Online claiming for PBS
Online claiming for PBS allows pharmacies to submit an electronic claim to Medicare each time a PBS or RPBS medicine is dispensed.
When you make a claim with online claiming for PBS you need to make sure you:
- are given a PBS or RPBS prescription
- enter the information about the prescription into your Prescription Dispensing Software
- the Prescription Dispensing Software sends a transaction to Medicare. Medicare checks the details of the prescription against PBS or RPBS rules including patient entitlement checks through a direct link to Centrelink
- Medicare sends a message to inform you whether the claim is payable
- In some cases, you will need to correct an error or omission before making a claim. This can be done before you supply the medicine to the customer
- There will be some cases where Medicare will not make a payment until the paper prescription has been checked. This generally involves high-cost or high-risk items
- the medicine is supplied to the customer
- at the end of your pharmacy's claim period, send the paper prescriptions to Medicare for audit and verification processing
Online claiming benefits
Online claiming for PBS gives you faster and better ways to claim by:
- paying you more frequently, with Medicare paying the pharmacy each week
- giving you more certainty of the amount that Medicare will pay before the medicine is supplied to the customer
- showing potential rejections at the point of dispensing, allowing any errors to be corrected before the customer leaves the pharmacy
- sending electronic statements that are automatically reconciled by your dispensing software
Register for online claiming for PBS
To register for online claiming for PBS please follow the steps below:
- Complete the Online Claiming for Pharmaceutical Benefits Scheme Application and Terms and Conditions form (PB010). Make sure all approved pharmacy owners sign the agreement.
- Return the completed agreement to PBS approvals clerk. Medicare will then complete the registration process and issue you with a digital certificate.
If you are an existing pharmacy who may be changing location or adding a business partner, please see approved PBS pharmacists for more information. As well as a new approval number, you will need to apply for a new digital certificate to continue to claim online.
Concessional entitlement checking
Online claiming for PBS conducts a real time check with Centrelink of your customers' concessional entitlement. You need to validate your customer's entitlement to the PBS and Repatriation Pharmaceutical Benefits Scheme (RPBS) before supplying medicine.
If a customer is not entitled to PBS or RPBS medicine at the subsidised rate, they should pay an increased contribution, or private rate, depending on their level of entitlement. You can validate all levels of your customer's entitlement to subsidised PBS/RPBS medicine including:
- PBS Safety Net
- Centrelink - Pensioner Concessions Card, Commonwealth Seniors Health Care and the Health Care Card
- Department of Veterans' Affairs - Gold, White and Orange cards, Pensioner Concession Card and Commonwealth Seniors Health Care Card
You can provide your customers with the information, The PBS concessional rate has not been applied if they are not entitled to medicines at a concessional rate.
Manual entitlement checking
There are two scenarios which may result in a small number of cases requiring you to manually intervene to ensure your customer receives their correct entitlement.
On the prescription please write:
- 'refer prescription - interim card' or
- 'refer prescription - overseas departure'
The prescription will be flagged for payment on receipt of your paperwork.
Centrelink interim confirmation of concessional entitlement
In a very limited number of cases Centrelink may issue an interim confirmation of concessional entitlement. This could be presented by a customer at your pharmacy before their details have been updated within the Centrelink database.
When a concessional entitled customer is travelling overseas they must notify Centrelink of their departure date. Centrelink will end date the customer’s concessional entitlement record effective from the date of departure. In this situation, when a prescription is submitted via Online Claiming for PBS it will return a negative response in relation to the customer’s concessional entitlement on the day of departure.
In both scenarios, the concessional entitlement validation (CEV) process through the refer prescription facility enables you and Medicare to honor valid prescriptions at the concessional rate.
Access the refer prescription facility
If you find yourself with a customer in either of these scenarios and have submitted the prescription via Online Claiming for PBS and received a negative response, call PBS general enquiries and ask for the refer prescription facility helpdesk.
Please have the following information ready which the operator will record against your current claim:
- your approval number
- your claim period number
- the script number and payment category
- your customer's name and Medicare number
Customer holding an interim concession card
If your customer is holding an interim concession card you will need the:
- interim concession card or confirmation of concession card letter details
- serial number
- name of issuing Centrelink office
Customer is departing for overseas travel
If your customer is departing for overseas travel:
- confirm the date of their overseas departure
The National Health (Pharmaceutical Benefits) Regulations allow for medicine to be dispensed before the written prescription has been supplied. In a case of urgency a prescriber may advise you of the details of the prescription or fax you the written and signed prescription. Prescriptions requiring prior approval still require approval before being dispensed. You will need to ask the prescriber for the Authority approval number to ensure approval has been obtained.
After contacting you, the prescriber is required to provide you with the original PBS prescription within seven days. When the prescription is provided, use the owing mark-off functionality to enter the prescribing date and mark-off the prescription recorded in the Prescription Dispensing Software (PDS). The date of supply should not be amended.
- are not claimable until you receive the paper prescription
- on receiving the prescription, make sure the prescribing date is the date the prescriber requested the prescription
- if the prescription is received more than seven days after the date of supply, the prescription is still payable provided it meets all other requirements including Authority approval requirements
- in the absence of a patient's signature normal receipting rules apply. You must certify the date on which the supply was made and the indicate why the patient's signature could not be obtained
PBS claim statements
Pharmacies claiming through online claiming for PBS receive two sets of hardcopy claim statements:
- Payment Correspondence is produced after each deposit is made into a pharmacy's bank account and is sent weekly in hardcopy
- PBS Reconciliation Statements
- Interim Reconciliation Statements are provided weekly. Final PBS Reconciliation Statements are produced after each claim package has been received and processed by the department
- Pharmacies claiming manually or by the Claims Transmission System (CTS) will receive the payment correspondence once the claim has been processed and paid
Payment Correspondence provides information regarding the payment of a claim and any associated tax or fee information, allowing you to reconcile your bank account with payments made by online claiming for PBS. It consists of up to three different documents:
- Payment Advice - every pharmacy will receive a Payment Advice. This contains information on payments made to your bank account.
- Tax Invoice - this details any bureau fees that have been charged by Medicare. This will only be issued if fees have been charged. Only pharmacists that submit their claims manually will receive a tax invoice.
- Recipient Created Tax Invoice (RCTI) - this details the payments that have been made for items that come under the Recipient Created Tax Invoice (RCTI) agreement. This will only be issued as required. This also includes any adjustments to the taxable amount of a supply (and the GST).
PBS reconciliation statement
The PBS reconciliation statement is divided into four parts. This allows you to reconcile online claiming for PBS results of a prescription against the prescription details in your prescription dispensing software:
- Prescription Summary and Adjustments - this part of the statement provides you with an overview of all the prescriptions that have been processed or adjusted in the claim period. The summary provides summary totals relevant to the prescriptions that were submitted in the claim. The Adjustments detail information relating to prescriptions that were adjusted since the previous statement.
- Prescription Details - this section details each prescription that was submitted during the claim period. The table within this part lists each prescription, its price if it has been accepted, and relevant reason codes.
- PBS Entitlement Errors - the table in this statement contains each prescription for which there was an associated entitlement error. It also displays the relevant rejects, warnings or information and provides the pharmacist with details.
- Explanation of Reason Codes - this part of the statement gives a brief explanation of the reason codes that were returned for the prescriptions within the claim period. Reason codes are provided to the pharmacy as an explanation of a warning or rejected prescription.
For more information about online claiming for PBS contact us at PBS general enquiries.