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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 reached.

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 a Medicare Safety Net threshold reached

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 a Medicare Safety Net threshold reached

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 verification is required

Table 4: this table provides an example of the calculation of an account where less than 20% has been paid and verification 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 threshold reached

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 the Medicare Safety Net threshold reached

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

Message 8-CONFIRM

Table 8: this table provides examples of what actions to take when presented with a message 8-CONFIRM during processing.

Claim type

Action

Manual Patient Claim or Medicare Online Account/myGov app

Make one genuine attempt to contact the patient or claimant to confirm the Medicare Safety Net details. Exception - For ART/IVF claims. Staff must make two genuine attempts to contact at two different times.

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

If contact unsuccessful,

  • Press [F9] to acknowledge the 8-CONFIRM message
  • Continue processing the claim
  • Add the relevant PaNDA and CDMS comments.

Medicare Online Claims (Provider lodged General Onlines)

  • [F9] to acknowledge the 8-CONFIRM message and continue to process the claim
  • Exception - For ART/IVF claims. Staff must make two genuine attempts to contact at two different times. If unsuccessful [F9] to acknowledge the 8-CONFIRM message and continue to process the claim. Leave notes in CDMS/PaNDA on details of contacts attempted