Changes to PBS and RPBS claiming arrangements

On 1 April 2015 we implemented changes to the way PBS and RPBS claims are processed and handled.

On 1 April 2015 we implemented changes to the way Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) claims are processed and handled.

Prescriptions and claim paperwork no longer need to be sent to us to finalise a claim

Approved Suppliers submitting claims through PBS Online claiming with upgraded dispensing software are no longer required to send in paper prescriptions or claim paperwork to us to finalise a claim. Approved Suppliers are required to retain prescriptions and claim paperwork in paper or scanned electronic form for post payment compliance checks for a period of 2 years from date of supply under the legislation. Prescriptions that are retained in scanned electronic form must be of the same quality as the original prescription. The scanned version must be of the front and back of the original prescription if the back contains dispensing information. The destruction of the paper prescription or the electronically stored record after the 2 year retention period is at the discretion of the Approved Supplier.

The Manual claiming channel is not affected by the new claiming arrangements. Approved Suppliers who choose to claim manually are still required to provide the paper prescriptions and claim paperwork for processing and payment to occur. Processing by the department will attract a cost of 47 cents per prescription.

Claims must be closed electronically through dispensing software

Claims must be closed electronically, by an authorised person, using the ‘Close a Claim’ transaction through PBS Online claiming. An authorised person is any pharmacist, medical practitioner or hospital authority, approved under sections 90, 92, 94 or 100 of the National Health Act 1953, or any person acting on behalf of the approved pharmacist, medical practitioner or hospital authority.

The ‘Close a Claim’ transaction involves:

  1. The authorised person uses the ‘Close a Claim’ function
  2. The authorised person is presented with a ‘certification of supply’ statement that summarises the claim details
  3. The authorised person must acknowledge the ‘certification of supply’ summary
  4. The ‘Close a Claim’ transaction is sent through to us for processing

Claims that have successfully been closed using the ‘Close a Claim’ transaction will receive a return message advising of the successful closure of the claim. Adjustments can be made to prescriptions for up to 90 days from date of claim closure.

Transition period

We supported a transition period to allow for dispensing software changes. The transition period was for 3 months, from 1 April 2015 until 30 June 2015. 

Following the transition period, any claim started:

  • during the transition period and closed after 30 June 2015, must be closed using the 'Close a Claim' transaction - prescriptions and claim paperwork sent to us will not be accepted and will be returned to the Approved Supplier
  • after 30 June 2015, must be closed using the ‘Close a Claim’ transaction - prescriptions and claim paperwork sent to us will not be accepted and will be returned to the Approved Supplier

If a claim package is received by us and is found to have been closed by the ‘Close a Claim’ transaction, the claim package will be returned to the Approved Supplier.

If the Approved Supplier has previously sent the claim package to us, and then sends the ‘Close a Claim’ transaction electronically for the same claim period number, the item will be rejected.

The PBS online claiming channel now delivers improved real time feedback

Improvements have been implemented to the real time feedback provided through the PBS Online Claiming channel to deliver greater transparency of payment eligibility for medicines dispensed by Approved Suppliers. This means that:

  • no payments will be held up due to pending paperwork
  • payments are more timely
  • reconciliation is finalised in a timely manner

Enhanced post payment compliance activity for PBS and RPBS claiming

We will continue to monitor all prescriptions claimed and we will undertake compliance checks as follows:

  • We may, at any time request a copy of the prescription and claim paperwork which can be provided in a scanned electronic or paper form - if a scanned version of the original prescription is provided, it must be of the front and back if the back contains dispensing information
  • Current documentary evidence that a particular drug has been prescribed in relation to paperless prescribing, electronic prescriptions and medication charts must be retained by pharmacies - if we wish to view this documentation, we will request a copy
  • We may retain the documentary evidence in some circumstances

As per legislation at 1 April 2015, Approved Suppliers are required to retain all prescriptions and claim paperwork for a period of 2 years from date of supply.

Claims Transmission System (CTS) diskette claiming channel

For PBS and RPBS Claims

Since 1 April 2015, Approved Suppliers can no longer claim PBS and RPBS prescriptions via the CTS diskette claiming channel. A transition period was supported to allow time for Approved Suppliers to finalise any prescriptions claimed via the CTS diskette claiming channel prior to 1 April 2015.

During the transition period, all CTS diskette claims are processed based on date of supply. All prescriptions claimed via the CTS diskette channel that have a date of supply:

  • before the start of the 1 April 2015 transition period will be assessed and paid if eligible
  • on or after the start of the 1 April 2015 transition period will be rejected and returned to the pharmacy for resubmitting via the new claiming arrangements

For Aids Assistance Programs

The CTS diskette claiming channel will remain in place to support the Aids Assistance Programs including:

  • the Stoma Appliance Scheme (SAS) and the
  • Section 100 Paraplegic and Quadriplegic (ParaQuad) Program

A new authority approval number created for prescriptions prescribed under Emergency Provision arrangements

On 1 April 2015, the department introduced a generic Authority Approval Number in the assessment of authority prescriptions that are written under the emergency provision arrangements. Approved Suppliers are required to supply this generic number when claiming a prescription written under the emergency provision arrangements. The emergency provision authority approval number should only be used where a prescription is presented with annotations from the doctor noting the prescription was written under the authority emergency provisions arrangements, because we were not contactable at the time of writing the prescription. The emergency provision authority approval number is P9999RX.

Page last updated: 25 January 2016

This information was printed Sunday 4 December 2016 from humanservices.gov.au/health-professionals/enablers/changes-pbs-and-rpbs-claiming-arrangements It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.