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

This page contains basic procedures to assist in completing Latter Day Adjustment (LDA) claims for Medicare.

Step	Action
1	Keying Process any adjustment involving over keying, including transferring, the service line(s) with adjustment details.
2	Insertion of service lines Process any adjustments involving the insertion of service lines.
3	Deletion of service lines Process any deletions of service lines.
4	Suppress Suppression will usually be done in a separate adjustment claim.

Register bulk bill claim for adjustment

Table 2: this table describes how to register a bulk bill claim for adjustment.

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Step	Action
1	Log into Mainframe
2	Key details 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.
3	Details validated 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

Amend a service in a bulk bill LDA claim

Table 3: this table describes how Service Officers amend services that have been previously paid.

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Step	Action
1	Locate service line(s) that need amending 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
2	Close adjustment 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
3	Over-key required fields On the unlocked restated line(s), over-key: Item DOS BN ASG Referring/Requesting details Press [Enter]
4	Check amended line 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
5	Finalise adjustment Assess and apply MBS restrictions and rulings as normal Over-key DHAC to DHAU to 'U' to update Press [Enter]
6	Check if adjustment results in overpayment Yes, see Table 13 No, process ends here

Insert a service during adjustment processing

Table 4: this table describes how Service Officers insert a line during a bulk bill adjustment.

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Step	Action
1	Insert service line A new service line can be added during the adjustment claim processing.
2	Identify restated lines Are any restated lines displayed for the patient requiring adjustment? No, go to Step 3 Yes, go to Step 4
3	Create an amended line 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).
4	Insert new line 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.
5	Enter new service details 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
6	Check 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.
7	Finalise adjustment 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]
8	Does adjustment result in overpayment Yes, see Table 13 No, procedure ends here

Delete service(s) or total overpayment

Table 5: this table describes how Service Officers delete a service (raise an overpayment) during a bulk bill adjustment.

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Step	Action
1	Locate service(s) line 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.
2	Check deleted line(s) 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.
3	Finalise adjustment 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]
4	Check if adjustment results in overpayment Yes, see Table 13 No, procedure ends here

Transfer service from one patient to another

Table 6: this table describes how Service Officers can transfer services from one patient to another when processing a bulk bill adjustment.

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Step	Action
1	Locate service line(s) 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.
2	Over-key details Over-key where applicable: card number patient name press [Enter]
3	Check revised line 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.
4	Finalise adjustment 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]
5	Check if adjustment results in overpayment Yes, see Table 13 No, procedure ends here

Process bulk bill LDS to include additional services in a claim

Table 7: this table describes how Service Officers assess multiple claims that are subject to a multiple services rule, due to the health professional submitting 'split' claims for the same DOS.

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Step	Action
1	Information required before processing 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.
2	Assess restrictive claim 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
3	Locate original claim information 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
4	Key details of restrictive claim that needs adjusting Key DHSI,PROVIDER NO,CLAIM ID,DOL=DDMMYY Press [Enter]
5	Create an amended line 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).
6	Insert new line 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.
7	Enter new service details 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
8	Check 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.
9	Finalise adjustment 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]
10	Check if adjustment results in overpayment Yes, see Table 13 No, procedure ends here

Recall a bulk bill LDA claim

Table 8: this table describes how Service Officers recall a bulk bill LDA claim from pend and further steps required if adjustment results in an overpayment (OPAY).

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Step	Action
1	Key control line Key control line DHAI,PROVIDER NO,CLAIM ID,DOL=DDMMYY. This will re-assess the claim.
2	Assess Apply MBS restrictions and rulings as normal. Complete adjustment and U to Update and finalise the adjustment

Reset a bulk bill LDA claim

Table 9: this table describes how Service Officers reset a bulk bill LDA claim to start again.

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Step	Action
1	Key control line Key control line DHAC,PROVIDER NO, CLAIM ID,DOL=DDMMYY,RESET. This action resets the claim to start again with the first adjustment.

Action a same day bulk bill LDA claim reversal

Table 10: this table describes how Service Officers action a same day bulk bill LDA claim reversal.

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Step	Action
1	Key control line Key control line DHRI,PROVIDER NO,CLAIM ID,DOL=DDMMYY Press [Enter] Mainframe will display the message 'R' to RVRSE
2	Reverse adjustment 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)
3	Bulk Bill LDA needs deletion Yes, see Delete a Bulk Bill LDA claim table No, procedure ends here

Delete a bulk bill LDA claim

Table 11: this table describes how Service Officers delete a bulk bill LDA claim.

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Step	Action
1	Key control line 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 Matrix - Process for claims that return 1-PREV CON message - Bulk bill

Table 12: processing Steps for surgery claims that return a 1-PREV CON message.

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Step	Action
1	Co-claiming 1-PREV CON warning message 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
2	Service Officer unable to perform overpayment, or same day reversal (SDR) in Bulk Bill 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
3	Face to Face staff without PaNDA access Park, Pend or Action as required, the manual surgical T8 claim Complete the 1 PREV CON escalation template Email to Medicare Claims Helpdesk
4	Service Officer able to perform overpayment, or same day reversal (SDR) in Bulk Bill 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
5	Bulk Bill Helpdesk processing 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.

Bulk bill LDA results in overpayment

Table 13: this table describes how Service Officers process a Debt Advice Notice (DAN).

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Step	Action
1	Attach copy of LDA statement 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.
2	Update DCEI 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
3	Access the Debt Advice Notice (DAN) 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
4	Complete DAN 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]

Bulk bill adjustments voluntary recovery

Table 14: this table describes the process when the agency receives a payment that is cheque or money order from a health professional in relation to a bulk bill overpayment.

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Step	Action
1	Scan documentation into PaNDA 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
2	Locate PaNDA work ID 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
3	Confirm adjustment has been actioned 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
4	Attach copy of LDA statement 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.
5	Update DCEI 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
6	Check overpayment amounts against payment received 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.
7	Print DPSI screen 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
8	Forward Payment to Medicare Debt Recovery Parramatta 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

Register bulk bill adjustment on adjustment

Table 15: this table describes how Service Officers register a bulk billing adjustment on adjustment using the DHSI screen and provides the required fields to be completed.

Note: bulk billing adjustment on adjustments can only be actioned by experienced Service Officers who have been granted access.

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Step	Action
1	Assess adjustment request 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.
2	Log into Mainframe (CICS) and key details 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.
3	Validate details 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.

Suppress services in a bulk bill LDA claim

Table 16: this table describes how Service Officers can suppress services on a patient's record. Suppression of claims is only performed by experienced Service Officers. Most commonly for compliance adjustment or fraud remediation.

Note: suppression of claims is only performed by experienced Service Officers.

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Step	Action
1	Locate service line(s) 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
2	Check suppressed line(s) 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.
3	Finalise adjustment 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]

Voluntary acknowledgement of incorrect payments form

Table 17: this table describes how Service Officers action voluntary acknowledgement of incorrect payments forms.

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Step	Action
1	Identify the form Review the form in full. If the documentation received is the Department of Health, Disability and Ageing's Voluntary acknowledgment of incorrect payments. Go to Step 2. If this is the Department of Veterans' Affairs voluntary acknowledgement of incorrect payments, see Processing and recovery of overpayments for Veterans' Affairs Processing (VAP).
2	Save work item 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 dropdown box Select Save
3	Send the work item to the Department of Health, Disability and Ageing 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, Disability and Ageing (Voluntary Compliance Team) mailto:voluntary.compliance.team@health.gov.au Select Official as the email classification Select Send
4	Close PaNDA work ID 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

Operational Information

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

On this page:

Order of entry

Register bulk bill claim for adjustment

Amend a service in a bulk bill LDA claim

Insert a service during adjustment processing

Delete service(s) or total overpayment

Transfer service from one patient to another

Process bulk bill LDS to include additional services in a claim

Recall a bulk bill LDA claim

Reset a bulk bill LDA claim

Action a same day bulk bill LDA claim reversal

Delete a bulk bill LDA claim

Co-claiming Matrix - Process for claims that return 1-PREV CON message - Bulk bill

Bulk bill LDA results in overpayment

Bulk bill adjustments voluntary recovery

Register bulk bill adjustment on adjustment

Suppress services in a bulk bill LDA claim

Voluntary acknowledgement of incorrect payments form