Medicare Easyclaim terms

General terms explained for Medicare Easyclaim.

Allied Health professionals

Any Medicare Benefits Schedule item lodged for services provided by Allied Health professionals listed should be accepted, unless restrictions are applied, for example, a care plan MBS item is not present on the patient's history, or the maximum number of services have been performed.

  • Aboriginal Health Workers
  • audiologists
  • chiropodists
  • chiropractors
  • dentists
  • dental specialists, non-Medical Benefits (Dental Practitioners) Advisory Committee
  • diabetes educators
  • dieticians
  • exercise physiologists
  • mental health nurses
  • occupational therapists
  • oral medical and pathology practitioners
  • osteopaths
  • paedodontists
  • periodontists
  • physiotherapists
  • podiatrists
  • prosthodontists
  • psychologists
  • social workers
  • speech pathologists

Cancel (bank initiated)

An auto-cancel will be initiated when a financial transaction has been transmitted but no response has been received within the timeout period.

Claimant

The person who incurred the expense for services provided. The claimant is not always the patient, for example, a parent.

Claimant Medicare card number

The claimant must have a valid Medicare card number in order to transmit patient claims through Medicare Easyclaim.

Date of service

The date of service will be automatically generated as the date the claim is created and transmitted.
In circumstances where the date of service is different to the date the claim is being transmitted, the date of service must be manually entered and must:

  • be in the format DDMMYY
  • be a valid date
  • not be in the future
  • not be more than 2 years old

Diagnostic imaging

Request details may be required with diagnostic imaging services.

Equipment identification number

The identification number (allocated by the Department of Health) of specific equipment that needs to be registered in order to claim certain items. This commonly applies to radiotherapy equipment.

Item override code

 Under certain circumstances, health professionals need to give more information on an account so that a service can be assessed. The item override code will allow you to submit the extra information for a specific situation. If you leave this information out when it is needed, it will result in rejection.

  • AO = not normal aftercare
  • AP = not duplicate service (am-pm)

Location Specific Practice Number (LSPN)

The LSPN is applicable to services:

  • within Group T2 - radiation oncology services as described in the MBS
  • within Category 5 - diagnostic imaging services as described in the MBS
  • where a general practitioner has remote area exemption and performs diagnostic services

Where these services occur, this field is considered mandatory.

Medicare card flag values

An indicator that shows the problem we have with the submitted Medicare card. This indicator may appear on the bulk bill processing report against a claim.

  • A = patient identification amended
  • I = patient Medicare issue number changed
  • C = patient Medicare number changed
  • W = patient card used will expire shortly
  • S = patient card expired. Future services may be rejected
  • X = old Medicare issue number for patient, future services may be rejected

MBS item number

The MBS item number is required for each service. It must be valid at the date of service for that health professional. Miscellaneous taxable services and ancillary items that do not attract a Medicare benefit cannot be entered. View the MBS online.

Pathology

Pathology services provided by an eligible health professional, including Group 9 for patient claims.

Patient

Identifies the individual who receives the services.

Patient Medicare card number

The patient must have a valid Medicare card number to transmit patient or bulk bill claims through Medicare Easyclaim.

Patient Individual Reference Number (IRN)

The IRN is on the left of the patient’s name on their Medicare card.

Payee provider number

Provider number of the health professional who is to be paid for the service. Only required if the payee provider is not the servicing provider.

Pended claim

Claims that need a Customer Service Officer to manually review due to complexity or special circumstances.

Real-time Medicare eligibility validation

We will validate the patient’s eligibility when the claim is lodged.

Referral details

Required for certain services provided by specialists, allied health professionals or consulting physicians, where a Medicare benefit is dependent on acceptable evidence that the service has been provided following referral from another health professional.

Referral details for initial consultations and other referred services (including subsequent consultations) are mandatory.

The referring provider must have a current and valid registration at the date of referral.

Referring provider number

The provider number, allocated by us, of the referring provider.

Referral issue date

This field must be keyed if referral details are given. The date keyed is the date on the letter of referral.

Referral period type code

Indicates the period of referral. This field must be entered if you have entered a referring provider number and referral issue date.

Values

  • S = standard (12 months from a GP and 3 months from a specialist)
  • I = indefinite

Referral override type code (specialist services only)

Indicates why referred services were provided without referral from another health professional.

Lost or emergency referral indication

This data is only needed in cases where a written referral was lost, or in the case of an emergency situation where the servicing provider believed the service needed to be given as quickly as possible.

Lost and emergency referrals are applicable to initial consultation items only. All referral requirements must be met for following consultation items.

  • L = lost
  • E = emergency
  • N = not required may need to be entered where referral details are not required

Request details

Required for items that are subject to the written request requirement and are classified as R-Type (requested) services in the MBS.

The following data is required

  • requesting provider number
  • request issue date

Requesting provider number

The provider number, allocated by us, of the requesting provider.

Request issue date

Date the request was issued.

Request override type code

Lost or emergency request indication

Required where a written request was lost, or in the case of an emergency where the servicing provider believed the service needed to be rendered as quickly as possible.

The requesting provider must have a current and valid registration at the date of request.

Values

  • L = lost
  • E = emergency
  • N = not required (for bulk bill pathology only)

Restrictive override code

Under certain circumstances, providers need to give more information on an account to allow assessment of a service. If the information is left out, it will be rejected or the practice will be contacted for more details. The restrictive override code enables health professionals to send the extra information, for specific situations, through a 2-character indicator for correct assessment and payment for the service.

Separate sites - when this indicator is set, item numbers 30071, 30061, 30192 and 30195 will automatically override where

  • the services are within 1 claim and are for the same patient, health professional and date of service
  • there are combinations of items 30071 and 30061 plus only 1 x 30195 or only 1 x 30192
  • there are multiples of items 30071 and 30061 within 1 claim

The time-dependency restrictions for items 30192 and 30195 will continue to apply.

Values

  • NC = Not for comparison
  • SP = Separate sites
  • NR = Not related (care plans for allied health)

Specimen collection point identification number (SCP ID)

For bulk bill pathology services only. The provider number is used along with the SCP ID for assessment of the claim. The claim will be rejected if the provider number used is not registered in the Medicare system to allow that provider to perform services with the SCP ID entered.

Self deemed code

SD is an optional element. However, conditions apply depending on the SD value selected. SD applies to both pathology and diagnostic claims. When the SD value is present, request details cannot be set.

Pathology claims may only have an SD indicator.

SS only applies to diagnostic claims.

When the SS value is present, request details are required.

There may be claims where neither the request details nor request override type code are set; instead, a self-deemed value of SD applies.

  • SD = self deemed
  • SS = substituted service

Servicing provider number

Provider number of the provider who rendered the service.

Types of EFTPOS receipts

The EFTPOS terminal will produce the following types of receipts, which must be given to the patient or claimant.

  • Medicare patient claim receipt - for all fully paid, assessed patient claims
  • Medicare lodgement receipt - for all unpaid, partially paid or pended patient claims
  • Cancelled Medicare claim receipt - for all patient claims that have been cancelled by the medical practice or claimant
  • Bank cancelled claim receipt
  • Bulk bill assignment advice - for all bulk bill claims following acceptance of the claim by the medical practice and assignment of benefit by the patient

Page last updated: 1 February 2016

This information was printed Friday 9 December 2016 from humanservices.gov.au/health-professionals/enablers/medicare-easyclaim-terms 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.