Eligibility check coverage

RebateRight checks the full Medicare Benefits Schedule. This page explains what we check on every item, and what each result means — so you know exactly what you’re getting before you rely on it.

What we check on every MBS item

We check the full MBS — all 6,039 items, with nothing skipped. On every item, every time, RebateRight:

• Verifies the patient with Medicare — that the card is valid and the patient’s details match Services Australia’s records.
• Checks the patient’s age against the item’s age rules.
• Checks referral requirements — whether a referral is needed, and whether the referrer is eligible.
• Checks the item’s eligibility rules — patient sex, in-hospital vs out-of-hospital, and more.
• Applies hundreds of Medicare rules through our rules engine, with the exact reason on every result.

For most items we then confirm the result live with Services Australia. For the rest, that live confirmation isn’t available — so we give you our own assessment, clearly labelled. Here’s how that breaks down.

How confident each result is

Every result is one of three kinds:

• Confirmed — about 87% of items. Confirmed live with Services Australia. The strongest result.
• Indicative — about 13% of items. Services Australia doesn’t verify these items online, so the result is RebateRight’s own assessment from all the checks above. A strong guide, not a confirmed answer.
• Indicative, with a frequency limit — about 2.7% of items (part of the indicative group). These items cap how often they can be claimed, and we can’t check that cap — confirming it needs the patient’s Medicare claim history, which Services Australia doesn’t share for these items. We still run our checks: if one fails, you get a clear not eligible with the reason; only when they all pass do we return cannot determine, rather than guess.

The indicative carve-out is named in section 7 of our Licence Agreement.

Check whether your items are affected

165 of 6,039 MBS items (about 2.7%) are indicative items with a frequency limit — items that cap how often they can be claimed. Most are common GP, allied-health, mental-health, and telehealth services. On these items, RebateRight still runs all of its own checks: patient verification, age, referral, and more.

For developers

The same picture, in the API.

Item metadata

GET /MedicareItems and GET /MedicareItems/{itemNumber} return:

• EligibilityCheckLimitation — null for confirmed items, "Indicative" for items Services Australia doesn’t verify online.
• ClaimHistoryLimitation — the item’s frequency-of-service limit, when it has one.

An item that’s "Indicative" and has a ClaimHistoryLimitation is one that can return cannot-determine. To pull the current set, list GET /MedicareItems and keep those entries.

1
GET /MedicareItems/701
2
3
{
4
  "ItemNumber": "701",
5
  "BenefitType": "_100",
6
  "EligibilityCheckLimitation": "Indicative",
7
  "ClaimHistoryLimitation": "Applicable according to MBS Note AN.0.36 ..."
8
}

Eligibility responses

Each Rebates entry carries:

• ReasonCode — two parts joined by a pipe (a RebateRight code and a Medicare code), for example RREligible|MedicareUnverifiedItem. Indicative items carry MedicareUnverifiedItem as the Medicare part.
• IsEligible — true or false when RebateRight’s own rules decide it (a failed rule gives false with the exact reason); null (cannot determine) when every rule passes but the frequency limit can’t be checked.
• Reason — plain-English, with each sentence tagged [RebateRight] or [Medicare].

Indicative (rules pass, no frequency limit):

1
{
2
  "ItemNumber": "3",
3
  "IsEligible": true,
4
  "ReasonCode": "RREligible|MedicareUnverifiedItem",
5
  "Reason": "[RebateRight] All RebateRight eligibility checks have passed … [RebateRight] Services Australia doesn't verify this item online, so this result is indicative. It comes from RebateRight's own rules, not a confirmed Medicare check.",
6
  "Benefit": "20.05",
7
  "ItemScheduleFee": "20.05"
8
}

Indicative with a frequency limit (rules pass):

1
{
2
  "ItemNumber": "701",
3
  "IsEligible": null,
4
  "ReasonCode": "RREligible|MedicareUnverifiedItem",
5
  "Reason": "[RebateRight] All RebateRight eligibility checks have passed … [RebateRight] Services Australia doesn't verify this item online, so this result is indicative. We can't check its frequency-of-service limit without the patient's claim history, which we don't receive, so we can't confirm eligibility.",
6
  "Benefit": "0",
7
  "ItemScheduleFee": "69.20"
8
}