Claiming online for PBS medicines

To claim for PBS medicines, you must have approval under either section 90, 92, 94 of the National Health Act 1953.

Benefits of online claiming

Claiming PBS medicines online is fast and easy. With online claiming you’ll:

• be paid each week
• know how much we’ll pay before you supply the medicine to the customer
• be able to correct errors immediately as you’ll see possible rejections at the time you dispense the medicine
• get electronic statements reconciled by your PDS.

Register for online claiming for PBS

To register for online claiming for PBS, you need a pharmacy or hospital approval number. You also need to record your ABN with us for your pharmacy or hospital approval number.

Once you have your approval number you’ll need to:

1. Complete the notification of Australian Business Number and reference identification for tax treatment purposes and recipient created tax invoice agreement form.
2. Register your organisation in Provider Digital Access (PRODA).

Once you’ve set up PRODA, make sure you add the PBS Online service provider and register your B2B device.

Online claiming process

When you claim make sure:

• the customer gives you a PBS or RPBS prescription
• you enter the prescription information into your prescription dispensing software (PDS).

When you make the entry into your PDS:

1. The PDS sends us a transaction. We check the prescription details against PBS or RPBS rules.
2. We check if your patient has an entitlement with Centrelink.
3. We’ll send you a message to tell you if the claim is payable.
4. Sometimes you’ll need to correct an error or omission before making a claim. You can do this before you supply the medicine to the customer.
5. You can supply the medicine to the customer.

At the end of your pharmacy's claim period, close the claim through your PDS.

You need to keep all prescriptions and claim-related paperwork for 2 years for audits and verifications. You can keep records in electronic or paper form.

Check for a concessional entitlement

When you claim PBS medicines online, we check your customer’s concessional entitlement with Centrelink in real-time. This is how we confirm your customer is entitled to subsidised medicine.

Please check your customer’s concession card before supplying medicine.

You can use PBS Online Claims Processing to confirm your customer is eligible for the PBS and RPBS, including:

• Medicare
• PBS Safety Net
• concession and health care cards, such as Pensioner Concessions Card, Commonwealth Seniors Health Care and the Health Care Card
• Department of Veterans' Affairs - Gold, White and Orange cards, Pensioner Concession Card and Commonwealth Seniors Health Care Card.

If a customer isn’t entitled to PBS or RPBS medicine at the subsidised rate, they should pay either:

• an increased contribution
• a private rate.

The rate type will depend on their level of entitlement.

You can give your customers information about why we haven’t applied the PBS concessional rate.

Owing prescriptions

The National Health (Pharmaceutical Benefits) Regulations allow pharmacists to dispense medicine before the customer has supplied a written prescription. In urgent cases, a prescriber may tell you the details of the prescription or send a fax of the written and signed prescription.

Prescriptions that need prior authority approval still need approval before you can dispense them. You’ll need to ask the prescriber for the authority approval number to ensure they have approval.

After contacting you, the prescriber has to give you the original PBS or RPBS prescription within 7 days. When you have the prescription, use the owing mark-off function to enter the prescribing date. Mark-off the prescription recorded in your PDS. You shouldn’t amend the date of supply.

You can’t claim an owing prescriptions until you have the paper prescription.

When you get the prescription, make sure the prescribing date is the date the prescriber requested the prescription. If you get the prescription more than 7 days after the date of supply, it’s still payable as long as all other requirements including authority approval are met.

If you don’t have the patient's signature the normal receipting rules apply. You must certify on the prescription the date of supply and the reason you couldn’t get the patient's signature.

PBS claim statements

Pharmacies who claim PBS medicines online will receive:

• payment correspondence
• PBS reconciliation statements.

Payment correspondence

You’ll get hard copy payment correspondence about your PBS medicine claims each week. You’ll find information about your payments and any associated tax or fee information. Use this correspondence to reconcile payments made into your bank account.

Payment correspondence may include:

• a payment advice note with details about payments we made to your bank account
• a tax invoice detailing any fees we've charged. We’ll only issue this if we've charged fees. Only pharmacists who submit their claims manually will receive a tax invoice
• a recipient created tax invoice (RCTI) detailing the payments that we've made under the RCTI agreement. We’ll only issue this as required for payments that include GST.

PBS reconciliation statement

There are 2 types of PBS reconciliation statements you can get through your PDS:

• interim reconciliation statements - provided weekly
• final PBS reconciliation statements - produced after each claim period closes.

These statements help you reconcile your online claims with the prescription details in your PDS. The statements have 4 parts:

• The prescription summary and adjustments shows an overview of all prescriptions you processed or adjusted in the claim period. The summary shows totals relevant to the prescriptions you submitted in the claim. The adjustments detail information relating to prescriptions you adjusted since the previous statement.
• The prescription details show each prescription you submitted during the claim period. The table lists each prescription, price, if it was accepted, and relevant reason codes.
• PBS entitlement errors is a table of each prescription where there was a related entitlement error. It details the relevant rejects, warnings or information and provides the pharmacist with details of the entitlement errors.
• The explanation of reason codes explains the reason your PDS returned for prescriptions within the claim period. Your PDS provides reason codes to explain warnings or rejected prescriptions.

Check the PBS system status before you claim

You can check there are no system disruptions using the PBS services status tool. The tool is updated in real-time.

You can also check the operational status of phone lines.

Compliance

We perform data mining on all prescriptions you claim. We also do audit checks.

At any time, we may refer your pharmacy to the Department of Health and Aged Care (Health and Aged Care) who do compliance checks. They may ask you for a copy of prescription and claim paperwork. You can provide this in electronic or paper form.

You should document prescriptions and medication charts. Health and Aged Care may ask for a copy of this documentation. In some situations, they may keep these documents.

As an approved supplier, you must keep all prescriptions and claim paperwork for 2 years from the date of supply.

Manual claiming

If you claim manually, please provide paper prescriptions and claim paperwork to us to process for payment. Processing by the department will attract a processing cost per prescription. Complete and submit these forms with any manual claiming application:

• Manual prescription processing fee for pharmaceutical benefits form
• Approved supplier manual payment reconciliation form.

More information

For more information about online claiming for PBS contact us at PBS general enquiries.