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

This document outlines how Service Officers help customers with the progress of their claims. It includes the manual processing of claims, digital self service lodged claims processed incorrectly and claims with a single item charge of $10,000 or more.

Customer phones with a digital self service claim enquiry

Do not process digital self-service claims on the same day they are lodged (day zero) where the total Medicare benefit amount of all claims is greater than or equal to $100.

If the customer is stating financial hardship and insisting the claim be paid on day zero:

service officers must call the clinic to confirm the account is valid, see Table 1 in Suspected Medicare fraud and Business Integrity (BI) flags
if after hours, tell the customer that the claim will be actioned on the following business day
if staff cannot verify the details or the call is after hours:

add a processing note, and
recategorise the claim in PaNDA to MOA - Medicare Claim Escalated

for further assistance, escalate to a Medicare and Aged Care – Local Peer Support (LPS)

Step	Action
1	Customer phones with a query about their digital self service claim + Read more ... 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 their Medicare online account or myGov 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 digital self-service claims? Yes, if the total Medicare benefit amount is; less than $100, process the claim regardless of date of lodgement, go to Step 2 greater than or equal to $100, go to Step 4 No, escalate to Medicare and Aged Care - Local Peer Support (LPS) for help
2	Check the customer's history + Read more ... 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 is processed: correctly, tell the customer of the outcome. Procedure ends here incorrectly or rejected incorrectly, go to Step 6 No, go to Step 3
3	Check for claim documents + Read more ... Search for the claim in Work Optimiser – Medicare (PaNDA). Is the claim in PaNDA? Yes, check the comments, go to Step 4 No, tell the customer to resubmit their claim using self service channels. Update CDMS comments with actions procedure ends here
4	Claims in PaNDA + Read more ... Check which folder the claim is in: MOA – Medicare Claim, or MOA – Medicare Claim Escalated. For claims in this folder, escalate to Medicare and Aged Care – Local Peer Support (LPS) MOA - Medicare Claim folder If the claim can be processed and the claim benefit is less than $100, process the claim regardless of date of lodgement. Go to Step 6 If the claim can be processed and the claim benefit is greater than or equal to $100, and the customer: states financial hardship, go to Step 5 does not state financial hardship, if the claim is: on day zero do not process the claim tell the customer their claim will be processed as soon as possible. Procedure ends here past day zero, process the claim. Go to Step 6
5	Customer states financial hardship + Read more ... If the customer is stating financial hardship and insists the claim be paid on day zero and the total benefit is $100 or more: call the clinic to confirm the account is valid. See Suspected Medicare fraud and Business Integrity (BI) flags if the details cannot be verified or the call is after hours: add a processing note, and 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 Medicare online account or myGov app for the claim outcome. Select View recent claims on the Home page. See Track Medicare claims online
6	Claim processed/rejected incorrectly + Read more ... If a claim has been processed incorrectly and needs an adjustment: reject the claim using reason code 151, and action the adjustment. See the Process a patient claim adjustment table If the Service Officer is not trained to make adjustments, and the claim is: urgent – contact Medicare and Aged Care – Local Peer Support (LPS). If a LPS cannot be contacted, complete an Adjustment for Patient Claims form not urgent – complete an Adjustment for Patient Claims form If a claim has been rejected incorrectly, process the claim manually on the NPOI screen. See Patient claims processing in Medicare. Customers do not need to resubmit their claim if it was incorrectly processed or incorrectly rejected, and there is sufficient information to reprocess. Only 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 PaNDA and the personal section of the claimant's CDMS record, to note the action taken. For example: MOA DOL ddmmyy DOS ddmmyy re processed - previously rejected in error MOA DOL ddmmyy/DOS ddmmyy - Adjustment form PP045 completed Procedure ends here.
7	Process digital self service claims + Read more ... The claim must be retrieved in Mainframe (CICS). Key: NQEI, CLMDID/Service ID (from PaNDA) Locate the claim document in PaNDA, confirm details from the uploaded image, are correct, assign to self Process claim. See Table 1 in Process digital self service claims Close the PaNDA work item by changing the status to Complete Procedure ends here.
8	Claim with a single item charge of $10,000 or more + Read more ... When claims with a single item charge of $10,000 or more have been submitted via digital self-service, see Table 2 in Process digital self-service claims for processing information

Operational Information

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

Customer phones with a digital self service claim enquiry