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. It also includes claims processed incorrectly and claim items over $10,000.
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 amount of the Medicare benefit is greater than or equal to $100.
If the customer is in financial hardship and insisting the claim be paid on day zero:
- staff must call the clinic to confirm the account is valid, see 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, 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 the Service Officer skilled in digital self-service claims? Yes, process the claim if the total Medicare benefit amount is less than $100 regardless of date of lodgement, go to Step 2
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2 |
Check the customer's history + Read more ... Access the Medicare claims history on Mainframe (CICS). Key:
Has the claim been processed?
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3 |
Check for claim documents + Read more ... Search for the claim in Work Optimiser – Medicare (PaNDA). Is the claim in PaNDA?
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4 |
Claims in PaNDA + Read more ... Only Service Officers skilled in digital self-service claims complete these claims. Check which folder the claim is in:
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 6. Note: do not process digital self-service 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. If the customer is in financial hardship and insists the claim be paid on day zero and the total benefit is $100 or more:
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5 |
Claim processed incorrectly + Read more ... If a Service Officer identifies that a claim has been processed incorrectly and requires an adjustment, 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:
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:
Note: include a comment in the personal section of the claimant's CDMS record, which advises the action taken. For example:
Procedure ends here. |
6 |
Manual payment for digital self service claims + Read more ... Service Officers must retrieve the claim in Mainframe (CICS) by keying:
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7 |
Claim items over $10,000 + Read more ... When claims over $9,999.99 have been submitted via digital self-service, see Table 2 in Process digital self-service claims for processing information |