Process Medicare Safety Net claims 011-43080040

This document explains how to process claims when a Medicare Safety Net threshold has reached.

Step	Action
1	Key claim details The warning message 1-SEL FAM is displayed, where a person is registered on 2 Safety Net family registrations.
2	Determine correct Safety Net family Determine which Safety Net family paid for the service by checking the claimant details. Go to the patient's history in mainframe Place the cursor on the Charge field and press [F1] If unable to determine Family Safety Net, go to Step 3 If able to determine Family Safety Net, go to Step 4
3	Further investigation required to determine correct Family Safety Net The service officer should: attempt to contact the claimant on at least 2 occasions to discuss which Medicare Safety Net family registration to allocate the out-of-pocket (OOP) to record all contact attempts and relevant details in CDMS amend the Family Safety Net composition if either: the information provided by the claimant indicates that changes are necessary if the total OOP amount towards the threshold is over 70% If contact is successful, go to Step 4 If contact is unsuccessful, make additional checks to determine registered Medicare Safety Net family, including: checking whether the family contact is listed on the Medicare card associated with the claimant reviewing claims from the same provider within the previous 12 months to identify whether a different claimant has been used for similar services checking if the patient has accumulated a higher level of OOP expenses under one Family Safety Net registration compared to another determining the most appropriate Medicare Safety Net family based on the available evidence Record a detailed CDMS note and include: all unsuccessful contact attempts the reason contact was attempted any investigation actions taken to determine the Medicare Safety Net family. Note: if the Medicare Safety Net family registration cannot be identified using the methods above, locate the servicing provider postcode and select the registration with the closest postcode. Go to Step 4
4	Select the correct Safety Net family Select the correct Safety Net family by positioning the cursor under the relevant family registration, below the Medicare Patient Claims screen in mainframe and press [F5]. Process the claim. Procedure ends here.

Online claim with a partial payment

Table 2: This table describes what service officers need to do for an online claim lodged by a health professional with a return message of 1-SNET PND. Note: the source office code to process claims for return message 1-SNET PEND is AJPP and must be selected before processing.

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Step	Action
1	Select claim Log into Mainframe Select source office code AJPP Key MQRI Press [Enter] Select a claim by keying 'S' in the 'A' field Press [Enter]
2	Check for partial payments Place the cursor on the Fee field and press [F1]. Partial payments will appear on the bottom left of the screen. Take a snip of the claim that has been selected for processing (this is to retain the details of the claim for verification later).
3	Action return messages Review and apply assessing restrictions by following warning messages Warning messages must be actioned in order from left to right More details can be viewed by placing the cursor at the beginning of the return message and pressing [F1]
4	Confirm the amount of partial payment made is correct Add the partial payment amount and the benefit together. Does the partial payment and the benefit equal the charge? Yes Key P to pay the claim. A PDVC cheque will be generated to the health professional Go to Step 5 No, if the partial payment has been allocated incorrectly or the partial payment is greater than the benefit, go to Step 6 Medicare benefit under $2.00, go to Step 7
5	Verify the service Payment to the claimant is now made via the Substantiate patient contribution (NSCI) screen. Ensure the partial payment amount matches the amount shown in the NSCI screen. To action the verification, see Table 1 in Verify services for Medicare Safety Net Where the claim has entire partial payment against the one item, it cannot be modified. When the claim is verified by the service officer via the NSCI screen the system will automatically allocate the partial payment against one item. Procedure ends here
6	Partial payment more than 100% of OOP If a claim contains multiple items, and the partial payment has been allocated to one item number only, the service officer must make one genuine attempt to contact the practice. This may occur because the health professional does not know that OOP amounts should be against each item. An outbound call is made to explain that the partial payment should be distributed across the items. Note: the intent of the outbound call is to educate the health professional. If contact is: successful - explain how the partial payment should be distributed across the items. Do not process the claim. Advise the health professional to resubmit the claim with the partial payment allocated correctly. unsuccessful - continue processing the claim. Procedure ends here
7	Medicare Benefit under $2.00 Complete this step only when the Medicare benefit is less than $2.00. If an online claim with a partial payment result in a PDVC benefit of less than $2.00, cancel the claim and change the status to unresolvable. Do not pay the claim. The claim must be cancelled Press [F2] to access the NQ menu Key ‘C’ in the S field and press [Enter] Select option 1 by keying ‘1’ in the Change Status field and press [Enter] Key ‘U’ to Update Press [F2] to return to the NQ menu Key ‘T’ in the S field Add the text message ‘Benefit greater than 100% OOP benefit less than $2.00’ Note: it is important to leave a text message because this will help service officers when responding to enquiries about the claim. To view messages left by service officers, use control line NQEI,DA,cardnumber and key a ‘T’ in the S field. Procedure ends here.

Digital self-service and manual patient claims with a partial payment

Table 3: This table describes what service officers need to do to action either a digital self-service claim or manual patient claim with a return message of 1-SNET PND. Note: the source office code to process claims for return message 1-SNET PEND is AJPP and must be selected before processing.

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Step	Action
1	Select claim Log into Mainframe Select source office code AJPP For digital self-service claims Key control line NQEI,CLAIMID/Service ID (from PaNDA) Press [Enter] For manual patient claims Key claim details Review and apply assessing restrictions by following warning messages Warning messages must be actioned in order from left to right More details can be viewed by placing the cursor at the beginning of the return message and pressing [F1]
2	Confirm the amount of partial payment made The account will show the amount of the partial payment made by the claimant. If the receipt shows a lump sum for multiple services, allocate the partial payment to each service. Deduct the benefit displayed in Mainframe from the charge for each service Add all partial payments together Note: make sure the outstanding balance on the receipt, less the partial payment, is correct before paying the claim. Does the amount shown as the partial payment made equal the OOP? Yes Key ‘P’ to pay the claim. This will generate a pay doctor via claimant (PDVC) cheque to the health professional Go to Step 3 No The service officer must make one genuine attempt to contact the health professional Add a processing note in PaNDA Go to Step 4
3	Verify the service Payment to the claimant is made via the NSCI screen. Make sure the partial payment amount matches the amount shown in the NSCI screen. See Verify services for Medicare Safety Net > Table 1 for help on how to action the verification Go to Step 4.
4	Partial Payment not equal to the OOP amount If the partial payment made is less than the OOP amount, pay the claim but do not verify the partial payment. The claimant will need to provide a receipt showing services paid in full to verify the services. If the partial payment made is more than the owed OOP cost, pay the claim. Procedure ends here.
5	Partial payment more than 100% of OOP For Digital self-service and manual patient claims, the service officer must apportion the payment across the items when verifying the service. This is done by distributing the partial payment amount into the number of services on the account (provided the OOP amount is correct). The Resources page contains an example of when more than 20% of the OOP has been paid. If a claim contains multiple items, and the partial payment has been allocated to one item number only, the service officer must make one genuine attempt to contact the practice. This may occur because the health professional does not know that OOP amounts should be against each item. An outbound call is made to explain that the partial payment should be distributed across the items. Note: the intent of the outbound call is to educate the health professional. If contact is: successful - explain how the partial payment should be distributed across the items. Do not process the claim. Advise the health professional to resubmit the claim with the partial payment allocated correctly. unsuccessful - continue processing the claim.
6	Finalise the work item Record a processing note in PaNDA explaining actions taken and complete the work item

Operational Information

Process Medicare Safety Net claims 011-43080040

On this page:

Selecting the correct Safety Net family for Medicare claims

Online claim with a partial payment

Digital self-service and manual patient claims with a partial payment