Medicare Easyclaim reference guide

Aboriginal health workers
Allied health dental
Audiologists
Chiropractors
Diabetes educators
Dieticians
Exercise physiologists
Mental health nurses
Occupational therapists
Osteopaths
Physiotherapists
Podiatrists
Psychologists
Social workers
Speech pathologists

Any Medicare Benefits Schedule (MBS) item lodged for services provided by the above should be accepted unless restrictions are applied (e.g. a care plan MBS item is not present on the patient’s history or the maximum number of services have been performed).

The date of service will be automatically generated as the date the claim is created and transmitted.
In circumstances where the date of service is different to the date the claim is being transmitted, the date of service must be manually entered and must:

• be in the format DDMMYY
• be a valid date
• not be in the future
• not be more than two years old.

Item override code

Values
AO =  not normal
aftercare
AP =  not duplicate
service (am/pm)

The LSPN is applicable to services:

• within Group T2 – radiation oncology services as described in the MBS
• within Category 5 – diagnostic imaging services as described in the MBS
• where a general practitioner has remote area exemption and performs diagnostic services.
• Where these services occur, this field is to be considered mandatory.

Medicare card flag
values:

A = Patient identification amended
I =Patient Medicare issue
number changed
C = Patient Medicare number changed
W = Patient card used will expire shortly
S = Patient card expired. Future services may be rejected
X = Old Medicare issue number for patient, future services may be rejected

The MBS item number is required for each service. It must be valid at the date of service for that provider.
Miscellaneous taxable services and ancillary items that do not attract a Medicare benefit cannot be entered.

View the MBS online

This data is only required for certain services provided by specialists, allied health or consulting physicians, where a Medicare rebate is dependent on acceptable evidence that the service has been provided following referral from another health provider.

Referral details for initial consultations and other referred services (including subsequent consultations) are mandatory.

The referring provider must have a current and valid registration at the date of referral.

Referral period type code

Values
S = standard
(12 months from a GP and 3 months from a specialist)
I =  indefinite

Referral override type code (specialist services only)

Values
L =  lost
E = emergency
N = not required – may need to be entered where referral details aren’t required

Indicates why referred services were provided without referral from another provider.

Lost or emergency referral indication

This data is only required in instances where a written referral was lost or in the case of an emergency situation where the servicing provider was of the opinion that the service needed to be rendered as quickly as possible.

Lost and emergency referrals are applicable to initial consultation items only. All referral requirements must be met for subsequent consultation items.

This information is only required for items which are subject to the written request requirement and are classified as R-Type (requested) services in the MBS.

The following data is required:

• requesting provider number
• request issue date.

Request override type code

Values
L = lost
E = emergency
N = not required (for bulk bill pathology only)

Lost or emergency request indication
This data is only required in instances where a written request was lost, or in the case of an emergency where the servicing provider was of the opinion that the service needed to be rendered as quickly as possible.
The indicator will be used where the request:

• has been lost
  or,
• is for an emergency situation.

The requesting provider must have a current and valid registration at date of request.

Restrictive override code

Values
NC = Not for comparison
SP = Separate sites
NR = Not related (care plans for allied health)

Under certain circumstances, providers are required to provide additional information on an account to enable assessment of a service. Omission of this information would result in either a rejection or further contact with the practice for clarification. The restrictive override code will enable providers to submit the additional information, for specific situations, through a two character indicator that will enable the correct assessment and payment for the service.

Separate sites—when this indicator is set, item numbers 30071, 30061, 30192 and 30195 will automatically override where:

• the services are within one claim and are for the same patient, provider and date of service
• there are combinations of items 30071 and 30061 plus only 1 x 30195 and/or only 1 x 30192
• there are multiples of items 30071 and 30061 within one claim.

Note: the time dependency restrictions for items 30192 and 30195 will continue to apply.

Where Medicare Australia is unable to assess a patient claim immediately, the claim will be returned to the practice site via the EFTPOS terminal together with a four digit return code.

The four digit return code is designed to assist the provider to resubmit the claim with amendments, if appropriate, allowing a successful transmission. Alternatively, these claims may be lodged through an alternate channel (refer to list of return codes [PDF, 150Kb]).

Real-time processing by Medicare Easyclaim transmits, assesses and returns an outcome to the sending location as a single process.

Lodgement of a real-time Medicare Easyclaim patient claim requires specific information to be entered into the claim while the patient/claimant is present.

There are three payment options for patient claims that can be lodged through Medicare Easyclaim. The type of claim submitted is dependent on the manner in which the patient/claimant and the provider have chosen to settle the account.

• Fully paid account – patient/claimant has paid their account in full with the provider.
• Part paid account – patient/claimant has paid a contribution toward the settlement of the account.
• Unpaid account – account has not been paid.

The payment method for claims lodged through Medicare Easyclaim is dependent on whether the account is fully paid, part paid or unpaid.

Fully paid: EFT – where the account has been paid in full, payment will be made to the claimant’s nominated bank account. This payment will be initiated by the claimant swiping their EFTPOS card.

Part paid: where a claimant has made a part payment contribution towards the account.

Where Medicare benefits are assessed as payable for a claim, a statement and/or cheque in the provider’s name will be forwarded to the claimant’s address recorded by Medicare. The cheque is then forwarded by the claimant to the provider with any outstanding balance. Where no benefit is assessed as payable, a statement only will be forwarded to the claimant’s address recorded by Medicare.

Where a Medicare Safety Net threshold has been reached and the patient is entitled to an additional safety net benefit, this amount will be either paid by cheque to the claimant or by EFT if this information is stored by Medicare Australia.

Unpaid: where the account is unpaid.
Where Medicare benefits are assessed as payable for a claim, a statement and/or cheque in the provider’s name will be forwarded to the claimant’s address recorded by Medicare. The cheque is then forwarded by the claimant to the provider with any outstanding balance. Where no benefit is assessed as payable, a statement only will be forwarded to the claimant’s address recorded by Medicare.

A bulk bill claim is where a patient who is eligible for a Medicare benefit(s) assigns his/her right to the rebate(s) to the servicing provider as full payment for that service(s) and the provider lodges the claim with Medicare Australia.

It is at the provider’s discretion whether to bulk bill a patient or not.

For Medicare Easyclaim, the rebate returned in a bulk bill claim refers to an estimate of the benefit that the provider will be paid.

This amount may be adjusted in accordance with the rules set out in the MBS.

Bulk bill claims are transmitted to Medicare Australia in real time but are not assessed immediately.

Basic patient or provider eligibility checks occur before the patient and provider accept or decline the assignment of benefit. The patient must be present to press OK to assign their benefit.

The receipt that is printed is an Assignment of Benefit Advice only and indicates that the claim has been successfully transmitted to Medicare Australia.

The practice must give the patient a copy of the receipt.