In-patient claims (ECLIPSE) | RebateRight

You lodge an in-patient medical claim for the medical services a practitioner gives a patient admitted to a hospital. Medicare assesses the claim. For every claim type except Medicare Only, Medicare then sends the claim to the patient’s health fund. Your software retrieves the outcome as a report, and the record of the payment as a remittance advice.

Services Australia carries these claims through its Electronic Claim Lodgement and Information Processing Service Environment (ECLIPSE). Practice software often calls this ECLIPSE claiming.

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

When you lodge

Acknowledged

Medicare accepts the claim for processing. The acknowledgement carries no assessment.

Once assessed

Reported

The claim’s report gives Medicare’s assessment, and the health fund’s where the claim type has one.

Once paid

Paid

The remittance advice gives the deposit amount and the benefit paid for each claim.

A Patient Claim follows steps 1 and 2 only. Patient Claims describes its outcome.

You need to	Go to
Choose the claim type	Which claim type do I send?
Choose the endpoint	Specialties
Build your first claim	Before the first claim, then Lodge a claim
Get the outcome and the payment	Follow the claim to its outcome, then Reconcile payments

Which claim type do I send?

The claim type decides who pays whom. Set it in claimTypeCode.

Who pays whom for each claim type. Agreement and Scheme: Medicare pays its benefit to the health fund, and the fund makes one payment to the provider for both benefits. Billing Agent: Medicare and the health fund each pay the billing agent. Medicare Only: Medicare pays the billing agent, and no health fund takes part. Patient Claim with a paid account: Medicare pays the claimant, and the fund pays the patient, its member. Patient Claim with an account not paid in full: Medicare and the fund each pay by a cheque made out to the provider, which the patient passes on.

Claim type	`claimTypeCode`	Who pays whom
Agreement	`AG`	The provider has an agreement with the patient’s health fund. Medicare pays its benefit to the fund, and the fund makes one payment to the provider for both benefits.
Scheme	`SC`	The provider treats the patient under a scheme with the patient’s health fund. Medicare pays its benefit to the fund, and the fund makes one payment to the provider for both benefits.
Billing Agent	`MB`	Medicare and the health fund each pay the billing agent named in the claim.
Medicare Only	`MO`	Medicare pays the billing agent named in the claim. No health fund takes part.
Patient Claim	`PC`	The patient is a member of the health fund. For a paid account, Medicare pays the claimant and the fund pays its member. For an account not paid in full, Medicare and the fund each pay by a cheque made out to the provider, which the patient passes on.

What each claim type sends

These fields change with the claim type. A Patient Claim sends its own set, listed in Patient Claims.

Field	`AG`	`SC`	`MB`	`MO`
`patient.healthFund`	Required	Required	Required	Not sent
`patient.alsoKnownAs`	Optional	Optional	Optional	Not sent
`accident.accidentInd`	Required	Required	Required	Not sent
`billingAgent.providerNumber`	Optional	Optional	Required	Required
`fundPayeeId`	Optional	Optional	Optional	Not sent
`benefitAssignmentAuthorisedInd`	`I` or `R`	`I` or `R`	`I` or `R`	`I` or `R`
`accountPaidInd`	`N`	`N`	`N`	`N`
`claimant`, `submissionAuthorityInd`	Not sent	Not sent	Not sent	Not sent
`ifcIssueCode`, on each medical event	`V`, `W` or `X`	`W` or `X`	Optional	Optional
`financialInterestDisclosureInd`, on each medical event	Optional	`Y`	Optional	Optional

Each claim type’s endpoint pages give every field’s meaning, format and values.

Assignment of benefit

In every claim type except Patient Claim, the patient’s Medicare benefit is assigned to the health fund or the billing agent. benefitAssignmentAuthorisedInd declares which pathway applies, and that its legislative requirements are met. For a claim with a service given before 1 July 2026, send I.

Pathway	Value	When it applies	What the provider, hospital or organisation does
Implied assignment	`I`	An insurer arrangement covers the service, such as a gap cover agreement or a medical purchaser provider agreement.	Declares in the claim that the requirements are met, and keeps the assignment records for 7 years.
Requested assignment	`R`	No insurer arrangement covers the service.	Helps the patient request the assignment, and gets the patient’s approval for any new or added services. Declares in the claim, keeps the request and any changed request for 7 years, and gives the patient a copy on request.

Digital requests, notices and questions

Digital requests. Services Australia notes that your software may collect a requested assignment digitally.
Notifying the patient. The health fund or billing agent that receives the Medicare benefit notifies the patient within 6 months of receiving it. It keeps its records of the assignment or the notice for 7 years. Services Australia’s specification sets this rule beside implied assignment, and does not say whether it also applies to requested assignment.
Questions. Send questions about these rules to AssignmentofBenefit@health.gov.au.

Specialties

Each claim type has a general, a specialist and a pathology endpoint. Send each claim to the endpoint for its services, and set serviceTypeCode to match.

General: O

General services need no referral or request.

Specialist: S

Specialist and diagnostic imaging services need a referral, a request, a referral override or a self-deemed service in each medical event.

Pathology: P

Pathology services need a pathology request or a self-deemed service in each medical event.

Claim type	General `O`	Specialist `S`	Pathology `P`
Agreement `AG`	`ag/general`	`ag/specialist`	`ag/pathology`
Scheme `SC`	`sc/general`	`sc/specialist`	`sc/pathology`
Billing Agent `MB`	`mb/general`	`mb/specialist`	`mb/pathology`
Medicare Only `MO`	`mo/general`	`mo/specialist`	`mo/pathology`
Patient Claim `PC`	`pc/general`	`pc/specialist`	`pc/pathology`

The wrong endpoint. Medicare rejects a claim with 2030 when its claimTypeCode or serviceTypeCode does not match the endpoint it was sent to.
Referral fields. Each specialist and pathology endpoint’s page sets out the referral, request, override and self-deemed fields it takes.
Keep the referral. Services Australia requires your software to keep a patient’s referral details for use at a later consultation.
Group attendances. In every claim type except Patient Claim, send an item for a group attendance or a home, hospital or institution visit through the general endpoint, with numberOfPatientsSeen set. A specialist endpoint assesses the item with no benefit and explanation code 402.

Validations

Rule	Limit
Patients per claim	One
Medical events per claim	Maximum 16
Services per medical event	Maximum 14
Services per Patient Claim	Maximum 16 in total
Medical event IDs	Start at `01` and increase by one
Service IDs	4 digits, such as `0001`, unique within the claim
Servicing provider in a Patient Claim	The same on every medical event
Date of service	Not in the future, and less than 2 years before Medicare receives the claim
`accountReferenceId`	1 to 20 letters or digits, or 1 to 9 in a Patient Claim. Every report for the claim carries it

Patient Claims

A Patient Claim (PC) has rules of its own:

Declaration and consent. Before you lodge, present the Patient Claim consent and declaration to the patient, on screen or printed, and get their verbal consent. Services Australia publishes the current declaration, with its privacy notice, on its Health Systems Developer Portal. Services Australia advises that legislation requires the current version.
Lodging later. Services Australia requires your software to be able to create the account now and lodge the claim on a later date.
Outcome. Medicare sends the assessment to the patient. The claim’s report gives its status only.

A Patient Claim sends these fields where they differ from the other claim types:

In a Patient Claim	Fields
Required	`patient.healthFund`, `accident.accidentInd`, `claimant` and `submissionAuthorityInd`
Either value	`accountPaidInd`: `Y` or `N`
Optional	`patient.alsoKnownAs`, and `ifcIssueCode` and `financialInterestDisclosureInd` on each medical event
Not sent	`billingAgent.providerNumber`, `fundPayeeId` and `benefitAssignmentAuthorisedInd`

Before the first claim

Get the current fund list

Send Get Participants before your first claim, and keep the list current as Fund codes sets out. A claim names the patient’s health fund by its fund code from that list.

Verify the patient

Check the patient’s Medicare details, and their health fund details where the claim type has a fund, as Patient verification sets out. Where Medicare returns different details, offer the user an update to the patient’s record.

Check eligibility

Check eligibility before you lodge, so the patient can give informed financial consent.

To estimate Medicare’s benefit for each service, send Eligibility Check with InHospitalTreatment set to true.
To estimate what the patient’s health fund pays under their cover, send a health fund eligibility check.

Lodge a claim

Create the correlation ID

Create a correlationId for the claim, and store it with the claim before you send it. You need it to follow the claim to its report and its payment. Correlation ID gives the format.

Send the claim

Send the claim to the endpoint for its claim type and specialty.

Read the acknowledgement

Response	Meaning	What to do
`200`, with a `status` of `SUCCESS`	Medicare has accepted the claim for processing. The acknowledgement returns the claim’s `correlationId`, and carries no assessment.	Follow the claim to its outcome.
`400`	The claim failed validation.	Show each `reason` to the user exactly as returned. Correct the claim, and send it with a new `correlationId`. The endpoint’s `400` response lists the codes and what to do.
`503`	RebateRight got no response from Medicare.	Follow When a claim gets no response.

Follow the claim to its outcome

The assessment takes place after the acknowledgement. Your software follows the claim with a status request, then retrieves the report once the status says it is ready. The remittance advice follows the same pattern, once the claim is paid.

How your software follows an in-patient claim with its transaction ID, which is the claim's correlationId without urn:uuid:. For the report: send the transaction ID to Status Report, and check again later until the status is READY or REPORTED. Then send the transaction ID to In-Patient Claim Report. For the remittance advice: send the transaction ID to Status Report as a remittance advice lookup. When the status is READY or REPORTED, the row gives the remittance advice ID. Send that ID to Remittance Advice.

Transaction ID. A claim’s transaction ID is its correlationId without the urn:uuid: prefix, such as MDE00000b896820b03e348a5. Every status request and report request names the claim by it. A remittance advice has its own ID, the remittance advice ID, which a status request returns.
Same Minor ID. Send every request with the x-minor-id that lodged the claim.
For 6 months. For 6 months from lodgement, you may check a claim’s status and retrieve its report and remittance advice as many times as you need.

Request the status

Send the claim’s transaction ID to Status Report, or send a range of lodgement dates to list your claims.

Read the status

Each claim’s row gives a reportStatus and a processStatus. Status Report explains each value.

`reportStatus`	What to do
`PROCESSING`	Request the status again later.
`READY` or `REPORTED`	Retrieve the report.

Services Australia asks that you retrieve a report only once its status is READY or REPORTED. Your software may send both requests automatically.

Retrieve the report

Send the transaction IDs of claims whose report is ready to In-Patient Claim Report. An entry with a status of SUCCESS carries the claim’s report.

Services Australia requires your software to be able to retrieve an available report more than once.

Read the report

The report gives Medicare’s assessment of each service, then the health fund’s. Show each status.text and each explanation’s text to the user exactly as returned. Where Medicare returns different details in medicareAssessment.currentPatient, offer the user an update to the patient’s record. In-Patient Claim Report describes every field, and the claims whose report has no health fund assessment.

Reconcile payments

A remittance advice records a payment for in-patient claims: the amount deposited, the reference on the bank statement, and the benefit paid for each claim. Services Australia calls it an ECLIPSE Remittance Advice.

Claim type	Remittance advice
Agreement and Scheme	One, from the health fund. Each claim’s `benefit` is the Medicare and fund benefits together.
Billing Agent	Two, each with its own remittance advice ID: one from Services Australia for the Medicare benefit, and one from the health fund for the fund benefit.
Medicare Only	One, from Services Australia, for the Medicare benefit.
Patient Claim	None.

Request the remittance advice status

Once the claim’s processStatus is COMPLETE, send its transaction ID to Status Report, with requestTransmissionType set to mcp-eclipse-remittance-advice.

Read each row

When a row’s reportStatus is READY or REPORTED, its transactionId is the remittance advice ID. Store it. A Billing Agent claim returns a transaction ID for each of its 2 remittance advices once each is ready. Status Report explains each reportStatus.

Retrieve the remittance advice

Send the remittance advice’s transaction ID to Remittance Advice. That page also says when a remittance advice is ready.

Record the request

Store the date of your last successful remittance advice status request, as Services Australia requires. Show the user that request’s details, including its toDateTime.

Match the payment

Match the remittance advice to your bank statement by its paymentInfo.paymentReference and paymentInfo.depositAmount. Then match each claimSummary entry to your claim by its accountReferenceId. Remittance Advice describes every field.

In the test environment

Assessed claims. Claiming in the test environment says how the test environment handles in-patient claims.
Test data. Use the fund code, facility ID and billing agent in Hospital, fund, and billing IDs, with the Medicare test patients and providers on the same page.

What Services Australia requires

Each rule Services Australia sets for in-patient claims appears at the step it applies to. What Services Australia requires of your software lists the rules that apply across every step.