Online claiming for PBS

Information for pharmacists about electronic claiming of PBS or RPBS medicines with Medicare.

Online claiming process

When you make a claim with online claiming for PBS make sure you:

  • are given a PBS or RPBS prescription
  • enter the information about the prescription into your Prescription Dispensing Software

Once this has been done:

  1. the Prescription Dispensing Software sends a transaction to Medicare which checks the details of the prescription against PBS or RPBS rules including patient entitlement checks through a direct link to Centrelink
  2. Medicare sends a message to inform you whether the claim is payable
  3. 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
  4. the medicine is supplied to the customer
  5. at the end of your pharmacy's claim period, close the claim through your Prescription Dispensing Software. You will need to retain all prescriptions and claim related paperwork in an electronic or paper form for a period of 2 years for audit and verification purposes.

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 Prescription Dispensing Software

Register for online claiming for PBS

To register for online claiming for PBS please follow the steps below:

  1. Complete the Online Claiming for Pharmaceutical Benefits Scheme Application and Terms and Conditions form (PB010)
  2. Make sure all approved pharmacy owners sign the agreement
  3. Return the completed agreement to PBS approvals clerk

Medicare will then complete the registration process and issue you with a digital certificate.

You may need to provide additional information to become an approved PBS supplier if you are already registered for online claiming and are changing location or adding a business partner. You will need to apply for a new approval number and 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 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 and RPBS medicine including:

  • Medicare
  • PBS Safety Net
  • concession and health care cards, such as 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.

Owing prescriptions

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 authority 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 or RPBS 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. The date of supply should not be amended.

Owing prescriptions:

  • 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 7 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 on the prescription the date of supply and the reason why the patient's signature could not be obtained

PBS claim statements

Pharmacies claiming through online claiming for PBS will receive the following claim statements:

  • Payment Correspondence
  • PBS Reconciliation Statements

Payment correspondence

Payment correspondence is produced after each claim is processed and payment is received by the pharmacy. Payment correspondence is sent weekly in hardcopy, and provide information regarding a payment and any associated tax or fee information, allowing you to reconcile payments made into your bank account. Payment correspondence may include:

  1. Payment Advice containing information on payments made to your bank account
  2. Tax Invoice detailing any 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
  3. Recipient Created Tax Invoice (RCTI) detailing the payments that have been made under the Recipient Created Tax Invoice (RCTI) agreement. This will only be issued as required for payments that include GST

PBS reconciliation statement

There are 2 types of PBS reconciliation statement and each are retrieved electronically through your Prescription Dispensing Software product:

  1. Interim Reconciliation Statements –provided weekly
  2. Final PBS Reconciliation Statements –produced after each claim period has been closed through your Prescription Dispensing Software product and processed by us

The PBS interim and final reconciliation statements are divided into 4 parts. This allows you to reconcile online claiming for PBS results of a prescription against the prescription details in your Prescription Dispensing Software.

The 4 parts of the PBS interim and final reconciliation statements include:

  1. Prescription Summary and Adjustments - an overview of all 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
  2. Prescription Details - 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
  3. 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 of the entitlement errors
  4. Explanation of Reason Codes - 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

Post payment compliance

We will perform data mining on all prescriptions claimed and will undertake compliance and audit checks as follows:

  • we may, at any time request a copy of the prescription and claim paperwork which can be provided in an electronic or paper form
  • in relation to paperless prescribing, electronic prescriptions and medication charts, current documentary evidence that a particular drug has been prescribed is to be retained by pharmacies. If we wish to view a copy of this documentation, we will request a copy
  • we may retain the documentary evidence in some circumstances

From 1 April 2015, Approved Suppliers will be required to retain all prescriptions and claim paperwork for a period of 2 years from date of supply.

More information

For more information about online claiming for PBS contact us at PBS general enquiries.