Online Claiming for PBS for public hospitals
What is Online Claiming for PBS for public hospitals?
Online Claiming for PBS offers HSD approved public hospitals a faster, more efficient claiming solution when claiming HSD items and PBS trastuzumab (Herceptin®) from Medicare Australia. Online Claiming for PBS allows public hospital pharmacies to submit a claim to Medicare Australia each time a PBS/RPBS HSD medicine is dispensed.
Public hospitals that are participating in the Pharmaceutical Reforms (participating public hospitals) are able to claim all pharmaceutical benefit items, including HSD items through Online Claiming for PBS, however public hospitals that are not participating in the Pharmaceutical Reforms (non participating hospitals) can claim HSD medicines only.
Public hospitals that want to claim HSD medicines via the Online Claiming for PBS claiming channel will require approval under section 94 (s94) of the National Health Act 1953 (NH Act), or section 100 (s100) of the NH Act in the case of non-dispensing public hospitals. Public hospitals must register and be approved prior to submitting claims through Online Claiming for PBS.
Before obtaining s94 or s100 NH Act approval, hospitals that are not currently a participating public hospital will need to obtain a hospital provider number.
For more information on how to register go to the Hospital authority page.
How does Online Claiming for PBS work?
The following steps are involved when you make a claim with Online Claiming for PBS:
- The patient presents you with a PBS/RPBS prescription.
- You enter the prescription information into your prescription dispensing software.
- The prescription dispensing software sends a transaction to Medicare Australia.
- Medicare Australia checks the details of the prescription against PBS/RPBS rules including patient entitlement checks through a direct link to Centrelink before you dispense the medicine.
- Medicare Australia sends a message to inform you whether the claim is payable. In some cases, you will need to correct an error or omission before making a claim. This can be done before you supply the medicine to the patient.
- The medicine is supplied to the patient.
- At the end of your hospital pharmacy's claiming cycle (claim period), you send a Claim for Payment/Payment Reconcilation form and the paper prescriptions for any increased quantities and repeats and Complex Authority Required (CAR) medicines to Medicare Australia for audit and verification processing.
- Paper prescriptions and internal medication forms for HSD must be retained by the hospital for 24 months for audit purposes.
Business process diagram
Online Claiming for PBS business process diagram [PDF, 187Kb]
Benefits
Claiming HSD medicines using Online Claiming for PBS gives public hospitals a faster and better way to claim HSD. The benefits of using Online Claiming for PBS include:
- automatic assessment and claiming, including online eligibility checking, which flags potential rejections at the point of dispensing, allowing errors to be quickly corrected
- reduction in paperwork and processing time resulting in increased efficiency
- certainty of the amount that Medicare Australia will pay
- more regular (weekly) automatic payments from Medicare Australia
- electronic statements automatically reconciled by the hospital pharmacy’s dispensing software.
Public hospital prescriptions for Authority required (STREAMLINED) HSD claimed via Online Claiming for PBS can be claimed as paperless. This means that the paper prescription does not need to be submitted to Medicare Australia with the claim.
Claims for increased maximum quantities and repeats, and claims for CAR HSD and PBS trastuzumab (Herceptin®) cannot be paperless. At the end of the hospital pharmacy’s claiming cycle, the paper prescriptions for all increased maximum quantities and repeats, and paper prescriptions for CAR HSD and PBS trastuzumab (Herceptin®) must be submitted to Medicare Australia as part of the hospital’s claim.
A claim may contain both paper and paperless claims.
Participating vendors
Software vendors need a Notice of Integration before they are permitted to communicate with any Medicare Australia system to ensure the prescription dispensing software meets the Online Claiming for PBS requirements.
Four software vendors have already integrated Online Claiming for PBS into their products for use by public hospitals. These vendors are:
Corum Health Services - LOTS
iSoft
Pharmhos Software Pty Ltd
Phoenix Computer Systems
Dispensing and claiming under Online Claiming for PBS
How do I dispense prescriptions with online claiming?
The patient presents you with a prescription for a HSD item. You will need to enter the prescription details into your Prescription Dispensing Software (PDS). Each prescription will be sent to Medicare Australia through the Online Claiming for PBS claiming channel as it is dispensed. The specific process you use will depend on your PDS.
Once received via the online channel, Medicare Australia will assess the prescription details against the relevant PBS rules and return an online response to you. The response will be one of the following:
- the prescription has been accepted for payment
- the prescription has been accepted for payment but may contain errors that have resulted in a warning and/or information reason codes
- the prescription contains errors that has resulted in a rejection
Errors (information, warnings or rejections) are displayed to you during the dispensing process. How these details are displayed will vary between different software products.
How frequently will I close my claim period when using online claiming?
Hospital pharmacies must close their claim period and open a new claim period every month, or sooner. No more than 3,500 prescriptions are allowed in a claim period. When a new claim is opened the hospital must close off the current claim and send a Claim for Payment/Payment Reconciliation form and any required paperwork relating to that claim to Medicare Australia.
Supporting documentation must be submitted to Medicare Australia not more than 30 days after the last day of the period in respect of which the claim is made.
How do I close an online claim period?
Once you have dispensed all of the prescriptions for a claim period, you will need to go into your PDS and close off that claim period. The process of closing and submitting a claim period within the PDS will vary depending on the software product you use.
Once the claim period is closed, you will need to send all of the required paperwork to Medicare Australia.
What do I need to send to Medicare Australia in my claim package?
Once a claim period has been closed and finalised in the PDS, you will need to provide the following paperwork to Medicare Australia:
- authority prescriptions for CAR medicines and PBS trastuzumab (Herceptin®)
- authority prescriptions for increases to listed maximum quantities or repeats.
The required prescriptions should be bundled and a Claim for Payment/Payment Reconciliation form must also be included.
A public hospital claim for pharmaceutical benefits consists of:
- the original and duplicate of a completed Claim for Payment/Payment Reconciliation form;
- the original orders for emergency treatment (doctor's bag) supplies in a separate bundle;
- the Medicare Australia/DVA copies of authority PBS prescriptions, and all repeat authorisations, separated into four bundles for benefits supplied to the general public; concessional beneficiaries/Safety Net Concession Card holders; Safety Net Entitlement Card holders and RPBS patients.
PBS prescriptions in each bundle should be in serial number order, with serial number 1 at the top of the bundle.
PBS prescriptions in the wrong bundle may be returned to the pharmacist for clarification. If appropriate, they can be resubmitted in the correct bundle in the next claim period.
Completing the claim form
The claimant's name, address of the pharmacy from which the pharmacist is approved to supply pharmaceutical benefits, approval number and claim period number should be entered on the Claim for Payment/Payment Reconciliation form. These details should match the latest written information held by Medicare Australia, as payments can be delayed while clarification is sought.
The claim period number should state how many claims have been submitted so far in a calendar year, (e.g. the sixth claim submitted by an approved pharmacist in 2010 should have a claim period number of 1006).
The first and last serial numbers given to items in each bundle are to be entered on the Claim for Payment/Payment Reconciliation form.
The declaration must be signed by the person authorised to act for the approved supplier/s.
Lodging claims
A claim may be lodged at any time during the month at the relevant Medicare Australia state office. Unless other arrangements have been made with Medicare Australia, the following conditions apply:
- only one claim period can exist and only one claim can be lodged per month;
- the claim period shall cover pharmaceutical benefits supplied during one month; and
- the claim shall be sent within 30 days from when the benefits were supplied.
Claims for pharmaceutical benefits supplied over 18 months earlier may not be accepted for computer processing. Pharmacists with such claims should contact Medicare Australia.
Medicare Australia will register the claim package once received, which will be the final step in closing the claim period. This means that the date you close your claim period will differ from the date that the claim period is closed in the Medicare Australia processing system.
Once you have sent the required paperwork to Medicare Australia for a claim period, you will no longer be able to adjust prescriptions in that claim period. If you require changes to be made to a prescription in a closed claim period, the prescription will need to be moved to the current, open claim period. Your PDS may automatically do this for you when adjusting prescriptions in closed claim periods. You will still be able to cancel (not delete) prescriptions in closed claim periods.
You cannot move a prescription that is in a claim period that has been closed for more than three months. You must cancel and resubmit the prescription in the current open claim period.
Reconciliation statements
A pharmacist will receive a PBS reconciliation statement after a claim period has been processed. This statement provides details of each prescription for each brand of each pharmaceutical benefit item supplied in that claim period.
Reasons for non-payment of any item are coded, with the code numbers explained in the statement.
PBS authority prescriptions and repeat authorisations not accepted for payment will be returned. If a PBS prescription was not accepted and can be re-submitted, it must be given a new serial number and included in a subsequent claim period.
Payment for claims
Payment for claims processed through Online Claiming for PBS will be made directly into the hospital authority’s bank account. Hospital authorities are required to register their bank account details with Medicare Australia using the ‘Notification of hospital authority bank account details’ [PDF, 133Kb] form.
The ‘Notification of hospital authority bank account details’ [PDF, 133Kb] form can also be used to advise Medicare Australia of any changes to bank account details.
Medicare Australia must be notified in writing—on the approved bank details form—of changes to bank account details. You will need to allow at least nine working days for the change to take effect and to receive your next payment.
Audits
Hospital pharmacies must be able to satisfy Medicare Australia requirement that adequate and auditable systems are in place which meet the following conditions:
- supply is to eligible patients
- prescribing is in accordance with PBS restriction criteria
- prescribing is consistent with the therapeutic uses approved by the Therapeutic Goods Administration (TGA) for the supply of the drug.
Medicare Australia's Compliance area will monitor the prescribing and supply of HSD medicines—and with the agreement of the hospital pharmacy—Medicare Australia can audit patient records.
Prescriptions and internal medication records must be retained for 24 months from the date of dispensing for audit purposes.
Contacts
For more information on Online Claiming for PBS, or for any of your online claiming support needs, please contact Medicare Australia on 132 290*.
*Call charges apply.
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Last updated: 1 July, 2010