Guides

Eligibility check coverage

A clear answer on almost every item, and the few where we can't
View as Markdown

On almost every item in the Medicare Benefits Schedule (MBS), RebateRight gives a clear eligible or not eligible. On a small set (167 items, 2.8% of the MBS), we sometimes return cannot determine instead: never a wrong answer, just an honest “we can’t determine this one.” Whether it affects you depends on what you bill.

When you’ll see cannot determine

You’ll only see cannot determine when all four of these are true at the same time:

  • the patient is treated out of hospital
  • the item is one of the 167 listed below
  • the patient’s Medicare details are valid
  • every other RebateRight check passes, such as the referral and the patient’s age

If any one of these is not true, you get a clear eligible or not eligible instead, with the reason. So even on these 167 items, RebateRight still catches what it can: a wrong Medicare detail or a rule that finds the item not eligible is flagged before the claim goes in.

When all four are true, cannot determine tells you the claim already clears everything RebateRight can check: the patient’s Medicare details matched, and every other check found the item eligible. The only thing left is how many times the item has already been claimed. These items have a limit on that, and out of hospital, Services Australia doesn’t share the patient’s claim history. So rather than guess, we show cannot determine.

See if your items are affected

The 167 items are below (as at July 2026), grouped by MBS category. Search by item number or by what the item is, or open a category to browse. Each number links to its descriptor on MBS Online.

Affected MBS item numbers: 139 145 147 177 228 245 249 291 293 296 299 300 302 304 306 308 310 312 314 316 318 319 699 701 703 705 707 715 900 903 10910 10911 10921 10924 10926 10927 10928 10929 10931 10938 10939 10940 10941 10942 10943 10944 91827 91828 91829 91830 91831 91837 91838 91839 91868 91869 91870 91871 91872 91873 91879 91880 91881 92004 92011 92029 92112 92113 92116 92117 92118 92119 92122 92123 92140 92141 92142 92422 92423 92434 92435 92436 92437 92443 92444 92448 92623 92624 92762 92763 92767 92768 11342 11345 11707 11714 11716 11717 11723 11735 12218 12219 13104 16400 16408 91850 91851 91852 91855 91856 91857 57541 73839 73840 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970 10987 10997 81000 81005 81010 81100 81105 81110 81115 81120 81125 81300 81305 81310 81315 81320 81325 81330 81335 81340 81345 81350 81355 81360 82100 82115 82116 82140 82301 82302 82304 93000 93013 93026 93029 93048 93061 93284 93285 93286

Three MBS categories have no affected items at all. Every item in them gets a clear eligible or not eligible, none are excluded:

  • Category 4 · Oral and maxillofacial services
  • Category 7 · Cleft lip and palate services
  • Category 10 · Child Dental Benefits Schedule

Indicative items

Services Australia verifies most MBS items live. For the rest, RebateRight applies the MBS rules and gives you a clear eligible or not eligible, what we call an indicative result. It’s a straight answer from our rules engine, not a live Services Australia confirmation, and clearly labelled every time.

The 167 items above are the indicative items that also have a limit on how often they can be claimed. That’s the one check that can’t be confirmed out of hospital, so they’re the only ones that can return cannot determine.

Indicative items are named in section 7 of our Licence Agreement.

Reciprocal Medicare cardholders

Patients covered by Australia’s Reciprocal Health Care Agreements (RHCAs) carry a reciprocal Medicare card. They’re entitled to medically necessary care while in Australia, and they’re subject to the same MBS item rules as a standard cardholder, including claim frequency limits. Cover terms vary by country: see Reciprocal Health Care Agreements on the Services Australia site, or MBS note GN.3.9.

Services Australia doesn’t check these patients online, so Medicare returns no eligibility assessment for them.

RebateRight’s own rules still run, so an item can still get a definite answer. It comes back:

  • not eligible when one of our checks rules it out, such as patient age or in-hospital status. That answer stands on its own and needs no confirmation.
  • cannot determine when our rules all pass. We’ve found nothing wrong, but the checks only Medicare can run haven’t happened.

Either way Checks shows exactly what ran, so you can see what we cleared and what we couldn’t reach.

For developers: PatientVerification.Verified is null, and the entry for Medicare’s assessment in Checks is IsEligible: null, carrying Medicare’s own sentence in Reason. The item’s IsEligible follows the two cases above.

For developers

Pull the set. List GET /MedicareItems and keep items where BenefitType is _85 or _100 and ClaimHistoryLimitation is not empty.

In an eligibility response, cannot determine is IsEligible: null, and the unchecked limit appears as an IsEligible: null Frequency of service entry in Checks. It’s returned only for out-of-hospital requests where every RebateRight check finds the item eligible. A check that finds it not eligible returns IsEligible: false with the reason. An in-hospital request returns the live result.

GET /CalculateRebate -> Rebates[]
{
  "ItemNumber": "701",
  "IsEligible": null,
  "Reason": "This item has a frequency-of-service limit, and Medicare doesn't verify it online for out-of-hospital claims. Without the patient's claim history, eligibility can't be determined.",
  "Benefit": "0"
}

The null entry in Checks names the cause: its Reason says what couldn’t be checked, whether that’s a missing ReferrerProviderNumber, a patient sex recorded as not stated, or the claim-frequency limit. Indicative items with no frequency limit return IsEligible: true, the frequency check reporting the item eligible. The answer always lives in IsEligible.