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Medicare Australia - Australian Government
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claiming at the doctor's

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What type of information is available?

Information available from Medicare Australia includes (but is not limited to):

Eligible Medicare Providers

  • provider information:
    • name and address
    • speciality by qualification
    • registered major speciality
    • derived speciality based on type of claims
    • sex

Medicare

  • item number
  • Medicare benefit
  • period of service and processing and dates of request/referral—monthly/quarterly/yearly
  • indication of whether or not the service was provided in hospital
  • total number of services, rendered/referred
  • total number of patients

Patients/Medicare Enrolment Information

  • Medicare card information:
    • name and address of cardholder
    • date of birth
    • sex

Pharmaceutical Benefits Scheme (PBS)

  • medicine: item code, generic name, brand of item, strength and quantity
  • cost
  • original or repeat prescription
  • date of supply
  • payment category e.g. concession, safety net, doctor’s bag
  • number of repeats
  • authority items
  • state (supply—based on approval ID)
  • total number of scripts
  • total number of patients

Australian Childhood Immunisation Register (ACIR)

  • immunisation due date
  • statistical local area
  • local government area
  • provider details (type, state)
  • provider number (GP and ancillary) and sex
  • practice address
  • child’s information (name, date of birth, sex, ACIR or Medicare address, immunisation history, immunisation due date)

Generic Practice Register (GPR)

Incorporating Practice Incentives Program (PIP), General Practice Immunisation Incentives (GPII)

  • practice details
  • registration type (i.e. PIP, GPII)
  • rurality (rural, remote and metropolitan area)
  • solo or group practice
  • profile of practice arrangements (e.g. after hours care, electronic prescribing)
  • provider start date and end date

Rural Retention Program (RRP)

  • provider service summary data
  • provider rurality details (rural, remote and metropolitan area)

General Practice Registrars Rural Incentive Payments Scheme (GPRRIPS)

  • rurality (rural, remote and metropolitan area)
  • payment information

HECS Reimbursement Scheme

  • rurality (rural, remote and metropolitan area)
  • payment information

Safety nets

Both Medicare and PBS have Safety Net schemes to protect against high out-of-pocket medical and pharmaceutical costs. Safety Nets increase the benefit payable for a particular service when the threshold is reached. Medicare Australia can report on the increase in benefit paid due to the Safety Net and the number of patients who have reached the Safety Net threshold.

Considerations and limitations

Medicare

Medicare records only include services that qualify for Medicare benefits and for which claims have been processed. They do not include services, which qualify for benefits under the Department of Veterans' Affairs National Treatment Account. Medicare Australia does not hold information about services, which have been provided in public hospitals to public patients, or services provided in outpatients or emergency departments of public hospitals. Only information related to claims is collected by Medicare Australia; therefore diagnostic or clinical information is not available.

Medicare Australia information about claims processing is only held for the last five years. If information is required for longer than this period archive records which are stored off site must be retrieved. However, some summarised aggregated information is available for periods beyond five years.

Pharmaceutical Benefits Scheme (PBS)

The PBS reimburses pharmacists who have dispensed eligible prescription pharmaceuticals at a cost that is greater than the patient contribution (general or concessional). Medicare Australia only collects sufficient information to enable these reimbursements to be made to pharmacists.

In May 2002 the Improved Monitoring of Entitlements (IME) program was introduced. Under this program stricter requirements are placed on recipients to prove their entitlement to subsidised pharmaceuticals. Recipients are required to produce their Medicare card at the time of dispensing. As a result of this, more reliable information is available regarding the recipient.

For data requests made before May 2002 Medicare Australia can only provide historical information, at an individual level, about prescriptions dispensed to a person who has been issued with an entitlement card (such as those issued by the Department of Family and Community Services, or a Safety Net card). With regard to Safety Net entitlements, before May 2002, the PBS only records prescriptions in the name of the entitlement cardholder and does not identify separate members of a family eligible to receive prescriptions under each card.

The accuracy of PBS records depends on a pharmacist identifying patients by their correct entitlement numbers (e.g. Medicare card or Health Care card) and prescribers by their correct prescriber number on claims for payment. Information held by Medicare Australia is restricted to data recorded from prescriptions where the cost of a pharmaceutical was greater than the patient contribution (at the general or concessional rate) and where a pharmacist required reimbursement.

Repatriation Pharmaceutical Benefits Scheme (RPBS)

PBS information does not include items supplied under the RPBS. Requests for access to RPBS information should be directed to the Department of Veterans' AffairsEmail

Summary RPBS information

Schedule of Pharmaceutical Benefits

The Schedule of Pharmaceutical BenefitsExternal link provides detailed information regarding names and costs of eligible medicines.

General information about the operation of the PBS:

Additional information

Last updated: 22 July, 2008

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