Education guide - Medicare Easyclaim claiming and functions

Help with Medicare Easyclaim functions, including claiming, bulk billing, reconciling payments, and definitions of common terms.

Claiming and other functions

Medicare Easyclaim provides a secure connection through your EFTPOS terminal to transmit bulk bill and patient claims to us.

Medicare Easyclaim is a stand-alone solution, meaning that it can work independently of practice management software (PMS). This means you don’t have to change your computer software to use it.

Depending on your practice, you may prefer the Medicare Easyclaim integrated solution. Financial institutions developed this solution with software vendors. The integrated solution connects your EFTPOS terminal with your software. This allows practices to combine Medicare Easyclaim and Medicare Online functions for a fully integrated solution. Integrated Medicare Easyclaim is available for doctors, specialists and allied health professionals.

Functions may vary between different software products and EFTPOS providers.

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Reconciling payments

You should choose the claiming option or combination that best suits your business needs. One thing you should consider is how you reconcile bulk bill claims, or how you would like to.

For Medicare Easyclaim operating as stand-alone, obtain bulk bill processing and payment reports through Health Professionals Online Services (HPOS). Download and print a PDF or Excel file and reconcile this report against your claims. It isn’t possible to get these via the EFTPOS terminal because of the:

  • information in the reports
  • size of the reports
  • need to print the reports.

For Medicare Easyclaim integrated solutions, obtain bulk bill processing and payment reports through your PMS. Use the retrieve report function. You will not need to download or print a PDF or Excel file.

The availability, format and content of reports depend on the software and Medicare Online release installed on your PMS.

Medicare Easyclaim Reference Guide

This section is to help you with Medicare Easyclaim:

  • processing
  • payments
  • patient claiming definitions
  • bulk bill claiming definition
  • return codes.

Helpful tips

When using Medicare Easyclaim all health professionals must ensure they have registered with us and have a provider number before transmitting claims.

For a patient to assign their benefit for bulk bill claims, it’s a legal requirement for the patient to either:

  • press OK on the EFTPOS terminal
  • sign an approved DB4 form if the EFTPOS terminal system is unavailable.

Health professionals need to have their bank account details lodged with us to receive bulk bill payments.

We’ll pay bulk bill claims transmitted and assessed by 5:30 pm Australian Eastern Standard Time in 2-3 working days.

You can transmit general practitioner (GP) consultation and diagnostic items in 1 claim. This is as long as:

  • the items are non-referred or requested services
  • the servicing provider is qualified to perform the services.

If the EFTPOS terminal times out or there is a communication failure during a patient claim, the practice should issue an account or a receipted account to the patient or claimant to receive their benefit either:

You don’t need the item override code - AP value - for Concession Entitlement Verification (CEV) items. The AP value is for not duplicate services - am/pm. For example, when claiming MBS item 23 and CEV MBS item 10990, you don’t need to use the AP value for the CEV item.

Health professionals should only use the item override code - AP value - when claiming a second visit using the same item number for a patient on the same day. For example, you provide MBS item 23 twice on the same date at separate visits.

Services not accepted through Medicare Easyclaim

Items not accepted through Medicare Easyclaim include:

  • in-hospital items
  • Australian Immunisation Register information
  • bulk bill claims more than 2 years from the date of service
  • patient claims more than 2 years from the date of service
  • time duration dependent items
  • notional charges, for example, a health professional has raised a total charge to cover a group of services
  • patient claims for pathology items, except Group 9 items
  • bulk bill pathology S4B3 items or Rule 3 exemptions
  • patient claims and bulk bill claims with non-standard referrals
  • items where the charge exceeds $9,999.99
  • GP multiple attendance items, for example, MBS items 24 and 35
  • separate sites override, unless the item is under restrictive override code in the Medicare Easyclaim terms explained list below
  • patient claims for assisted reproductive technology services
  • claims requiring text.

These items may be claimed through Medicare Online, by phone or at a Medicare service centre.

Call the eBusiness Service Centre to:

  • get help accessing your bulk bill processing and payment reports through HPOS
  • change your contact or practice details - you can also do this through HPOS
  • organise an on-site visit by a business development officer.

For technical problems, call the financial institution that supplied the service.

Medicare Easyclaim terms

For explanations about Medicare Easyclaim code and field terms read our data elements guide and see the table of common elements.

Allied health professionals

These allied health professionals can claim eligible MBS items through Medicare Easyclaim:

  • Aboriginal health workers
  • Aboriginal and Torres Strait Islander health practitioner
  • audiologists
  • chiropodists
  • chiropractors
  • dental specialists
  • dentists
  • diabetes educators
  • dieticians
  • exercise physiologists
  • mental health nurses
  • occupational therapists
  • oral medical and pathology practitioners
  • osteopaths
  • paedodontists
  • periodontists
  • physiotherapists
  • podiatrists
  • prosthodontists
  • psychologists
  • social workers
  • speech pathologists.

Some restrictions may apply. For example:

  • when a care plan MBS item isn’t present on the patient's history
  • the patient has reached their maximum number of services.

You can check your patient’s eligibility to claim these items using the HPOS MBS item online checker. This will help you prevent unnecessary rejections.

Cancel - bank initiated

An auto-cancel will be initiated when a financial transaction has been transmitted but no response has been received within the timeout period.

Claimant

The claimant is the person who incurred the expense for services provided. The claimant isn’t always the patient. They could be, for example, a parent.

Claimant Medicare card number

The claimant must have a valid Medicare card number in order to transmit patient claims through Medicare Easyclaim.

Date of service

Medicare Easyclaim automatically generates the date of service at the date you create and transmit the claim.
You must manually enter the date of service when it is different to the date you’re transmitting the claim. The date of service must:

  • be in the format DDMMYY
  • be a valid date
  • not be in the future
  • not be more than 2 years old.

Diagnostic imaging

You may require request details with diagnostic imaging services.

Equipment identification number

Equipment identification numbers identify specific equipment. They’re allocated by the Department of Health. They show what equipment you need to register to claim certain items. This usually applies to radiotherapy equipment.

Item override code

Sometimes health professionals have to give more information in a claim so that we can assess the service. The item override code lets health professionals submit information for specific situations. It uses a 2-character indicator so that we correctly assess the service and pay the right amount.

2-character values include:

  • AO = not normal aftercare
  • AP = not duplicate service (am/pm).

Location Specific Practice Number (LSPN)

The LSPN is applicable to services:

  • within Group T2 - radiation oncology services as described in the MBS
  • within Category 5 - diagnostic imaging services as described in the MBS
  • where a GP has a remote area exemption and performs diagnostic services.

Where these services occur, this field is mandatory.

Medicare card flag values

Medicare card flag values indicate the problem we have with the submitted Medicare card. This indicator may appear on the bulk bill processing report against a claim.

Medicare card flag values are:

  • A = patient identification amended
  • I = patient Medicare issue number changed
  • C = patient Medicare card number changed
  • W = patient card used will expire shortly
  • S = patient card expired, and we may reject future services
  • X = old Medicare issue number for patient, and we may reject future services.

MBS item number

You need the MBS item number for each service. It must be valid at the date of service for the health professional. You can’t enter miscellaneous taxable services and ancillary items that do not attract a Medicare benefit. View the MBS online.

Pathology

Pathology services provided by an eligible health professional, including Group 9 for patient claims.

Patient

Patients are those who receive services.

Patient Medicare card number

The patient must have a valid Medicare card number to transmit patient or bulk bill claims through Medicare Easyclaim.

Patient Individual Reference Number (IRN)

The IRN is to the left of the patient’s name on their Medicare card.

Payee provider number

Payee provider numbers are the provider numbers of the health professional who we’ll pay for the service. It’s only needed if the payee provider isn’t the servicing provider.

Pended claim

Pended claims need a customer service officer to review manually because of complexity or special circumstances.

Real-time Medicare eligibility validation

We will validate the patient’s eligibility when you lodge the claim.

Referral details

We need referral details for certain services provided by specialists, allied health professionals or consulting physicians. We need them when a Medicare benefit is dependent on acceptable evidence showing the health professional provided the service following referral from another health professional.

Referral details for initial consultations and other referred services - including subsequent consultations - are mandatory.

The referring health professional must have a current and valid registration at the date of referral.

Referring provider number

A referring provider number is the provider number of the referring health professional. We assign provider numbers.

Referral issue date

You have to fill in this field in Medicare Easyclaim if you have the referral details. You should put in the date on the letter of referral.

Referral period type code

The referral period type code indicates the period of referral. You must fill in this field if you have entered a referring provider number and referral issue date.

The referral period type code values are:

  • S = standard which are valid for 12 months from a GP and 3 months from a specialist
  • I = indefinite.

Referral override type code (specialist services only)

The referral override type code indicates why referred services were provided without referral from another health professional.

Lost or emergency referral indication

You only need to fill in the lost or emergency referral indication field either:

  • when a written referral was lost
  • in an emergency situation where the servicing health professional believed they needed to give the service as quickly as possible.

Lost and emergency referrals are only applicable to initial consultation items. You must meet all referral requirements for these consultation items.

The lost or emergency referral indication values are:

  • L = iost
  • E = emergency
  • N = not required.

Request details

You need request details for items that are subject to the written request requirement and are R-Type (requested) services.

You need the:

  • requesting provider number
  • request issue date.

Requesting provider number

A requesting provider number is the provider number of the referring health professional. We assign provider numbers.

Request issue date

The request issue date is the date the health professional issued the request.

Request override type code

Health professionals should use the request override type code if they’re lodging a claim and they need to indicate why they provided request services without a request from another health professional.

Lost or emergency request indication

You only need to fill in the lost or emergency request indication field either:

  • when a written request was lost
  • in an emergency situation where the health professional believed they needed to give the service as quickly as possible.

The requesting health professional must have a current and valid registration at the date of request.

The lost or emergency request indication values are:

  • L = lost
  • E = emergency.

Restrictive override code

Sometimes health professionals have to provide more information in a claim so that we can assess it correctly. The restrictive override code lets health professional submit information for specific situations. It uses a 2-character indicator so that we correctly assess the service and pay the right amount.

2-character values include:

  • SP = separate sites
  • NR = not related (care plans)
  • NC = not for comparison.

When the separate sites indicator is set, MBS items 30071, 30061, 30192 and 30195 will automatically override where:

  • the services are within 1 claim and are for the same patient, health professional and date of service
  • there are combinations of items 30071 and 30061 plus only 1 x 30195 or only 1 x 30192
  • there are multiples of items 30071 and 30061 within 1 claim.

The time-dependency restrictions for MBS items 30192 and 30195 will continue to apply.

Specimen collection point identification number (SCPId)

The SCPId is only for bulk billing pathology services. We use the provider number and SCPId to assess the claim. We’ll have to reject the claim if the provider number isn’t registered in the Medicare system to allow that health professional to perform services with the SCPId entered.

Self-deemed (SD) and substituted service (SS) codes

SD is an optional element. However, conditions apply depending on the SD value you select. SD applies to both pathology and diagnostic claims. When the SD value is present, request details can’t be set.

Pathology claims can only have an SD indicator.

SS only applies to diagnostic claims. When the SS value is present, you need request details.

There may be claims where neither the request details nor request override type code are set. Instead, a self-deemed value of SD applies.

The values for SD and SS codes are:

  • SD = self-deemed
  • SS = substituted service.

Servicing provider number

A servicing provider number is the provider number of the health professional who rendered the service.

Types of EFTPOS receipts

The EFTPOS terminal will produce the following types of receipts, which you must give to the patient or claimant:

  • Medicare patient claim receipt - for all fully paid, assessed patient claims
  • Medicare lodgment receipt - for all unpaid, partially paid or pended patient claims
  • cancelled Medicare claim receipt - for all patient claims cancelled by the medical practice or claimant
  • bank cancelled claim receipt
  • bulk bill assignment advice - for all bulk bill claims following the medical practice accepting the claim and the patient assigning the benefit.

Patient claim definitions

Patient claims

Medicare patient claims are lodged by a patient or claimant who has received professional medical services for items covered under the MBS.

Cancel indicator

The cancel indicator will show when we have assessed the claim and shown a benefit amount. This may show if the:

  • claimant doesn’t have a bank debit card
  • EFTPOS terminal can’t read the card
  • claimant doesn’t wish to continue with the claim.

In these cases, the practice cancels the claim.

Rejected claims

If we can’t assess a patient claim immediately, we’ll return the claim to the practice via the EFTPOS terminal. It will have a 4-digit return code.

The 4-digit return code helps the health professional resubmit the claim with correct or additional information, if that’s appropriate. Alternatively, the health professional can lodge these claims through an alternate channel. Refer to the list of return codes.

Real-time patient claim

Real-time processing transmits, assesses and returns an outcome to the sending location as a single process.

For real-time claims, you need to enter specific information while the patient or claimant is present.

Types of patient payment options

There are 3 payment options for patient claims that you can lodge through Medicare Easyclaim. The type of claim depends on how the patient or claimant and the health professional choose to settle the account:

  • fully paid account - when the patient or claimant has paid their account in full with the health professional
  • part paid account - when patient or claimant has paid a contribution toward the settlement of the account
  • unpaid account - when the patient or claimant hasn’t paid the account.

Types of benefit payment

The payment method for claims lodged through Medicare Easyclaim depends on whether the account is either:

  • fully paid
  • part paid
  • unpaid.

Fully paid is when the account has been paid in full.

We’ll pay into to the claimant's bank account almost immediately. This payment is initiated when the claimant swipes their EFTPOS card.

Part paid is when a claimant has made a part payment contribution towards the account. For part paid accounts:

  • if we assess that Medicare benefits are payable for a claim, we will send a statement or cheque in the health professional's name, for the claimant then has to send the cheque to the health professional with any outstanding balance
  • if no benefit is payable, we’ll send a statement to the claimant
  • if the patient has reached their Medicare Safety Net threshold and they are entitled to an additional safety net benefit, we’ll pay the amount to the claimant by EFT if we know their details.

Unpaid is when the claimant hasn’t paid the account. For unpaid accounts:

  • if we assess that Medicare benefits are payable for a claim, we’ll send a statement or cheque in the health professional's name to the claimant, for the claimant to then send the cheque to the health professional with any outstanding balance
  • if we assess that no benefit is payable, we’ll send a statement to the claimant.

When sending information to claimants we use the address we have in our records.

Bulk bill claim definitions

Bulk bill claims

A bulk bill claim is where a patient who is eligible for a Medicare benefit assigns their right to the benefit to the servicing provider as full payment for that service. The health professional lodges the claim with us.

It is at the health professional’s discretion whether or not to bulk bill a patient.

Accept or decline indicator

If we return a Medicare eligibility or concession entitlement, the medical practice or patient can choose to accept or decline the claim using the accept or decline indicator.

Assignment of benefit

Assignment of benefit is when a patient assigns their right to the benefit to the servicing provider as full payment for the services.

Benefit assigned amount

For Medicare Easyclaim, the benefit returned in a bulk bill claim refers to an estimate of the benefit that we’ll pay the health professional.

This amount may be adjusted in accordance with the rules set out in the MBS.

Claims per transaction

You can only submit 1 bulk bill claim per transmission. This claim can contain more than 1 service item.

Real time Concession Entitlement Verification (CEV)

When you lodge bulk bill claims, we’ll only validate the patient’s concession entitlement if their Medicare card is valid.

Retention of records

We recommend practices keep all records associated with benefits paid for at least 2 years. These records can include electronic billing information, notes in practice software, appointment records and assignment of benefit forms. If audited, this information will help you prove to us that we’ve paid all claims correctly.

Transmission of bulk bill claims

Medicare Easyclaim transmits bulk bill claims to us in real time but we don’t assess them immediately.

Basic eligibility checks occur before the patient and health professional accept or decline the assignment of benefit. The patient must be present to press OK to assign their benefit.

The receipt printed is an assignment of benefit advice only. It indicates that Medicare Easyclaim has successfully transmitted the claim to us.

As per legislative requirements, the practice must give the patient a copy of the receipt.

More information

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Contact us at the eBusiness Service Centre.

Contact us at Online Technical Support (OTS) team for software vendors for specific technical enquiries on:

  • policy and procedures
  • complaints and disputes
  • feedback and suggestions.

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Page last updated: 20 February 2020