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Process Medicare Safety Net claims 011-43080040

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Example of system calculated benefit on fully paid accounts

Table 1: this table provides an example of how the system calculates the benefit on fully paid accounts when the Medicare Safety Net has been met.

Billing scenario

Amount paid

Doctor’s charge

$55.00

Patient payment

$55.00

Standard Medicare benefit

$31.45

Benefit to patient (Standard benefit + Additional benefit)

Note: where an extended Medicare Safety Net (EMSN) benefit cap applies, the additional benefit may be less than the 80% out-of-pocket expense.

$50.30

Pay doctor via claimant (PDVC)

NIL

Example of an account where 20% has been paid and the Medicare Safety Net met

Table 2: this table provides an example of the calculation of an account where 20% has been paid.

Billing scenario

Amount paid

Doctor’s charge

$55.00

Patient payment

$4.70

Standard Medicare benefit

$31.45

Benefit to patient

NIL

Pay doctor via claimant (PDVC)

$50.30

Example of an account where less than 20% has been paid and the Medicare Safety Net met

Table 3: this table provides an example of the calculation of an account where less than 20% has been paid.

Billing scenario

Amount paid

Doctor’s charge

$55.00

Patient payment

$4.00

Standard Medicare benefit

$31.45

Benefit to patient

NIL

Pay doctor via claimant (PDVC)

$31.45

Example of an account where less than 20% has been paid and substantiation is required

Table 4: this table provides an example of the calculation of an account where less than 20% has been paid and substantiation is required for a further benefit to be paid.

Billing scenario

Amount paid

Doctor’s charge

$55.00

Initial patient payment

$4.00

Standard Medicare benefit

$31.45

Benefit to patient

NIL

Pay doctor via claimant (PDVC)

$31.45

Additional patient payment

$19.55

Benefit to patient (Standard benefit + Additional benefit)

Note: where an extended Medicare Safety Net (ESMN) benefit cap applies, the additional benefit may be less than the 80% out-of-pocket (OOP) expense.

$18.85

Example of an account where more than 20% has been paid and the Medicare Safety Net met

Table 5: this table provides an example of the calculation of an account where more than 20% has been paid.

Billing scenario

Amount paid

Doctor’s charge

$55.00

Patient payment

$10.00

Standard Medicare benefit

$31.45

Benefit to patient

$5.30

Pay doctor via claimant (PDVC)

$45.00

Example of unpaid accounts when Medicare Safety Net met

Table 6: this table provides an example of the calculation when an unpaid account is claimed.

Billing scenario

Amount paid

Doctor’s charge

$55.00

Patient payment

NIL

Standard Medicare benefit

$31.45

Benefit to patient

NIL

Pay doctor via claimant (PDVC)

$31.45

Description of transaction codes and modifiers for Medicare Safety Net

Table 7: this table provides a description of the control lines and modifiers for the Medicare Safety Net Family Registration and Enquiry system.

Transaction

Consumer Directory Maintenance System (CDMS)

Description

Inquire on a Safety Net record

Inquire on Consumer Details link on CDMS

Service Officers see:

  • Registration summary
  • Consumer details
  • Family Safety Net Registration details
  • Threshold details
  • Confirmation details
  • Letter details
  • Comments

Amend a Safety Net registration

Amend on Consumer Details link on the CDMS home page

Service Officers can:

  • Amend consumer details
  • Amend family member type
  • Remove a family member
  • Add a family member
  • End date a family
  • Request a letter
  • Add comments

Register a Safety Net family

Register New Consumer link on the CDMS home page

Service Officers can register a new Medicare Safety Net family.

Confirm a registered safety net family

Service Officers can:

  • confirm a family composition
  • print a confirmation form

Person unable to verify their family composition at a service centre

Table 8: this table provides examples of when a person is unable to verify their family composition at a service centre.

If the patient and claimant are on…

and are…

then…

the same Medicare card

able to be contacted

confirm the Medicare Safety Net family composition over the phone:

  • complete a security check
  • check safety net registration details
  • make any required adjustments
  • confirm safety net registration
  • process claim

the same Medicare card

not able to be contacted

Manual claim:

  • return the claim to the claimant with both a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit if they confirm their family composition prior to the claim being processed

Medicare online account, Express Plus Medicare/myGov app claim:

  • send the claimant a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed

Provider online claim:

  • [F9] to acknowledge the 8-CONFIRM message and continue to process the claim

different Medicare cards

on the same Safety Net registration and able to be contacted

confirm the Medicare Safety Net over the phone:

  • complete a security check
  • check safety net details
  • make any required adjustments
  • confirm safety net
  • confirm the family composition over the phone
  • process claim

different Medicare cards

on the same Safety Net registration and not able to be contacted

Manual claim:

  • return the claim to the claimant with both a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed

Medicare online account, Express Plus Medicare/myGov app claim:

  • send the claimant a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed

Provider online claim:

  • [F9] to acknowledge the 8-CONFIRM message and continue to process the claim

different Medicare cards

not on the same Safety Net registration and able to contact the patient

confirm the Medicare Safety Net with the patient over the phone:

  • complete a security check
  • check safety net details
  • make any required adjustments
  • confirm safety net
  • confirm the family composition over the phone
  • process claim

different Medicare cards

not on the same Safety Net registration and unable to contact the patient

Manual claim:

  • return the claim to the claimant with both a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed

Express Plus Medicare/myGov app claim:

  • send the claimant a Medicare Safety Net confirmation form and a letter advising them that they may be entitled to a higher benefit when they confirm their family composition prior to the claim being processed

Online claim:

  • [F9] to acknowledge the 8-CONFIRM message and continue to process the claim

Medicare Safety Net templates

Standard Letters Template