Medicare benefit not received (EFT dispute) 011-43120010

The claimant needs to provide confirmation of identity. Where the claimant is:

• present at a Medicare Service Centre, sight Acceptable identification
• not present at a Medicare Service Centre or is unable to produce acceptable identification conduct a security check

Claim details can only be discussed with the claimant.

Does the customer confirm they are the claimant for this service?

• Yes, go to Step 2
• No, tell the customer only the claimant can get information about the service

To identify the disputed EFT transaction, the claimant must supply the following information in relation to the payment in dispute:

• patient name and Medicare card number
  Note: when the Medicare card number is unknown, search CDMS to get the card number or Consumer ID
• servicing health professional
• Bank, State, Branch (BSB), account number and account name of the account where the claimant believes the funds should have been directed
• Date of services (DOS), if known

Key NHSI, card number, patient > [Enter]:

• claims history is displayed against the patient's Medicare card history

Scroll [F8] through the patient history to identify the disputed claim.

Claim on system

If the claim relating to the dispute has been processed:

• key [F1] under the charge amount to confirm the claimant details matches the claimant disputing non-payment (claimant name will display bottom left hand corner). If the claimant’s details:
• match, go to Step 5
• do not match, see Table 2

Claim not on system

If the claim relating to the dispute was not processed (not showing on history), refer to CDMS and check the comments tab for information indicating if the claim was returned to the claimant.

• ask the claimant if the claim was submitted at point of service. If so, contact the health professional
• if the claim was returned tell the claimant that the claim was returned, the date it was returned and the reason. Procedure ends here
• if no comments are recorded in CDMS and the claim was not received, tell claimant that the claim was not received by Medicare and to resubmit the claim. Procedure ends here

On the service line, press [F10] to display the EFT details used for the claim:

• press [F1] under the account number displayed in the CHQ/EFT field
• verify details of the bank account where the claimant believes the funds should have been directed

If the bank details are incorrect, go to Step 6.

If the EFT payment status displays PAID the payment has been deposited into the displayed bank account.

Check the Paid Date on the claim history screen. If the paid date is:

• less than 3 days, tell claimant to wait as some financial organisations hold funds for a number of days before depositing to claimant accounts
• greater than 3 days, go to Step 6

Note: if the claimant wants confirmation of the nominated bank account the payment was deposited into, Service Officers can only disclose the name of the bank (not the branch or BSB number) and the last 3 digits of the account number. Procedure ends here.

If the status displays HELD, the claimant does not have bank details registered. Ask the claimant to provide the bank details and update CDMS. The payment will be released in the overnight payment run.

If the EFT payment status displays REJECT, the payment has been rejected by the financial institution and returned to the agency. Tell the claimant that the payment has been rejected by the financial institution and their bank details will need to be updated and the Medicare benefit repaid.

If the EFT payment status displays REDIRECT, the payment has been redirected to their nominated bank account. Tell claimant that the payment has been redirected to their newly nominated bank account.

Note: if the claim was originally held as no bank details were recorded, the system will display the payment date as the original processing date when bank detail are updated. Check if the bank account details have only been recorded in the past few days, as the day after the bank details have been recorded will be the actual payment date.

If the:

• claim has been processed
• correct claimant is recorded
• payment is not showing on Mainframe as being rejected by the bank

Determine if the correct bank account details have been keyed. See Table 3.

If the customer does not display as the claimant for the disputed claim, and

• the claim was transmitted electronically by the health professional and the patient and claimant is a child, and the child is only on one card and has bank account details recorded, determine:
• who the correct claimant is, refer to Held EFT payments for children under 14 years of age and follow the steps to identify who the claimant was
• who the bank details recorded belong to, see Table 3
• if the payment has been paid to someone other than the person identified as the correct claimant the claim must be reprocessed to the correct claimant
• if it has been identified whose account the benefit was paid to, a debt is to be raised for the person
• if it cannot be identified who belongs to the account an EFT retrieval must be completed (complete an EFT dispute form and send to MPS Assessing)
• the claim was transmitted electronically by the health professional and the patient and claimant is a child, and the child is on 2 cards:
• check if bank account details have been recorded for the child
• if bank details have been recorded, check if the payment has gone to anyone other than the person identified as the correct claimant. For example, the payment has been incorrectly paid to the other parent
• if the payment has been paid to someone other than the person identified as the correct claimant. For example benefit paid to other parent, the claim must be reprocessed with the correct claimant and a debt raised for the person whose bank account details were recorded
• if it cannot be identified who belongs to the account and EFT retrieval must be completed (complete an EFT dispute form and send to MPS Assessing)

For more details:

• see Table 3
• Policy held EFT payments for children under 14 years of age

If the customer does not display as the claimant for the disputed claim, and:

• the claim was transmitted electronically by the health professional
• the patient is an adult

The Service Officer must contact the servicing health professional to determine who is the correct claimant.

If the health professional confirms the claim was submitted incorrectly with the incorrect claimant, the Service Officer must either:

• request the service details and write on a VG4 form, or
• request the health professional send through an amended invoice

The correct claimant is to be paid the benefit and an overpayment raised against the incorrect claimant. See Table 5.

If the health professional cannot confirm that the claimant is incorrect, ask the claimant to provide evidence that they were the claimant.

Has the claimant provided evidence?

• Yes, the correct claimant is to be paid the benefit and an overpayment raised against the incorrect claimant. See Table 5
• No, an EFT retrieval should be undertaken. If the retrieval is unsuccessful, issue Claimant standard letter advising retrieval was unsuccessful

Request batch work to verify if the customer is the correct claimant.

Once batch work has been received and claimant is correctly recorded, establish who the bank details belong to, see Table 3.

If the batch work received confirms that the customer details do not match the claimant, establish if the claim has been processed correctly.

Has the claim ben processed correctly?

• Yes, EFT retrieval is to be undertaken. Complete an EFT dispute form, and MPS Assessing team sends EFT retrieval request to treasury
• No, see Table 6

If it has been determined that the claimant is correct, no more action is needed. Tell the customer.

Log on to Mainframe:

• key NHSI, card number, patient > [Enter]
• claims history is displayed against the patient's Medicare card and PIN history
• scroll [F8] through the patient history to identify the disputed claim

Once the claim has been identified:

• key [F10] under the benefit amount to display CHQ/EFT
• key [F1] under the CHQ/EFT field to display bank account details
• bank account details will display on bottom left hand side of screen
• the account number will display if the bank account details were permanently recorded (P), or temporarily recorded (T)
• if the account displays:
• P these bank details were sourced from Consumer Directory Maintenance System (CDMS), go to Step 2
• T these bank details were used for this claim only and would have been provided by either a claim form, health professional or telephone claim, go to Step 3

Logon to CDMS:

• select Amend on Consumer Details
• key the claimant’s ID number and ID number type. For example, if using the claimant’s Medicare card number, key the 10 digits of the Medicare card in the ID number field and select 'Medicare card' in the ID number type tab, then select Personal
• select the Comments tab to check if any comments have been recorded regarding banking details
• select the Banking Details tab
• compare the following fields with the details provided by the claimant and details recorded in Mainframe:
• BSB
• Account Number

Check if the bank details match.

Do the bank account details match?

• Yes, if the bank account is correct, and the accounts match, tell the claimant:
• that the benefit was paid into their nominated account
• the date it was paid, and
• the amount paid
• procedure ends here
• No, if the bank account is incorrect:
• end date the invalid or incorrect bank account details in CDMS
• go to Step 3

Note: Service Officers must look at all dot points in Step 2 to see if they apply to the claimant, and check comments/flags. If the claimant has an active Invest and/or CMBO flag send to MPS Assessing with EFT dispute form (noting on the form - invest flag on record). The Resources page contains a link to this form.

Check:

• if, and when, the bank account details were updated
• if the bank account details have been updated often, particularly in a short period of time this may be possible fraudulent activity. See Medicare fraud abuse and inappropriate practice
• identify the notification source of the updated bank details in CDMS next to the relevant start and end dates
• if the update was through a Medicare claim form (processed 2 years and less) request batch work to confirm if the bank account was keyed correctly. If batch work confirms agency error see Table 6. If the claimant is at fault request an EFT retrieval
• if batch work cannot be requested due to the source documents dating over 2 years, see Table 6
• if the update was made verbally, check if the comments in CDMS say that the bank account was read to the claimant who then confirmed the details were correct. If comments confirm this process was not followed, it is considered an agency error. See Table 6. If claimant confirmed bank details were correct, claimant is at fault. An EFT retrieval is to be undertaken
• if the update was made online, see Table 7
• if the bank account details have not been recently updated:
• ask the claimant if they may have neglected to notify the agency of their new bank account details following a change in circumstances. For example separation, closing bank account
• check the date the bank account details were updated and if the claim was processed before the bank account being registered. Payment will have been paid into the old account or if no bank details registered the payment will be held. Once bank details have been entered the benefit will be automatically paid the following day
• check if the payment was originally held and has only just been released. The payment day remains as the original processing date. Check CDMS to see what date bank details were recorded. Payment will be in the claimant’s bank account up to 3 days after this date

Note: a CDMS history search of the claimants banking details may be needed.

Log on to Mainframe:

• key NHSI, card number, patient > [Enter]:
• claims history is displayed against the patient's Medicare card and PIN history
• scroll [F8] through the patient history to identify the disputed claim

To check if the claim was submitted manually, request batch work to confirm if the bank account was keyed correctly.

Does the batch work confirm agency error?

• Yes, see Table 6
• No, if the claimant is at fault, request an EFT retrieval

Note: if batch work cannot be requested due to the source documents dating over 2 years, see Table 6.

Check if claim was submitted online at point of service.

If a practice has transmitted the incorrect bank account details:

• tell the claimant to discuss this with the practice to make sure the incorrect bank account details are not used again
• undertake an EFT retrieval
• complete an EFT dispute form and see MPS Assessing
• MPS Assessing forward EFT retrieval to treasury. If retrieval is successful, reimburse claimant. If retrieval is unsuccessful, issue Claimant standard letter advising retrieval was unsuccessful

Check for previous EFT disputes in the:

• Recorded Comments field of CDMS for the claimant. Identify any previous EFT disputes
• Reference field. Identify the date these were recorded

Has the claimant had 2 disputes within a 12 month period?

• Yes, disputes should be treated as benefit amount $100 and over. See Table 7
• if suspected that there is potentially fraudulent claiming activity, complete the EFT dispute form and send to the MPS Assessing Team to investigate further. See the Resources page for a link to the form
• for more details see Medicare fraud abuse and inappropriate practice
• No, go to Step 3

In the Comments tab in Personal key the following details in order:

• amount disputed
• EFT dispute
• item number(s)
• provider number
• date of service
• explain the situation

Example: $32.10, EFT dispute, 23 999999A 010101 immediate reimbursement of benefit amount below $100.

Note: it is critical to key the amount and EFT dispute in the correct order for each dispute as these will be used to generate reports on the numbers of disputes and will help in management reporting and ongoing policy decisions in this area.

Reverse the original claim(s) made to the incorrect bank account. This will be reported as an overpayment.

Reprocess claim as an adjustment to the correct bank account.

Initial investigation process (see tables 1 to 4) must have been undertaken first.

Key details

In the Comments tab in Personal key the following details in order:

• amount disputed
• EFT dispute
• item number(s)
• provider number
• date of service
• explain the situation

Example: $162.10, EFT dispute, 23 999999A 010101 benefit amount over $100.

Note: it is critical to key the amount and EFT dispute in the correct order for each dispute as these will be used to generate reports on the numbers of disputes and will help in management reporting and ongoing policy decisions in this area.

Determine who made the error that caused the incorrect payment. See policy to determine who is at fault:

• the agency, see Table 6
• a non-agency error (claimant/third party), go to Step 3
• details were updated online, see MPS Assessing

If the initial investigation establishes that the payment has gone into the wrong bank account due to claimant error or third party, the agency will attempt an EFT retrieval for any amounts totalling over $100:

• complete an EFT dispute form and forward to MPS Assessing to action
• tell the claimant that the claim has been paid using the EFT details supplied and confirmed by the claimant and an EFT retrieval will be completed
• complete the EFT dispute form and email to MPS Assessing team. The Resources page contains a link to the form

If the initial investigation establishes that the wrong claimant was selected due to claimant error:

• the claim is to be reprocessed with the correct details (the practice may need to be contacted to verify details. see Table 2
• if the payment did not go to the correct claimant, the claimant should be repaid, do not action an EFT retrieval, request for a debt to be raised against the incorrect claimant via MPS Assessing

Note: if bank account details were updated online and claimant advises they did not change their bank account details online. See Table 8.

Initial investigation process (see tables 1 to 4) must have been undertaken first.

Key details

In the Comments tab in Personal key the following details in order:

• amount disputed
• EFT dispute
• item number(s)
• provider number
• date of service
• explain the situation

Example: $162.10, EFT dispute, 23 999999A 010101 benefit amount over $100.

Note: it is critical to key the amount and EFT dispute in the correct order for each dispute as these will be used to generate reports on the numbers of disputes and will help in management reporting and ongoing policy decisions in this area.

If it has been determined that the claimant is eligible to be reimbursed:

• reverse the original claim(s) made to the incorrect bank account, this will be reported as an overpayment
• if the total benefit is $100 and over, tell Medicare Debt Recovery via email not to raise an overpayment or send a recovery letter to the claimant. This can be actioned by completing the Cancellation of Debt Recovery email template found in the Resources tab
• reprocess the claim as an adjustment using the correct details, for example, correct claimant, correct bank details
• if the Service Officer can determine to whom the incorrect payment was made to, for example, if on original claim incorrect claimant details provided or Service Officer established whose bank account details the benefit was paid, do not action an EFT retrieval, request for a debt to be raised against the incorrect claimant/bank holder via MPS Assessing
• if the Service Officer cannot determine who received the payment complete an EFT dispute request and forward to MPS Assessing

Make sure that the initial investigation process has been followed as first step:

• action any steps needed that were not undertaken
• review information on dispute form and confirm correct assessment was made

Note: if the claimant has advised they did not change their bank account details online. See Table 8.

Determine who made the error that caused the incorrect payment:

• agency, go to Step 3 (if the claimant has not been reimbursed)
• claimant, go to Step 4
• third party, go to Step 5
• unable to determine, details were provided in a form over 2 years ago, go to Step 3
• details were updated online, go to Step 4
• unsure, may involve fraudulent claiming, go to Step 7

If the Service Officer at the first point of contact has determined that the claimant is eligible to be reimbursed, and has not reprocessed the claim:

• reverse the original claim(s) made to the incorrect bank account/incorrect claimant, this will be reported as an overpayment. Tell Medicare Debt Recovery not to raise an overpayment against this claimant and not to send a recovery letter to the claimant
• if the Service Officer can determine to whom the incorrect payment was made to. For example if a Service Officer can establish whose bank account details the benefit was paid, do not action an EFT retrieval, request for a debt to be raised against the incorrect claimant/bank holder
• re-process the claim using the correct EFT details

If the Service Officer cannot determine to whom the incorrect payment was made complete an EFT retrieval form and send to Services Australia Treasury section to process.

Once confirmed claimant is at fault:

• complete an EFT dispute form and send to Treasury to process
• if the retrieval is successful, reimburse the claimant
• if the retrieval is unsuccessful, issue Claimant standard letter advising retrieval was unsuccessful

Note: if bank account details were updated online and claimant advises they did not change their bank account details online. See Table 8.

If the third party transmitted or provided incorrect bank account details:

• complete an EFT retrieval form and send to Treasury section to process
• if the retrieval is successful, reimburse the claimant
• if the retrieval is unsuccessful, issue Claimant standard letter advising retrieval was unsuccessful

If the third party selected an incorrect patient, claimant or Medicare card (also see determining correct claimant):

• reverse the original claim(s) in dispute, this will be reported as an overpayment
• if the Service Officer can determine to whom the incorrect payment was made. For example, if on original claim incorrect claimant details provided or Service Officer established whose bank account details the benefit was paid, do not action an EFT retrieval, request for a debt to be raised against the incorrect claimant/bank holder
• reprocess the claim using the correct EFT details

If the Service Officer cannot determine to whom the incorrect payment was made complete an EFT retrieval form and send to Treasury section to process:

• if the retrieval is successful, reimburse claimant
• if retrieval is unsuccessful, issue Claimant standard letter advising retrieval was unsuccessful

Check if the Comments are recorded in CDMS in Personal tab. If not, key the following details in order:

• amount disputed
• EFT dispute
• item number(s)
• provider number
• date of service
• explain the situation

Example: $162.10, EFT dispute, 23 999999A 010101 <reimbursement/no reimbursement> of benefit amount over $100, <claimant error/agency error/referred via the Report Suspected Fraud system for investigation>. Repaid on $ on / /

Note: it is critical to key the amount and EFT dispute in the correct order for each dispute as these will be used to generate reports on the numbers of disputes and will help in management reporting and ongoing policy decisions in this area.

Tell the claimant that their dispute will need to be investigated. The agency cannot repay any Medicare benefits, until the agency completes its investigation.

These issues are addressed via the Report Suspected Fraud system. The Resources page contains a link to this system.

Carry out an investigation including:

• checking CDMS for dates the bank account details were updated online
• check if bank account details have been changed often, particularly in a short period of time
• search Mainframe to see if any other claimants own the account where the Medicare benefits were deposited
• other comments/flags
• what other details were updated online, for example address/contact details

Is there enough evidence to support to claimant’s statement?

• Yes, go to Step 4
• No, go to Step 3

Contact the health professional to confirm the service(s) and check this matches information on the receipts provided by the claimant.

Is there enough evidence to support to claimant’s statement?

• Yes, go to Step 4
• No, go to Step 5

If it is has been determined that the claimant is eligible to be reimbursed:

• reverse the original claim(s) made to the incorrect bank account, this will be reported as an overpayment
• if the total benefit $100 and over, tell Medicare Debt Recovery not to raise an overpayment for the claimant and not to send a recovery letter to the claimant
• reprocess the claim using the correct EFT details
• report the activity via the Report Suspected Fraud system

Note: do not action recovery and/or an EFT retrieval in this case. This will be investigated following referral from the Report Suspected Fraud system.

Tell the claimant that their dispute will need to be investigated further and the agency cannot repay any Medicare benefits, until the investigation is completed.

Note: do not action recovery and/or an EFT retrieval in this case. These will be investigated following referral from the Report Suspected Fraud system. The Resources page contains a link to this system.

In the Comments tab in Personal, key the following details in order:

• amount disputed
• EFT dispute
• item number(s)
• provider number
• date of service
• explain the situation

Example: $162.10, EFT dispute, 23 999999A 010101 <reimbursement/no reimbursement> of benefit amount over $100, <claimant error/agency error/referred via the Report Suspected Fraud system for investigation>. Repaid on $ on / /

Note: it is critical to key the amount and EFT dispute in the correct order for each dispute as these will be used to generate reports on the numbers of disputes and will help in management reporting and ongoing policy decisions in this area.

Mainframe control line:

Key BRNA > [Enter]

In the Payee Type field, key:

• N for Patient claims
• P for Bulk Bill Claims
• G for 90 Day pay Doctor Cheque Scheme payments
• F for Simplified Billing Private Health Insurer (PHI) (fund)
• B for Simplified Billing (billing agent)

In the Payee ID field, key:

• Medicare number for patient claims
• Payee Provider Number minus the final alpha character for both Bulk Bill Claims and 90 Day payments
• the private health Insurer (fund) minor ID for Simplified Billing Private Health Insurer (PHI) (fund)
• the Registration Number for Simplified Billing agents
• Date in search criteria date in either:
• Date from and Date To fields (DDMMYY) Date range
• Claim date of Processing (DOP) in field for CLM DOP (DDMMYY) > [Enter]

The claimant needs to provide confirmation of identity:

• Service Officers must complete a security check

To identify the disputed EFT transaction, the claimant must supply one of the following in relation to the payment in dispute:

• Lodgement reference number from their bank statement, or
• BSB and account number where the monies were deposited

Key:

• BRNA, lodgement reference number, or
• BRNA, BSB and account number, date range > [Enter]

The Service Officer can find the claimant’s Medicare card number using the payment enquiry screen on BRNA, it is listed as the payee ID.

• key NHSI, card number, patient > [Enter]
• claims history is displayed against the patient's Medicare card history
• scroll [F8] through the patient history to identify the disputed claim

Confirm the banking details are the same as the details stated by the claimant who received the payment incorrectly:

• on the service line, press [F10] to display the EFT details used for the claim
• press [F1] under the account number displayed in the CHQ/EFT field
• verify details of the bank account are the same as those provided by the claimant

Reverse the original claim(s) made to the incorrect bank account. This will be reported as an overpayment.

Tell the claimant that they will receive a letter in the post requesting payment to be made to the agency, the letter will detail the amount and how to make payment.

For more details see Latter day adjustments (LDA) and HELD payments for patient claims.

Was the original claim processed correctly?

• Yes:
• attempt to contact the claimant by telephone
• if correct claimant contacted successfully, update CDMS with the correct bank account details
• go to Step 7
• No:
• end date the invalid or incorrect bank account details recorded in CDMS
• go to Step 7

Reprocess the claim with either the updated bank account details or leave the banking details blank if the claimant cannot be contacted.

Note: if the banking details are left blank, the claimant will receive a ‘Held payment’ letter requesting them to update their banking details.

Confirm the identity of the customer by performing a security check.

Did the customer pass the security check?

• Yes, go to Step 3
• No, go to Step 2

Tell the customer that you are unable to provide them with any information as they did not meet the requirements of the security check.

Note: the customer needs to attend a Service Centre and present the appropriate identification.

Procedure ends here.

Log on to Mainframe to use the patient claims history details.

In the Mainframe control line, key:

• NHSI
• Medicare card number, Patient name > [Enter]

The Medicare - Patient History screen is displayed.

On the patient claims history (NHSI) screen, confirm the below details with the customer:

• date of service
• name of servicing health professional
• charge amount

On the patient claims history (NHSI) screen, press [F10] function to get the below details:

• bank account details
• issue date of payment
• payment status

Press [F2] function to get the Date of Processing (DOP).

Note: the DOP must be obtained to redirect EFT rejected payment.

On the patient claims history (NHSI) screen, write the DOP from the PRC DT field.

If the EFT payment status displays:

• Paid, payment has been deposited into the nominated bank account. Go to Step 7
• Redirect, payment has been redirected to newly recorded EFT details. Go to Step 8
• Reject, payment has been rejected on the GDES report, see Table 12

If the customer states EFT payment was not received and the EFT payment status display Paid:

• check the Paid Date on the claimant history screen
• if paid date is less than 3 days, tell customer to wait as some financial organisations hold funds for a number of days before depositing to customer's accounts
• if paid date is greater than 3 days, see Table 1

Tell the customer that payment has been made and redirected to new bank account details:

• to show the banking details, press [F10] function on the patient history screen

Note: do not disclose bank account details to caller. The customer must confirm their bank account details.

Tell the customer payment has been rejected by their financial institution and the payment can be repaid to another debit bank account:

• if the customer wants the rejected EFT payment to be repaid, go to Step 2

Before repaying a rejected EFT payment, the transmission time is required

In the Mainframe control line, key BRNA > [Enter].

When the EFT Payment History Enquiry screen displays:

• key Medicare card number in Payee Id field > [Enter]
• locate the relevant claim by the Date of Processing (DOP) obtained in Step 5
• key the TIME in the TIME column
• clear screen and go to Step 3

In the Mainframe control line, key:

• NABI
• Medicare card number
• DOP/ddmmyy
• TIME/XXXXXX > [Enter]

The Patient Claims - EFT Reversal screen is displayed.

Example: NABI,123456789,DOP/010101,TIME/104603.

In the ADJ field, insert reason code LCR to reverse a claim:

• key LCR (not case sensitive) > [Enter]
• over key the control line NABC to NABU > [Enter] to update adjustment

The Medicare Patient Claims processing screen is displayed.

Go to Step 4.

A rejected EFT payment must be cancelled, before repaying the original claim.

On the processing Medicare Patient Claims processing screen:

• select [F4] function, if the customer has provided new banking details

Follow the prompts to process the claim, key:

• in the new banking details and key P in the EFT field, to store the banking details permanently; or key T in the EFT field, to temporarily store the banking details
• C in the EFT field, if using existing EFT details, or
• P in the STM field, to issue a statement to the customer. If no statement is needed, key N in the STM field

Claim details will be automatically populated from the NABI process, including:

• patient
• item
• date of service (FST DT)
• provider number
• payee code is '9' for claim to be paid via EFT
• charge amount

Assessing the claim:

• review and apply assessing restrictions by following warning messages
• each warning message must be actioned in order from left to right and further explanations can be viewed by placing your cursor at the beginning of the return message and press [F1]

Make sure reason code 349 shows in the RSN field > [Enter].

Key P to pay claim.

Note: the repaid benefit amount will equal the amount that was originally paid.

Where the repaid benefit amount exceeds the original payment amount or where a warning message directs to 'PEND' the claim:

• key the Medicare card number
• press Home function on keyboard
• over key the control line with NPND, Medicare number to pend claim
• complete a customer enquiry form and email to MPS Assessing

Note: all In-vitro Fertilisation and Assisted Reproductive Technology (IVF/ART) services (items 13200-13251) must not be finalised but pend with a customer enquiry form sent to MPS Assessing.

Mainframe control line:

Key:

• NHSI
• Medicare Card Number
• DOS/ddmmyy > [Enter]

The Medicare - patient history screen is displayed.

Example: NHSI,123456789,DOS/010101.

Note: the patient history should display reason codes LCR, 349 & 999.

For more details see Indicators, codes, modifiers and control lines for claims processing in Medicare.

These codes are for internal use only and will not appear on the statement issued to the customer:

• LCR = Repay cancelled service
• 999 = Line has been reversed

Note: where a payment has been cancelled, it will appear on the claimant history as a negative charge amount.

Reason code 349 & 205 definition:

• 349 = Original payment has been repaid
• 205 = Re-issue of previously cancelled cheque (Internal message only)

In the Mainframe control line, make sure the failed EFT payment is rejected before redirecting the payment.

To redirect a rejected EFT payment return to Mainframe:

• key BRNA in the control line
• key relevant SEL number in Selection field
• press [F9] to go to status update screen

On the EFT payment status update the BRNS screen:

• tab to Status field
• over key the status REJECT with REDIRECT
• key ‘Y’ in the Use Temporary redirect details field
• key new banking details taken from CDMS
• tab to Text field
• key ‘redirected to newly recorded EFT details’
• press [F5] to update and redirect the payment
  Note: where the payment needs to be redirected more than once the payment must be rejected first to allow the redirect function
• add a personal comment to the customers CDMS record, for redirected EFT payment key in comments: ‘EFT payment redirection, Amount $XX.XX’

Use the Mainframe system to determine if the claim has been received and processed successfully.

In the control line, key:

• DCEI, provider number, claim Id

Note: payment times may vary depending on claiming channel.

Has the claim been processed and paid?

• Yes, ask the health professional 'Have you completed an application form to receive your payments via EFT'? Where the answer is:
• Yes, go to Step 3
• Unsure, go to Step 5
• No, ask the health professional to complete an Application for EFT payments for Medicare bulk bill and all DVA claims form
• No, get more details in relation to the lodgement of the claim

Key BRNA on Mainframe > [Enter].

In the Payee Type field, key:

• P for Bulk Bill claims
• provider number (minus the last alpha) in PAYEE ID field
• date in search criteria - either date range in either:
• DATE field (ddmmyy)
• CLM DOP (ddmmyy)

The BRNA EFT Payment History Enquiry screen is displayed.

Check the minimum payment times for the claiming channel to make sure the bulk bill EFT payment has been released to the health professional.

Note: the minimum payment times count from the Date of Lodgement of the claim.

To check information on account details and when they were updated, search the Provider Directory System (PDS).

To locate stored account details, see Step 2 in Table 6 of Business structure and bank account details for EFT for health professionals.

Are there current EFT details?

• Yes, and the claim was lodged after the FROM date, the payment would have been released to the health professional. The health professional has a pay group link; escalate the call to the Local Peer Support
• No, ask the health professional to complete an Application for EFT payments for Medicare bulk bill and all DVA claims form. Tell the health professional to:
• go to the Services Australia website
• select Health Professionals button
• select the Provider Registration for Electronic Transfer form link on the right hand side under 'Popular Downloads'

Contact Medicare and Aged Care - Local Peer Support (LPS) if help is needed.

The Resources page contains a link to the Services Australia website.

Make sure that the appropriate security check has been performed.

See Perform telephone security check for Medicare health professionals.

Check PDS to see if the health professional has a debt recovery arrangement in place.

Go to the Provider Directory System Home Page:

• In the menu on the left of the screen, select the Provider tab
• Select View from the dropdown menu
• In the Basic Search tab key the Provider Stem or Unique Identifier
• Alternatively, select the Detailed Search tab and key the health professional’s Family Name and other known details
• Select the Search button
• Scroll down to the bottom of the Provider View page to the Debt Recovery section (under the Notes section)
• View if there is any Debt Recovery Instruction Present

Is a Debt Recovery Instruction present?

• Yes. If the caller:
• is the health professional and there is a debt recovery instruction present, go to Step 4
• is not the health professional and there is a debt recovery instruction present, go to Step 5
• No, go to Step 3

If the PDS Provider View screen does not display a debt recovery instruction, check Mainframe (CICS) to view if there is any health professional debt recovery.

In Mainframe (CICS), key BRNA into the control line > [Enter]. This will display the BRNA - EFT Payment History Enquiry screen:

• key P (for health professional bulk bill payments) in the Payee Type field
• key the provider number (minus the last alpha) in the Payee ID field
• key relevant details in the Search field:
• Dates of payment/s (ddmmyy to ddmmyy), or
• DOL/DOP (ddmmyy)
• the BRNA - EFT Payment History Enquiry screen will now display data as per the search terms entered
• if an automated debt recovery arrangement was in place at the time of the payment:
• the Claim ID column will include the relevant Agency Code for the department or agency recovering the debt
• the Amount column will show the corresponding deduction
• see the Resources page for a BRNA EFT Payment History Enquiry screenshot

If there is a Debt Recovery Instruction present on Mainframe (CICS), and the caller:

• is the health professional and there is a debt recovery instruction present, go to Step 4
• is not the health professional and there is a debt recovery instruction present, go to Step 5

If the caller is the health professional, proceed with the enquiry:

• take note of any department/s or agency/s listed on the PDS Provider View page as having a Debt Recovery Instruction Present
• tell the health professional:
  ‘There appears to be an arrangement in place with a Commonwealth department or agency. If you require further information you will need to contact the relevant department or agency.’
• give the health professional the relevant contact details. See the Resources page for Commonwealth department/agency contact details

If the caller is not the health professional, do not release any more details.

Tell the following:
‘I can confirm there is a discrepancy between the bulk bill statement and the amount deposited into the nominated bank account. Due to privacy restrictions, if the health professional requires further information they will need to contact the Medicare Provider Enquiries line on 132 150’.