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 and 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 and 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
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
|
Letters
Services Australia has endorsed the letter or electronic message for use. It is the latest version. Do not use locally produced letters or electronic messages.
Medicare Safety Net
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