What's new?

August 2013

The Department of Human Services Compliance Program for 2013-15 has been released.

Medicare Easyclaim reference guide

General information

This reference guide is to help you get started with Medicare Easyclaim. It explains important information about processing, payments, patient claiming definitions, bulk bill claiming definitions and return codes.

Helpful tips

  • 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 if the EFTPOS terminal/system is unavailable.
  • Bulk bill claims transmitted and assessed for payment by 17.30 Australian Eastern Standard Time will be paid within 2-3 business days for providers who have Electronic Funds Transfer (EFT) details registered with the Department of Human Services (Human Services). Claims that require operator intervention take longer.
  • Providers who do not have their bank account details registered with Human Services, will not have access to bulk bill processing and payment reports.
  • A GP consultation and a diagnostic item/s can be transmitted in one claim, as long as the items are non-referred/requested services and the servicing provider is qualified to perform those services.
  • If the EFTPOS terminal times out or there is a communication failure, the practice should issue an account/account receipt to the patient/claimant to receive their benefit through an alternative Medicare claiming channel (online, by phone or at a Medicare Service Centre).
  • The AP override code (not duplicate service am/pm) is not required for Concession Entitlement Verification (CEV) items. For example 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. For example item 23 is rendered twice on the same date of service at separate visits.

Services not accepted through Medicare Easyclaim

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 except 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, and
  • claims requiring text

Note: these items may be claimed through an alternative Medicare claiming channel (online, by phone or at a Medicare Service Centre). More information on claiming choices.

General terms explained

Term Description
Allied health
professionals
  • aboriginal health workers
  • audiologists
  • chiropodists
  • chiropractors
  • dentists
  • dental specialists (non-dpac)
  • diabetes educators
  • dieticians
  • exercise physiologists
  • mental health nurses
  • occupational therapists
  • oral medical and pathology practitioners
  • osteopaths
  • paedodontists
  • periodontists
  • physiotherapists
  • podiatrists
  • prosthodontists
  • 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).

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 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.
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, and
  • not be more than two years old
Diagnostic imaging Request details may be required with diagnostic imaging services.
Equipment identification number The identification number (allocated by the Department of Health) of specific equipment that needs to be registered in order to claim certain items. This commonly applies to radiotherapy equipment.

Item override code

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

Under certain circumstances, providers need to give more information on an account so that a service can be assessed. The item override code will allow you to submit the extra information for a specific situation. If you leave this information out when it is needed, it will result in rejection.
Location Specific Practice Number
(LSPN)

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, and
  • where a general practitioner has remote area exemption and performs diagnostic services

Where these services occur, this field is 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

An indicator that shows the problem Human Services 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.
Miscellaneous taxable services and ancillary items that do not attract a Medicare benefit cannot be entered.

View the MBS onlineExternal link

Pathology Pathology services provided by an eligible provider, including Group 9 for patient claims.
Patient Identifies the individual who receives the services.
Patient Medicare card number The patient must have a valid Medicare card number to transmit patient or bulk bill claims through Medicare Easyclaim.
Patient Individual Reference Number (IRN) The IRN is on 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 need a Customer Service Officer to manually review due to complexity or special circumstances.
Real-time Medicare eligibility validation Human Services will validate the patient’s eligibility when the claim is lodged.
Referral details

Required for certain services provided by specialists, allied health professionals or consulting physicians, where a Medicare benefit 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 Human Services) of the referring provider.
Referral issue date This field must be keyed if referral details are given.
The date keyed is the date on the letter of referral.

Referral period type code

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

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)

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 needed in cases where a written referral was lost or in the case of an emergency situation where the servicing provider believed the service needed to be given as quickly as possible.

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

Request details

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, and
  • request issue date
Requesting provider number The provider number (allocated by Human Services) of the requesting provider.
Request issue date Date the request was issued.

Request override type code

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

 

Lost or emergency request indication
Required where a written request was lost, or in the case of an emergency where the servicing provider believed 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 the 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 need to give more information on an account to allow assessment of a service. If the information is left out it will be rejected or the practice will be contacted for more details. The restrictive override code enables providers to send the extra information, for specific situations, through a two character indicator for 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.

Specimen Collection Point identification number (SCP Id) For bulk bill pathology services only. The provider number is used along 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 given 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 claim definitions

Term Description
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 Human Services has assessed the claim and shown a benefit 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.
Rejected claims

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

The four digit return code is to help the provider to resubmit the claim with changes, if appropriate, allowing a successful transmission. Alternatively, these claims may be lodged through an alternate channel (refer to list of Medicare Easyclaim return codes (11356) [PDF, 88Kb]PDF reader required).

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 3 payment options for patient claims that can be lodged through Medicare Easyclaim. The type of claim submitted is dependent on how 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
Types of benefit
payment

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

Fully paid: 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 sent to the claimant’s address recorded by Human Services. The cheque is then sent by the claimant to the provider with any outstanding balance. Where no benefit is payable, a statement only will be sent to the claimant’s address recorded by Human Services.

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

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 sent to the claimant’s address recorded by Human Services. The cheque is then sent by the claimant to the provider with any outstanding balance. Where no benefit is assessed as payable, a statement only will be sent to the claimant’s address recorded by Human Services.

Bulk bill claim definitions

Term Description
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 benefit(s) to the servicing provider as full payment for that service(s) and the provider lodges the claim with Human Services.

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 Human Services, 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 benefit(s) to the servicing provider as full payment for those services.
Benefit assigned amount

For Medicare Easyclaim, the benefit 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, Human Services will validate the patient’s concession entitlement only if the patient’s Medicare card is valid.
Retention of records Human Services recommends practices keep all records associated with benefits paid 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 Human Services that claims have been correctly paid.
Transmission
of bulk bill claims

Bulk bill claims are transmitted to Human Services 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 Human Services.

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

Return codes

View the list of Medicare Easyclaim return codes [PDF, 88Kb]PDF reader required.

Contact information

  • For health provider claiming enquiries, call 132 150*.
  • For technical problems, call the financial institution which supplied the service.

e-Business Service Centre

Call the eBusiness Service Centre on 1800 700 199**:

  • for help accessing your bulk bill processing and payment reports through the Health Professional Online Services.
  • to change contact/practice details
  • to register and amend bank details for providers, and
  • to organise an on-site visit by a Business Development Officer

* Call charges apply
** Call charges apply from mobiles or pay phones only

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Last updated: 19 March, 2014