Enquiries received via telephone for digital self service claims 011-43140100

If the customer:

• is seeking help in using digital self service to lodge their claim, see Claiming Medicare benefits online
• has lodged their claim using the Express Plus Medicare mobile app, ask the customer when they submitted their claim. See User Guides on the Resources page for more details

Is the Service Officer skilled in MOA?

Yes, process the claim if the total Medicare benefit amount is less than $100 regardless of date of lodgement, go to Step 2

• No, tell customers: there is currently a high number of claims on hand and these are taking longer than usual. Their claim will be processed as soon as possible
• they can track the progress of their claim through MOA or the Express Plus Medicare mobile app. Select View recent claims on the Home page
• procedure ends here

See Track Medicare claims online.

Access the Medicare claims history on Mainframe (CICS). Key:

• 'NHSI', card number, patient's IRN or first initial
• Press [Enter]

Has the claim been processed?

• Yes:
• if the claim has been rejected, go to Step 3
• if the claim has been processed, tell the customer of the outcome. Procedure ends here
• No, go to Step 4

Access the customer's record on the CDMS, and check comments in personal.

Are there comments about their claim?

• Yes, explain the information to the customer. Procedure ends here
• No, go to Step 4

If unable to locate comments in CDMS, search for the claim in Work Optimiser – Medicare (PaNDA).

Is the claim in PaNDA?

• Yes, check the comments, go to Step 5:
• No,
• tell the customer to resubmit their claim using self service channels. Update CDMS comments with actions
• procedure ends here

Only Service Officers skilled in MOA complete these claims.

Check which folder the claim is in:

• MOA – Medicare Claim, or
• MOA – Medicare Claim Escalated. For claims in this folder, contact the Medicare and Aged Care – Local Peer Support (LPS) line for assistance

MOA - Medicare Claim folder

If the claim can be processed and the claim benefit is under $100, process the claim regardless of date of lodgement. Go to Step 7.

Note: do not process MOA claims on the same day they are lodged (day zero) where total Medicare benefit amount of the claim is greater than or equal to $100.

Service Officers skilled in MOA, when processing claims must:

• check the information provided. Tell the customer that currently there is a high number of claims on hand and these are taking longer than usual. Their claim will be processed as soon as possible
• tell customers they can track their claim through MOA or the Express Plus Medicare mobile app. Select View recent claims on the Home page. See Track Medicare claims online
• see Suspected Medicare fraud and Business Integrity (BI) flags if they suspect fraud

If the customer is in financial hardship and insists the claim be paid on day zero:

• call the clinic to confirm the account is valid. See Suspected Medicare fraud and Business Integrity (BI) flags
• if staff cannot verify the details or if the call is after hours, recategorise the claim in PaNDA to MOA - Medicare Claim Escalated
• tell the customer that the claim will be actioned on the following business day. Customers can check their MOA or Express Plus Medicare mobile app for the claim outcome. Select View recent claims on the Home page. See Track Medicare claims online

If the claim is rejected, explain the details to the customer. Procedure ends here.

If the claim has been processed incorrectly, go to Step 6.

If a Service Officer realises a claim has been rejected incorrectly, they can process the claim manually. See the Process a patient claim adjustment table.

Service Officers not trained to make adjustments can contact the Medicare and Aged Care – Local Peer Support (LPS) line. If it is not urgent or the Service Officer cannot contact a LPS, they can complete a:

• LPS referral form, or
• Adjustment for Patient Claims form

Customers do not need to resubmit their claim if it was incorrectly processed, and there is sufficient information to reprocess.

Request the customer to resubmit a claim if:

• they have made an error in the claim. See Examples of amendments when processing claims with a minor difference, or
• there is not enough information to process the claim

Note: include a comment in the personal section of the claimants CDMS record, which advises the action taken. For example:

• MOA/APP DOL ddmmyy DOS ddmmyy re processed - previously rejected in error
• MOA/APP DOL ddmmyy/DOS ddmmyy LPS referral form OR Adjustment form PP045 completed

Procedure ends here.

Service Officers must retrieve the claim in Mainframe (CICS) by keying:

• for MOA claims: NQEI,HC,CardNumber
• for APP claims: NQEI,AC,CardNumber

Status of unprocessed claim will have a PEND Status:

• Key 'S' against the claim with matching Date of Lodgement (DOL) and press [Enter]
• Locate the claim document in PaNDA, confirm details from the uploaded image, are correct, assign to self
• Process claim. See, the Process claims table on the Process page of Process digital self service claims
• Close the PaNDA work item by changing the status to Complete

For calls about a claim item over $10,000, see: Claiming Medicare benefits online.