Interactive patient claims

You lodge an interactive patient claim when the patient keeps their right to the Medicare benefit for the services they received, rather than assigning it to the health professional.

The healthcare location lodges the claim on behalf of the claimant, who can be the patient or another person. Medicare pays the benefit to the claimant, or by a cheque made out to the provider when the account is not paid in full.

How the rebate is paid

Where Medicare pays the benefit depends on how much the patient paid at the time of service.

Account paid in full

To pay one claim’s benefit into a different account, send that account in claimant.eftDetails. Medicare uses it for that claim only, and the claimant’s registered account stays the same.

Deposit reference. Medicare creates the reference shown on the claimant’s bank deposit when it pays. Your software cannot set or change it. The accountReferenceId you send is a different reference, printed on the claimant’s statement.

Payment status. The claim response gives the benefit assessed for each service. It does not say whether Medicare has paid the claimant. If a claimant asks, tell them to call Medicare on 13 20 11.

Since 1 July 2016, Medicare has paid patients’ benefits only by EFT. When the claimant has no valid bank details registered, Medicare returns 9783, as the next section explains.

No valid bank details: code 9783

Medicare returns 9783 when the claimant has no valid bank details registered with Medicare. The code is a warning, not a rejection, so your request needs no change. Medicare assesses the claim, holds the benefit, and releases it once the claimant updates their bank details.

Medicare’s text: “The claimant will need to update their bank details registered with Medicare. This can be done through their Medicare online account, by calling Medicare or visiting a Service Centre.”

The claimant can update their bank details in any of these ways:

• Logging in to their Medicare online account through myGov
• Calling Medicare
• Visiting a Services Australia service centre

Account unpaid or part-paid

The patient forwards the PDVC cheque and their Statement of Benefit to the provider.

For an unpaid or part-paid account, the practice must hold the patient’s written authority to submit the claim, signed and dated. Set submissionAuthorityInd to Y to confirm the practice holds that authority.

Validations

Pendable claims

Some interactive patient claims need assessment by a Medicare operator. Medicare returns these with a claim status of MEDICARE_PENDABLE, and the claimant decides what happens next.

Medicare has received and checked a pendable claim, and has recorded its correlationId. Medicare queues the claim for an operator only if you resend it unchanged with the same correlationId within 60 minutes of the original submission.

Pendable vs pended at a glance

Only patient claims can be pended. The rules for every correlationId are in Correlation ID. For a patient claim that got no response, follow When a claim gets no response before you resend it, because a resend with the same correlationId pends a pendable claim.

Mixed referral and request services

One voucher in a specialist claim can hold services that need a referral and services that need a request. Put the referral details on the voucher, and the request details on each service that needs them.

Printed statements

When an interactive patient claim is lodged, the location gives the claimant a printed statement. What Services Australia requires of your software says which statement each outcome needs, and sets out the other rules for software that lodges patient claims.

Pathology request form

For pathology patient claims, the combined request form must include all of the following.

Requesting practitioner

• Surname and initials
• Address
• Provider number
• Date of request

Approved Pathology Authority or practitioner

The person the request is made to:

• Full name of the Approved Pathology Authority (APA), or surname and initials of the Approved Pathology Practitioner (APP)
• A place of practice address
• The letters APA or APP

Patient details

• Name (surname, first name)
• Address
• Date of birth
• Sex
• Medicare card number and Individual Reference Number
• Hospital status

Required sections

• Tests Requested. The form needs an area with this title. Terms such as order, require or referred must not be used.
• Self Determine (SD). The form needs a tick box, which the APP uses when they determine that pathologist-determinable tests are necessary.

Privacy notice

The patient’s copy of the form must carry the full Services Australia privacy notice and its acknowledgement line, word for word. The notice has 3 paragraphs. Services Australia publishes the exact wording in the Patient Claim Interactive specification, on its Health Systems Developer Portal.

The notice may go in the clinical notes area, or on the back of the patient copy where that is more practical.

Combined Online Patient Claiming Authority

The form must include the patient’s authorisation for the APP or APA to submit an electronic claim on the patient’s behalf. For example:

I authorise the approved pathology practitioner who will render the requested pathology services, and any further pathology services which the practitioner determines to be necessary, to submit my unpaid account to Services Australia, so that Services Australia can assess my claim and issue me a cheque made payable to the practitioner, for the Medicare benefit.

Patient Signature: _____ Date: _____ / _____ / _____

Where the patient cannot sign, use this wording:

Verbal consent was provided by patient to submit unpaid account to Services Australia. No signature available.

The form also needs a Practitioner’s Use Only text box, for when the patient cannot sign and an appropriate person endorses the claim on their behalf.