How claiming works | RebateRight

The claiming services let health professionals and healthcare locations lodge Medicare and Department of Veterans’ Affairs (DVA) medical claims electronically with Services Australia. RebateRight supports bulk bill claims, patient claims, in-patient medical claims and DVA medical claims. Each has its own guide.

Which claim do I send?

Bulk bill claim

The patient assigns their right to the Medicare benefit to the health professional. The practice lodges the claim, and Medicare pays the benefit directly to the provider.

Patient claim

The patient keeps their right to the Medicare benefit, and the practice lodges the claim for them. Medicare pays the benefit to the claimant, or by a cheque made out to the provider when the account is not paid in full.

In-patient medical claim (ECLIPSE)

The patient is admitted to hospital. Medicare assesses the claim, then sends it to the patient’s health fund for every claim type except Medicare Only. The claim type decides who is paid: the provider, a billing agent or the claimant.

Test environment only. Services Australia is certifying this service, and it reaches production once certified.

DVA claim

The patient is an eligible veteran or dependant, identified by a DVA file number rather than a Medicare card. DVA pays the benefit to the provider.

In production, each clinic registers a Minor ID with Services Australia before it claims. Go live lists what your software and each clinic need in place. What Services Australia requires of your software sets out how your software shows messages and prints statements.

Common concepts

The Medicare claim flows use these building blocks:

Concept	Description
Voucher (Medical Event)	One visit: all the services a patient received on a single date. A claim can contain multiple vouchers, up to 80 in a bulk bill claim, and 16 in an interactive patient claim or an in-patient medical claim.
Service	One MBS item within a voucher, such as item `23` for a standard GP consultation. Each voucher holds up to 14 services.
Referral	A referral from one practitioner to another, typically from a GP to a specialist. It carries the referring provider number, the referral date and the validity period. Specialist services and some diagnostic services need one.
Request	An order form a requesting practitioner issues for pathology tests or imaging. Pathology and diagnostic imaging services need one.
Correlation ID (also Transaction Id)	Your unique identifier for each claim you send. RebateRight returns it in every response that comes from Medicare. See Correlation ID.

DVA claiming follows a similar voucher-and-services model, with veteran details in place of the Medicare card.

Correlation ID

Services Australia calls this value dhs-correlationId in requests, and Transaction Id in its error messages. You may see either term.

Format. A correlationId is exactly 33 characters: the prefix urn:uuid:, then the Minor ID you send in the x-minor-id header, then 16 letters or digits, such as urn:uuid:MDE00000b896820b03e348a5. The value is not a standard UUID, despite its prefix. Medicare rejects a plain UUID with 9202.
Send your own. Create a correlationId for every claim, and store it with the claim before you send it. If your request omits the field, RebateRight generates one and returns it in the response. When no response arrives, you never see the generated value, and every step in When a claim gets no response needs the original correlationId.
A new ID for every new claim. Use a new correlationId for every new claim, including a corrected claim and a resubmission after a rejection or a 3004. Medicare returns 9777 for a claim whose correlationId it has already received, and does not process that claim.

Reuse the original correlationId only in these cases:

To	Send
Resend an unchanged claim that got no response	The same claim with the original `correlationId`. See When a claim gets no response.
Pend a patient claim that Medicare returned as `MEDICARE_PENDABLE`	The same claim, unchanged, with the original `correlationId`. See Pendable Claims.
Fetch a bulk bill or DVA processing or payment report	The original claim’s `correlationId`. See the bulk bill processing and payment reports, and the DVA processing and payment reports.
Request an in-patient claim’s status or report	The claim’s transaction ID: its original `correlationId` without the `urn:uuid:` prefix. See Follow the claim to its outcome.
Delete a patient claim on the same day	The original claim’s `correlationId`. See Same Day Delete.

Retrieving outcomes

Bulk bill and DVA claims are store-and-forward. A 200 means Medicare has accepted the claim for processing, and carries the claim’s claimId. Medicare assesses the claim later, and the outcome arrives in a processing report. Once the claim is paid, the payment report gives the payment run and the deposit amount.

Same day

Lodged

Medicare accepts the claim and returns a claimId.

From the next day

Assessed

The processing report gives the outcome for each service.

Once paid

Paid

The payment report gives the payment run and the deposit amount.

A lodged claim is not yet paid, and its processing report can still reject a service. The timing shown is for a bulk bill claim. A DVA report is ready once Medicare finalises the assessment or the payment.

	Bulk bill claim	DVA claim
Processing report	Bulk bill processing report, available from the day after lodgement	DVA processing report, available once Medicare finalises the assessment
Payment report	Bulk bill payment report, available once the claim is finalised and paid	DVA payment report, available once Medicare finalises the payment

Not ready. A request for a report before it is available returns REPORT_NOT_READY. For a bulk bill claim, schedule a daily retrieval from the day after lodgement. For a DVA claim, retry the report later.

See every request

Test claims. A test bulk bill or DVA claim never gets a processing report or a payment report, as Claiming in the test environment explains.

Patient claims. Patient claims are interactive. The 200 response carries the outcome: the claim status and the benefit for each service. Patient claims have no processing report.

In-patient medical claims. The 200 response acknowledges the claim, and 3 requests follow it to its payment:

Step	Request	Returns
1	Status Report	When the claim’s report is ready
2	In-Patient Claim Report	The outcome
3	Remittance Advice	The payment, once the claim is paid. A Patient Claim gets none.

Follow the claim to its outcome gives the steps.

When a claim gets no response

A claim has no response when your client times out, the connection drops, RebateRight returns 503, or Medicare returns a 5xx status without a serviceMessage. In each case, whether Medicare received the claim is unknown.

Recover the claim with its original correlationId. A new correlationId would lodge the claim a second time if the first attempt reached Medicare.

Bulk bill and DVA claims. Resend the claim unchanged with the same correlationId. A 200 means the first attempt did not reach Medicare, and the resend is now lodged. A 9777 means Medicare received the first attempt, and the claim’s processing report has the outcome.
Patient claims. Ask the user to confirm, then resend the claim unchanged with the same correlationId. Before they confirm, tell them that the resend pends the claim if Medicare found the first attempt pendable. A 9777 means Medicare received the first attempt, so the claim is lodged. Patient claims have no report, so the outcome of the first attempt is not available through the API. Sending the claim again with a new correlationId lodges a second claim.
In-patient claims. Resend the claim unchanged with the same correlationId. A 200 means Medicare has now accepted the claim for processing. A 9777 means Medicare received the first attempt. In both cases, Follow the claim to its outcome gives the next steps.

Client timeout. RebateRight waits up to 100 seconds for Medicare. Set your client timeout above 100 seconds, such as 120 seconds. A shorter timeout can report no response for a claim that Medicare then lodges.

Availability

Hours. Production accepts claims around the clock, so an evening or overnight batch is a supported pattern. Services Australia runs the claiming services to its published service level standards, with scheduled maintenance outages for deployments and system housekeeping.

Response time. Typical responses are under 4 seconds, though no response time is guaranteed.

Claim rate. Services Australia requires you to send no more than one bulk bill claim per second, and no more than one patient claim per second. RebateRight forwards each claim as it arrives, so pace your batches and resends to stay within that rate.

The test environment works to different hours from production. Integration test data says what to expect there outside Sydney business hours.