Interactive patient claims
Lodge claims where the patient retains their Medicare benefits
An interactive patient claim is submitted when a patient has received professional medical services and has not assigned their right to Medicare benefits to the health professional. The healthcare location lodges the claim on behalf of the patient or claimant, and Medicare pays the benefit directly to the patient.
Some interactive patient claim submissions cannot be processed automatically and need a decision from the claimant before Medicare will assess them. These are returned with a claim status of MEDICARE_PENDABLE.
A pendable claim has not yet been received by Medicare for assessment — it’s held by your software awaiting the claimant’s decision. You have 60 minutes from the original submission to act.
Medicare returns MEDICARE_PENDABLE, indicating the claim would need manual operator assessment if submitted as-is. Inspect claimAssessment.error (claim-level) or per-service assessmentCode: ACCEPTABLE_ERROR for the reason.
Present the pendable reason to the claimant or practitioner, along with three options:
correlationId to send the claim to a Medicare operator for manual assessment (see Step 3).duplicateServiceOverrideInd) or supporting service text, then resubmit with the same correlationId. Medicare may then assess it automatically, bypassing the operator queue.correlationId) if needed.Services Australia recommends streamlining the accept path — for example, a single checkbox or confirm button.
Resend the claim using the same correlationId within 60 minutes of the original submission. The status moves to MEDICARE_PENDED — the claim has now been received by Medicare and queued for manual operator assessment.
At this point:
claimId for your own reconciliation.If you resend the claim using a different correlationId, it is treated as a brand-new patient claim — not a continuation of the pendable one. The original pendable claim will simply expire after 60 minutes.
Specialists may submit claims with a mixture of services requiring both referral and request information in the same voucher. Include referral details at the voucher level alongside the relevant service-level request details.
This only applies to specialist services combining Referrals and Diagnostic Imaging Requests in the same voucher. Pathology Requests must be submitted separately.
Services Australia advises that using the most up-to-date statements, declarations, and privacy notes in your software is a legislative requirement.
When an interactive patient claim is lodged, the location must issue the claimant with a printed statement. Which one depends on the claim outcome:
Issued when the claim is processed in real-time and Services Australia returns a benefit amount.
Issued once the claim is pended — i.e. accepted by Medicare and queued for manual operator assessment. Must be printed and given to the claimant.
The location must produce a printed copy for the claimant’s record, and may keep its own copy in electronic or hard copy form.
If any of these override indicators are used in a claim, the printed statement must display additional information:
Any relevant supporting material or text must also appear on the printed statement.
For pathology patient claims, the combined request form must include all of the following.
The following wording must appear on the patient’s copy of the form:
Privacy Notice: Your personal information is protected by law, including the Privacy Act 1988, and is collected by Services Australia for the assessment and administration of payments and services. This information is required to process your application or claim.
The notice may sit in the clinical notes area or on the back of the patient copy if more practical.
The form must include patient authorisation for the APP/APA to submit an electronic claim on the patient’s behalf. Example wording:
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: _____ / _____ / _____
If the patient cannot sign:
Verbal consent was provided by patient to submit unpaid account to Services Australia. No signature available.
A Practitioner’s Use Only text box is also required for cases where the patient is unable to sign and an appropriate person endorses on their behalf.
Services Australia requires that error messages are displayed to the end user exactly as supplied in the response — not truncated, transformed, or changed in any way.