Medicare Easyclaim reference guide
This reference guide has been developed to help you get started with Medicare Easyclaim. It explains important information you need to know about processing, payments, patient claiming definitions, bulk bill claiming definitions and return codes.
- Allied health professionals must ensure they have a Medicare provider/registration number before transmitting claims.
- For a patient to assign their benefit for bulk bill claims, it is a legal requirement to press OK on the EFTPOS terminal or to sign an approved DB4 form.
- Bulk bill claims transmitted and assessed for payment by 17.30 AESDT will be paid within two to three days for providers who have Electronic Funds Transfer (EFT) details registered with Medicare Australia. Cheque payments may take longer. Claims that require operator intervention may have a longer turn-around time.
- If you have not already provided EFT details and want to be paid by EFT, complete and return the Medicare Easyclaim banking details for bulk bill claims form which is included in your starter kit.
- If you receive payments by cheque, you will not have access to bulk bill processing and payment reports.
- If you claim items from different categories, you must submit these claims seperately, for example a GP who is claiming diagnostic items, must process one claim for the consultation (using the GP claim type) and one claim for the diagnostic service (using the diagnostic imaging claim type).
- If the EFTPOS terminal times out or there’s a communication failure, the practice should issue an account/account receipt to the patient/claimant to receive their rebate through an alternative Medicare claiming channel (eg. at a Medicare office).
- The AP override code (not duplicate service am/pm) is not required for Concession Entitlement Verification (CEV) items, e.g. when claiming item 23 and CEV item 10990, it is not necessary to use the override code of AP for the CEV item.
- The AP override code should only be used when claiming a second visit using the same item number for a patient on the same day, e.g. item 23 is rendered twice on the same date of service at separate attendances.
The following items are not accepted through Medicare Easyclaim:
- in-hospital items
- Australian Childhood Immunisation Register (ACIR) information
- bulk bill claims more than two years from date of service
- patient claims more than two years from date of service
- time duration dependent items
- notional charges (e.g. provider has raised a total charge to cover a group of services)
- patient claims for pathology items excepting Group 9 items
- bulk bill pathology items which are self deemed or Rule 3 exemptions
- patient claims and bulk bill claims with non-standard referrals
- items where the charge exceeds $9999.99
- GP multiple attendance items (e.g. MBS item 24, 35 etc)
- Separate sites override—unless the item is listed under Restrictive override code in the ‘General terms explained’ list below.
- Assisted Reproductive Technology (ART) services
- Claims requiring text
Important: these items may be claimed through an alternative Medicare claiming channel (eg. Medicare online or a Medicare office). More information on claiming choices.
Aboriginal health workers
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).
|Cancel (bank initiated)||An auto-cancel will be initiated when a financial transaction has been transmitted but no response has been received within the timeout period.|
|Claimant||Identifies the person who incurred the expense for services provided. The claimant is not always the patient (e.g. a parent).|
|Claimant Medicare card number||The claimant must have a valid Medicare card number in order to transmit patient claims through Medicare Easyclaim.|
|Date of service||
The date of service will be automatically generated as the date the claim is created and transmitted.
|Diagnostic imaging||Request details may be required with diagnostic imaging services.|
|Equipment identification number||The identification number (allocated by the Department of Health and Ageing) of specific equipment that needs to be registered in order to claim certain items. This commonly applies to radiotherapy equipment.|
Item override code
|Under certain circumstances, providers are required to provide additional information on an account so that a service can be assessed. The item override code will enable you to submit the additional information for a specific situation. Omission of this information, when it is required, will result in rejection.|
|Location Specific Practice Number
The LSPN is applicable to services:
Medicare card flag
A = Patient identification amended
|An indicator that details the problem Medicare has with the submitted Medicare card.
This indicator may appear on the bulk bill processing report against a claim.
|MBS item number||
The MBS item number is required for each service. It must be valid at the date of service for that provider.
|Pathology||Pathology services provided by an eligible provider, including Group 9 for patient claims.|
|Patient||Identifies the individual to whom the services were rendered.|
|Patient Medicare card number||The patient must have a valid Medicare card number in order to transmit patient or bulk bill claims through Medicare Easyclaim.|
|Patient Individual Reference Number (IRN)||The IRN appears to the left of the patient’s name on their Medicare card.|
|Payee provider number||Provider number of the provider who is to be paid for the service. Only required if the payee provider is not the servicing provider.|
|Pended claim||Claims that require a Medicare officer to manually review due to complexity or special circumstances.|
|Real-time Medicare eligibility validation||Medicare Australia will validate the patient’s eligibility when the claim is lodged.|
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.
|Referring provider number||The provider number (allocated by Medicare Australia) of the referring provider.|
|Referral issue date||This field must be keyed if referral details are supplied.
The date keyed is the date on the letter of referral.
Referral period type code
|Indicates the period of referral.
This field must be entered if you have entered a referring provider number and referral issue date.
Referral override type code (specialist services only)
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||The provider number (allocated by Medicare Australia) of the requesting provider.|
|Request issue date||Date the request was issued.|
Request override type code
Lost or emergency request indication
The requesting provider must have a current and valid registration at date of request.
Restrictive override code
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:
Note: the time dependency restrictions for items 30192 and 30195 will continue to apply.
|Specimen Collection Point identification number (SCP Id)||For bulk bill pathology services only. The provider number is used in conjunction with the SCP Id for assessment of the claim. The claim will be rejected if the provider number used is not registered in the Medicare system to allow that provider to perform services with the SCP Id entered.|
|Self deemed code
SD = self deemed
SS = substituted service
|SD is an optional element. However, conditions apply depending on the SD value selected.
SD applies to both pathology and diagnostic claims.
When the SD value is present, request details cannot be set.
Pathology claims may only have an SD indicator.
SS only applies to diagnostic claims.
When the SS value is present, request details are required.
There may be claims where neither the request details nor request override type code are set, instead a self deemed value of SD applies.
|Servicing provider number||Provider number of the provider who rendered the service.|
|Types of EFTPOS receipts||The EFTPOS terminal will produce the following types of receipts, which must be provided to the patient/claimant.
Medicare patient claim receipt – for all fully paid, assessed patient claims.
Medicare lodgement receipt – for all unpaid, partially paid or pended patient claims.
Cancelled Medicare claim receipt – for all patient claims that have been cancelled by the medical practice/claimant.
Bank cancelled claim receipt.
Bulk bill assignment advice – for all bulk bill claims following acceptance of the claim by the medical practice and assignment of benefit by the patient.
|Patient claims||Medicare patient claims lodged by a patient/claimant who has received professional medical services for items covered under the Medicare Benefits Schedule (MBS).|
|Cancel indicator||Where Medicare Australia has assessed the claim and shown a rebate amount. The claimant may not have a bank debit card, or the card cannot be read by the EFTPOS terminal, or the claimant does not wish to continue with the claim. In these cases, the practice cancels the claim.|
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 patient claim||
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.
|Types of patient payment options||
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.
|Types of benefit
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.
|Bulk bill claims||
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.
|Accept/decline indicator||Where a Medicare eligibility and/or concession entitlement is returned by Medicare Australia, the medical practice and/or patient may choose to accept/decline the claim.|
|Assignment of benefit||When a patient assigns his/her right to the rebate(s) to the servicing provider as full payment for those services.|
|Benefit assigned amount||
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.
|Claims per transmission||Only one bulk bill claim can be submitted per transmission. This claim may contain more than one service item.|
|Real-time Concession Entitlement Verification (CEV)||When the bulk bill claim is lodged, Medicare Australia will validate the patient’s concession entitlement only if the patient’s Medicare card is valid.|
|Retention of records||Medicare Australia recommends practices keep all records associated with benefits paid by Medicare Australia for at least two years. These records can include electronic billing information, notes in practice software, appointment records and assignment of benefit forms. In the event of an audit, this information will help providers to validate to Medicare Australia that claims have been correctly paid.|
of bulk bill claims
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.
View the list of Return codes [PDF, 150Kb].
- For health provider claiming enquiries, call 132 150*.
- For technical problems, call the financial institution which supplied the service.
- Telephone: 1800 700 199**
- Information regarding Medicare Easyclaim.
- For assistance accessing your bulk bill processing and payment reports through the Health Provider Online Services.
- Changed contact/practice details.
- Registration and amendments to banking details for providers.
- To organise an on-site visit by a Business Development Officer to discuss any of the above issues.
* Call charges apply
** Call charges apply from mobiles or pay phones only
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Last updated: 11 December, 2012