Patient claim definitions
Medicare patient claims lodged by a patient or claimant who has received professional medical services for items covered under the MBS.
Where we have 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.
Where we are unable to assess a patient claim immediately, the claim will be returned to the practice site via the EFTPOS terminal with a 4 digit return code.
The 4 digit return code is to help the health professional to resubmit the claim with changes, if appropriate, allowing a successful transmission. Alternatively, these claims may be lodged through an alternate channel. Refer to the list of return codes.
Real time patient claim
Real-time processing by Medicare Easyclaim transmits, assesses and returns an outcome to the sending location as a single process.
Submitting of a real-time Medicare Easyclaim patient claim requires specific information to be entered into the claim while the patient or 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 or claimant and the health professional have chosen to settle the account.
- Fully paid account - patient or claimant has paid their account in full with the health professional
- Part paid account - patient or 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 depends on whether the account is fully paid, part paid or unpaid.
- where the account has been paid in full, payment will be made to the claimant's nominated bank account almost immediately. This payment will be initiated by the claimant swiping their EFTPOS card
- where a claimant has made a part payment contribution towards the account
- where Medicare benefits are assessed as payable for a claim, a statement or cheque in the health professional's name will be sent to the claimant's address recorded by us. The cheque is then sent by the claimant to the health professional with any outstanding balance
- where no benefit is payable, a statement will be sent to the claimant's address recorded by us
- 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 us
- where the account is unpaid
- where Medicare benefits are assessed as payable for a claim, a statement or cheque in the health professional's name will be sent to the claimant's address recorded by us. The cheque is then sent by the claimant to the health professional with any outstanding balance.
- where no benefit is assessed as payable, a statement will be sent to the claimant's address recorded by us
Page last updated: 22 February 2019
This information was printed 25 May 2020 from https://www.servicesaustralia.gov.au/organisations/health-professionals/services/medicare/medicare-easyclaim/resources/patient-claim-definitions. It may not include all of the relevant information on this topic. Please consider any relevant site notices at https://www.servicesaustralia.gov.au/individuals/site-notices when using this material.