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

Adjustment type

Documents required

Example of adjustment

Amendment to original:

• Item number(s)

Date of service or

• Add additional item number(s)

• Application for bulk bill claim adjustment form (DB018)
• New signed assignment of benefit form (by the patient) with the correct information

The health professional originally:

• Billed an item 23 however meant to bill item 2715
• Billed item 732 x 1, however meant to bill 732 x 3
• Billed an item for DOS 11/07/2023, however the service was performed on 10/07/2023

Deletion of previously paid claim(s)

• Application for Bulk Bill claim adjustment form (DB018) with all claim information present on the form, that is:
  • Patient's Medicare Number and Name
  • DOS
  • Item Number(s) etc. or
• A letter using the practice letterhead which includes all claim information and signed by the health professional

The health professional:

• Bulk billed the patient, however the patient was meant to be privately billed
• Bulk billed the patient, however the service did not occur
• Bulk billed the patient, however the claim was meant to be submitted via Simplified Billing
• Submitted the claim using the incorrect provider number

Amendment to:

• The date of referral (DOR)
• Referral period validity

• Application for bulk bill claim adjustment form (DB018)
• Copy of referral with correct date details

The health professional:

• Lodged the DOR as 13/02/2023, however it was meant to be 13/05/2023
• Lodged the referral as being valid for 12 months, however they have received an indefinite referral

Omitted bulk bill incentive or patient episode initiation (PEI) item(s)

This also includes omitted telehealth incentive items.

• Application for Bulk Bill claim adjustment form (DB018)
• A spreadsheet outlining service details (patient name, Medicare number, DOS etc.)

Note: a new signed assignment of benefit form is not required if this is the only change being requested

The health professional:

• lodged the Bulk Bill claim without any incentive items, however they are entitled to bill these items to Medicare i.e. item 10990 was not billed to the patients record

Adjustment to originally claimed bulk bill incentive or patient episode initiation (PEI) item(s)

• Application for Bulk Bill claim adjustment form (DB018)
• A spreadsheet outlining service details (patient name, Medicare number, DOS etc.)

Note: a new signed assignment of benefit form is not required if this is the only change being requested

The health professional:

• lodged the claim using item 10990, but meant to use item 75855

DHSC screen features

Description

Original line

All field are protected, except the A field which contains an O to indicate the Original line.

Reinstated line with corrected details

All keying fields are unprotected and an R is displayed in the A field to indicate the Reinstated line.

Zero in the FEE and BENEFIT fields

Restates PI's, IE, IL, IS and 11.

Any other PI's and all reason codes are not reinstated, allowing the adjustment line to be completely re-assessed.

Error messages

Relating to the accuracy of the new details.

Service lines

Nine service lines can be displayed.

If I is entered on the A field on the ninth line, the new line is positioned on the next DHSC screen.

Note: press [F8]-Forward to scroll forward to the next screen.

Code

Description

Explanation

DRD

Debt Received

Applies if the health professional has indicated that they have paid the overpayment and Medicare Debt Recovery can confirm that the amount has been received.

DRI

Doctor Refund Initiated

Applies if the recovery action needs to be pursued as monies are owed to Services Australia as a result of the overpayment.

EFT

Medicare Provider EFT returned

Applies if the agency's banking details were stored on the provider's records. An overpayment is then processed, and EFT is entered to advise debt recovery that the agency is in receipt of the overpayment amount.

VRC

Voluntary Recovery

Applies if the health professional submits a cheque or money order in relation to a Bulk Bill overpayment.

If the sum of all adjustments results in:

Then claim status is:

Either no change to benefit paid or an underpayment of less than $1.00

ADJ PAID

An underpayment of $1.00 or more

ADJ HIST

An overpayment (regardless of amount)

ADJ OPAY

If the sum of all adjustments results in:

Then claim status is:

Either no change to benefit paid or an underpayment of less than $1.00

ADJ PAID

An underpayment of $1.00 or more

ADJ HIST

An overpayment (regardless of amount)

ADJ OPAY

Adjustment type

Action:

Overkey

Key:

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

Transfer

Overkey:

• Card number and/or
• Patient's name

Suppress

Action codes:

• H - suppress HIC internal reasons
• M - suppress Medicare Online (MOL)
• F - suppress fraud

Delete total overpayment

Use action code T

Note: this has replaced action code D.

Insert

In the A field key action code I over:

• R or
• N

Original Line (System generated codes)

Action codes:

• O - replaced the action code entered by the Service Officer
• R - must have a matching O line. Can be overtyped with X or I action codes

Adjust

Action code:

• A - can only be used on an unadjusted line

Patient transfer

Action code:

• P - allows Service Officer to adjust a patient transfer

Reason code

Line type

888

Original line

816

Restated line

861 and item of UPAY

Result line

Reason code

Line type

888

Original line

818

Restated line

819 and item of OPAY

Result line

Reason code

Line type

888

Original line

821

Restated line

Result line

Reason code

Line type

889

Original line

821

Restated line

881 and item of UPAY

Result line

Reason code

Line type

889

Original line

841

Restated line

Result line

Reason code

Line type

889

Original line

841

Restated line

Result line

Reason code

Line type

898

Original line

890

Restated line

891 and item of OPAY

Result line

Reason code

Line type

898

Original line

891

Restated line

891 and item of OPAY

Result line

Reason code

Line type

898

Original line

891

Restated line

892 and item of OPAY

Result line