and granted access to bulk bill Adjustment on Adjustment processing will be made aware of the correct modifier by their Team Leader. Service Officers who do not have access to the ADJ on ADJ modifier will need to raise proficiency in PaNDA or discuss this with their Team Leader. The Team Leader needs to determine if the Service Officer has the appropriate knowledge and skills for experienced proficiency level for adjustments work type for them to be granted access to ADJ on ADJ processing.

If the details entered are:

• Not Accepted as valid, a 1-Claim ID message will display
• correct error
• press [Enter]
• Accepted as valid, the DHSC screen shows. Complete the adjustment as required.

Note when an adjustment is first accepted:

• When the DHSI control line is entered in the first instance, adjustment processing is initiated and the date of lodgement used on the control line is the DOL of the original claim
• The display will default to showing the Medicare card number/s in numerical order
• Key A at the end of the control line to display the claim in alphabetical order - the return message 'ALPHA' is displayed

After initiation of adjustment processing, the DOL shown on the control line of the DHSC screen is the new adjustment claim DOL.

Locate the service line/s that require suppression

• Key ‘H’ in the A field of the line to be suppressed if the suppression is for HIC internal reasons
• Key ‘M’ in the A field of the line to be suppressed if the suppression is for Medicare Online
• Key ‘F’ in the A field of the line to be suppressed if the suppression is for fraud
• Press [Enter]

Mainframe returns the message ORIG DOL = DDMMYY and displays:

• The original line. All fields are protected and the A fields contains an O
• A restated line. All fields are protected, except for the A field which contains an R. The RSN field has been updated and will display:
• 890 for claims suppressed using H
• 891 for claims suppressed using M
• 892 for claims suppressed using F

For more details about reason codes see Indicators, codes, modifiers and control lines for claims processing in Medicare

Have the correct line/s been suppressed?

• Yes, go to Step 3
• No, over-key the ‘R’ with an ‘X’ in the A field and press [Enter]

A ‘REV ADJ OK’ message will return in Mainframe.

This action will undo the suppression adjustment line.

Press [F3]

The system checks the claim and if background assessing is:

• Not completed - the error message 3-STATUS is returned
• Completed - the first DHAC screen for the claim is displayed

Assess and apply MBS restrictions and rulings as normal.

Check the adjustment displayed is correct then:

• Over-key DHAC to DHAU to ‘U’ to update
• Press [Enter]

Review the form in full. If the documentation received is the Department of Health and Aged Care’s Voluntary acknowledgment of incorrect payments.

Go to Step 2.

• Right mouse click on the document
• Select Save As
• Go to a chosen or temporary folder
• Rename the File name as the ‘provider number’ or ‘provider name’
• Select PDF (*.pdf) from the Save as type drop down
• Select Save

Open Microsoft Office Outlook.

Send the work item to the Provider Benefits Integrity Section:

• Select New Email
• Attach the work item
• Include standard wording in the body of the email "This has been received by Medicare in error on ddmmyy (panda lodgement date), please add to your current workflow"
• Send to: Department of Health and Aged Care (Voluntary Compliance Team) mailto:voluntary.compliance.team@health.gov.au
• Select Official as the email classification
• Select Send

• Add a note to the PaNDA file to confirm that the voluntary acknowledgement of incorrect payments form was sent to the Provider Benefits Integrity Section stating: ‘Voluntary acknowledgement of incorrect payments form sent to Health on DD/MM/YYYY,NFA’
• Change the status of the PaNDA file to Complete
• Press Save