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The following information helps reduce common reasons for claim rejection using patient verification and eligibility checks available through either:
- online claiming functions integrated with your practice management software
- Health Professional Online Services (HPOS).
Services eligible for Medicare benefits
We pay Medicare benefits for clinically relevant services. A service is clinically relevant if it is generally accepted by the relevant health profession as necessary for the appropriate treatment of the patient. Services listed in the Medicare Benefits Schedule (MBS) must also be rendered according to the provisions of the relevant Commonwealth, State and Territory laws.
When determining appropriate MBS items to bill, you should refer to the relevant MBS item descriptors and explanatory notes available at MBS Online on the Department of Health and Aged Care website.
Claiming rejections and reason codes
We may reject claims for Medicare benefits such as:
- an incorrect MBS item being used
- the patient having received the maximum allowable number of benefits for an MBS item
- issues with patient or health professional eligibility
- system issues
- further information being required to assess the claim.
When claims are rejected, a Medicare reason code provides a brief explanation or reason for the rejection. Generally, this information can be used to:
- identify any claiming errors
- make any corrections
- resubmit for payment.
Medicare reason codes are 3 digit codes found in processing reports and Medicare benefit statements. View the Medicare reason codes list.
Common reason codes for rejecting claims
| Reason code | Explanation | Actions to reduce rejected claims |
|---|---|---|
| 159 | Item associated with other service on which benefit payable |
If the service is eligible for a Medicare benefit such as the service is not performed on the same occasion, not associated with the other service, not performed through the same incision, then for:
For certain MBS items, you can use the MBS Items Online Checker in HPOS to check eligibility before you lodge the claim. Log on to HPOS to see what items can be checked using the MBS Items Online Checker. |
| 160 | Maximum number of services for this item already paid | For certain MBS items, you can use the MBS Items Online Checker in HPOS to check eligibility before you lodge the claim. Log on to HPOS to see what items can be checked using the MBS Items Online Checker. |
| 162 | Benefit has been previously paid for this service |
Where multiple eligible items are claimed such as 2 attendances, 2 skin biopsies or 2 x-rays make sure to provide information supporting payment for each service. If the service is eligible for a Medicare benefit because the service is not a duplicate service, such as attendances at different times, biopsies taken at different physical locations, x-rays of separate limbs and not for comparison purposes, then for:
For certain MBS items, you can use the MBS Items Online Checker in HPOS to check eligibility before you lodge the claim. Log on to HPOS to see what items can be checked using the MBS Items Online Checker. |
| 179 | Benefit not payable - associated service already paid |
Where multiple eligible items are claimed, such as 2 skin biopsies or 2 x-rays, make sure to provide information supporting payment for each service. If the service is eligible for a Medicare benefit such as biopsies taken at 2 different physical locations or x-rays of separate limbs and not for comparison purposes, then for:
For certain MBS items, you can use the MBS Items Online Checker in HPOS to check eligibility before you lodge the claim. Log on to HPOS to see what items can be checked using the MBS Items Online Checker. |
| 252 | Service possibly aftercare |
If the service is eligible for a Medicare benefit and the service is not normal aftercare, then for:
|
| 374 | Old card issue used - benefit not payable - also refer @ |
Check a patient’s Medicare card details to make sure the card is current and your practice records are up-to-date. Update your records, if required. For:
Patient verification can be done before you lodge claims. |
| 529 | Bulk bill additional item claimed incorrectly |
If the unreferred Medicare service and related bulk bill additional item are eligible for a Medicare benefit, make sure you lodge both items together in the same claim for the patient. Use the correct bulk bill incentive item that applies to the unreferred Medicare service.
Practices must check the validity of a patient's concession card by:
|
| 550 | Associated service not claimed - no benefit payable |
If the service is eligible for a Medicare benefit such as an associated service is required, then either:
For certain MBS items, you can use the MBS Items Online Checker in HPOS to check eligibility before you lodge the claim. Log on to HPOS to see what items can be checked using the MBS Items Online Checker. |
| 606 | Referring provider number not open at date of referral |
Make sure you always provide the correct referral or request details including both the:
Organisations and agencies such as private health insurers, pathology and diagnostic imaging companies can apply to us for approval to access the Medicare Provider Data File to verify provider details necessary for processing and paying Medicare claims. This is in accordance with legislative requirements contained in section 130 of the Health Insurance Act 1973. |
Where an @ symbol appears on a Medicare benefit statement, it means the Medicare card number that was quoted and lodged in the claim has now been changed and shows the current Medicare card issue number. You will need to check your practice records and update them with the current Medicare card issue number for future claims.
By completing some checks before you lodge claims or making sure you provide all the information needed to assess claims, you can reduce the likelihood of claim rejections.
Considerations for incorrect claiming
As an eligible health professional you are legally responsible for services billed under your provider number or in your name. This includes any incorrect billing of services that result in overpayment of Medicare benefits, regardless of who does your billing or receives the benefit.
You may be liable to pay an administrative penalty in addition to repaying Medicare payments for incorrectly claimed services.
More information
Online:
- Education services for health professionals to access other education resources.
| Service | Contact |
|---|---|
| Medicare reason codes list | Medicare provider enquiries |
| MBS Online | MBS Online on the Department of Health and Aged Care website |
| Enquiries on MBS item interpretation | MBS item interpretation |
| Medicare provider enquiries for Medicare card, claiming and payment enquiries | Medicare provider enquiries |
| HPOS | Health Professionals Online Services |
| Vendors offering online claiming functions available in software | Vendors offering Medicare online claiming |
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