What's new?

August 2013

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

Online Claiming for PBS

What is Online Claiming for PBS?

Online Claiming for PBS offers an improved claiming solution by allowing pharmacies to submit a claim to Medicare each time a PBS/RPBS medicine is dispensed. Online Claiming for PBS was piloted by a small number of pharmacies between 20 September 2004 and 20 December 2004 and was followed by an independent evaluation. Medicare has now implemented the recommendations of the evaluation report and is rolling out Online Claiming for PBS to the wider pharmacy community. 

How does Online Claiming for PBS work?

The following steps are involved when you make a claim with Online Claiming for PBS:

  1. The customer presents you with a PBS/RPBS prescription.
  2. You enter the information about the prescription into your prescription dispensing software
  3. The prescription dispensing software sends a transaction to Medicare at the same time the medicine is dispensed.
  4. Medicare checks the details of the prescription against PBS/RPBS rules including patient entitlement checks through a direct link to Centrelink
  5. Medicare sends a message to inform you whether the claim is payable-this is the claim for payment
  6. The medicine is supplied to the customer
  7. At the end of your pharmacy's claiming cycle (claim period), you send the paper prescriptions to Medicare for audit and verification processing as you do now.

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 customer.

There will be some cases where Medicare will not make a payment until the paper prescription has been checked. This generally involves high-cost or high-risk items.

Business process diagram

Benefits

Online Claiming for PBS gives you faster and better ways to claim by:

  • flagging potential rejections at the point of dispensing, allowing any errors to be corrected before the customer leaves the pharmacy
  • giving you more certainty of the amount that Medicare will pay before the medicine is supplied to the customer
  • paying you more frequently, with Medicare paying pharmacy each week
  • sending electronic statements that are automatically reconciled by your dispensing software  

Participating vendors

Sixteen software vendors have integrated Online Claiming for PBS into their products for use by pharmacy:

  • Simple Retail with Aquarius Dispense
  • CDC Systems
  • Corum Health Services with Amfac Windows Dispensing
  • Corum Health Services with Lots Dispense
  • Corum Health Services with QuickScript
  • Corum Health Services with Dispense 3
  • Healthsoft with PharmacyPro
  • iSoft with iPharmacy
  • KDAR
  • Minfos with Minfos Dispense
  • Fred Dispense
  • Pharmhos with Merlin
  • Phillips and Phillips
  • Pheonix
  • iSynergy

Registering for Online Claiming for PBS

To register for Online Claiming for PBS please follow the steps below:

  1. Complete the Online Claiming for Pharmaceutical Benefits Scheme Application and Terms and Conditions (4167) [PDF, 139Kb]PDF reader required. Please ensure that all approved persons (i.e. pharmacy owners) sign the agreement.
  2. Return the completed agreement to: PBS Approvals Clerk
    GPO BOX 9826
    In your capital city

Medicare will then complete the registration process and issue you with a digital certificate.

If you are an existing pharmacy who may be, for example, changing location or adding a business partner, please see the approved pharmacist page for the relevant forms. As well as a new approval number, you will need to apply for a new digital certificate to continue to claim online.

Concessional entitlement checking - refer prescription facility

As Online Claiming for PBS conducts a real time check with Centrelink of your customers' concessional entitlement, the '01' override facility was disabled in July 2007.

For more information about entitlement checking please download the following guide:

You can provide the following information sheet to your customers if they are not entitled to a concessional rate:

There are two scenarios which may result in a small number of cases requiring you to manually intervene to ensure your customer receives their correct entitlement:

1. Centrelink interim confirmation of concessional entitlement

In a very limited number of cases Centrelink may issue an interim confirmation of concessional entitlement. This could be presented by a customer at your pharmacy before their details have been updated within the Centrelink database.

2. Overseas departures

When a concessionally entitled customer is travelling overseas they are required to notify Centrelink of their departure date. Upon notification, Centrelink will end date the customer’s concessional entitlement record effective from the date of departure. In this situation, when a prescription is submitted via Online Claiming for PBS it will return a negative response in relation to the customer’s concessional entitlement on the day of departure.

In these two circumstances, the concessional entitlement validation (CEV) process - through a new refer prescription facility - enables you and Medicare to honour valid prescriptions at the concessional rate.

How to access the refer prescription facility:
If you find yourself with a customer in either of these two situations and have submitted the prescription via Online Claiming for PBS and received a negative response, please call 13 22 90* and select option 2.

Request to be put through to the Online Claiming for PBS operators and ask them to use the refer prescription facility.

Please have the following information ready which the operator will record against your current claim:

  • your approval number
  • your claim period number
  • the script number and payment category
  • your customer’s name and Medicare number.

And if your customer is holding an interim concession card their:

  • interim concession card or confirmation of concession card letter details
  • date, serial number, and name of issuing Centrelink office. 

Or if the customer is departing for overseas travel:

  • confirm date of their overseas departure.

Please write 'Refer prescription - interim card' or 'Refer prescription—overseas departure' on the prescription. The prescription will be flagged for payment on receipt of your paperwork.

Online Claiming for PBS information brochure

The following brochure provides an overview of Online Claiming for PBS [PDF, 125Kb]PDF reader required

Owing prescriptions

The National Health (Pharmaceutical Benefits) Regulations allow for medicine to be supplied before the written prescription has been supplied.  Where in a case of urgency: a prescriber advises you of the details of the prescription; or faxes you the written, signed prescription.  

After contacting you, the prescriber is required to provide you with the original PBS prescription within seven days. When the prescription is provided, the script does not need to be cancelled out of your dispensing system. The prescribing date on the earlier record should be changed to the date the prescription was signed by the prescriber. The date of supply should not be amended. 

Prescriptions requiring prior approval still require approval before being dispensed. Medicare recommends asking the prescriber for the Authority approval number to ensure approval has been obtained.

Some quick reminders about owing scripts:

  • owing scripts are not claimable until you receive the paper prescription
  • on receiving the prescription, the prescribing date within your system should be changed to the date the prescriber signed the prescription
  • if the date of prescribing is more than seven days after the date of supply, the script is still payable provided it meets all other requirements (including Authority approval requirements).
  • in the absence of a patient signature normal receipting rules apply. You are required to certify supply by indicating the date on which the supply was made and the reason why the patient signature could not be obtained.

Procedures for unscheduled system outages

Medicare is working towards refining its response to unscheduled system outages with Online Claiming for PBS should they occur. For this purpose, Medicare has defined two stages of unscheduled system outages. This circular defines the two stages and outlines the procedures that Medicare will follow to advise online pharmacies and other key stakeholders in the event of any unscheduled system outage occurring.

Stage one—Early warning

The early warning stage of a system problem with Online Claiming for PBS is defined as when:

More than 25 per cent of all online transactions are timing out, and this has been experienced for one continuous hour, or it will take over one hour to resolve the problem.

Communication procedure

In the event of early warning signs that the system is experiencing problems a message will be sent to key stakeholders. The message will advise that the Online Claiming for PBS system is currently experiencing problems and that we are working to resolve these problems as quickly as possible.

Key stakeholders will be advised in the following ways:

  • email sent to the Pharmacy Guild of Australia
  • message left with the receptionist of the Pharmacy Guild of Australia on (02) 6270 1888
  • email sent to all pharmacy software vendors
  • message placed on the 132 290—option 3 telephone line and updated hourly.

Stage two—Critical incident

A critical incident with Online Claiming for PBS is defined as when:

More than 25 per cent of all online transactions are timing out, and this has been experienced for two and a half continuous hours.

Communication procedure

If the problem has been resolved and the system has returned to normal operations within two and a half hours, Medicare will confirm the problem has been resolved to all online pharmacies and other key stakeholders.

If the problem has not been resolved after two and a half hours, Medicare will confirm it is now a critical incident.

In the event of a critical incident, a message will be sent to all online pharmacies and other key stakeholders. The message will advise that a critical incident has occurred with the Online Claiming for PBS system and that during this period, all rejected PBS prescriptions will be reviewed by Medicare  and paid according to the rules applying to a pharmacy operating in an offline environment (i.e. Claims Transmission System (CTS) diskette processing).

Online pharmacists and other key stakeholders will be advised of a critical incident in the following ways:

  • fax message sent to all online pharmacies
  • email sent to the Pharmacy Guild of Australia
  • message left with the receptionist of the Pharmacy Guild of Australia on (02) 6270 1888
  • email sent to all pharmacy software vendors
  • email sent to the Department of Health
  • message placed on the 132 290—option 3 telephone line and updated hourly.

Note: The National Secretariat of the Pharmacy Guild will advise all Guild Branches.

Once the critical incident has been resolved, and the system has returned to normal operations, a confirmation message will be sent to all online pharmacies and other key stakeholders.    

Notification by fax is an interim measure and Medicare is considering alternative communication channels.

Note: The Online Claiming for PBS service status page on the Medicare website, shows the current service availability.

Pharmacy Connectivity Incentive (PCI)

The new Pharmacy Connectivity Incentive (PCI) program provides financial incentives to pharmacies to maintain business grade broadband internet connections. The program will run from 1 January 2008 until 30 June 2010.
The PCI program aims to:

  • promote the use of Online Claiming for PBS
  • promote the continued use of business grade broadband connections by community pharmacies
  • increase awareness and understanding by community pharmacists of internet technologies and IT issues more generally.

The PCI program includes a Start-up Security allowance that will be made available to eligible pharmacies that have not previously been paid a Security Awareness and Conformance payment under the Broadband for Health: Pharmacy program, or a Start-up Security Allowance payment under the PCI program.

Changes to PBS Claiming

In addition to introducing the new PBS Online Claiming channel, Medicare is also replacing its PBS claims processing system. This new system will be used to process all PBS and RPBS prescription claims regardless of which method pharmacies choose to submit their claims. All pharmacies were mailed information about the new PBS claims processing system during September 2004 and November 2004.

Mailout to pharmacies on 20 September 2004

Mailout to pharmacies on 24 November 2004

New statements

Medicare will progressively roll out the new PBS claims processing system in 2005-06 to all of its processing centres. During this time, you will begin to receive new statements.

More information

For more information about Online Claiming for PBS, please call Medicare on 1322 90*.

* call charges apply

Some documents on this page may require the free Adobe PDF reader.

Last updated: 27 September, 2013