Online claiming for PBS

Information for pharmacists about electronic claiming of PBS or Repatriation Pharmaceutical Benefits Scheme (RPBS) medicines.

Online claiming process

When you claim online for PBS medicines make sure:

  • the customer gives you a PBS or RPBS prescription
  • you enter the prescription information into your prescription dispensing software (PDS).

After you enter the information into your PDS:

  1. The PDS sends us a transaction. We check the details of the prescription against PBS or RPBS rules. We also check for any patient entitlements through a direct link to Centrelink.
  2. We’ll send you a message to tell you if the claim is payable.
  3. In some cases you’ll need to correct an error or omission before making a claim. You can do this before you supply the medicine to the customer.
  4. You can supply the medicine to the customer.

At the end of your pharmacy's claim period, close the claim through your PDS.

Keep all prescriptions and claim-related paperwork for 2 years for audits and verifications. You can keep records in electronic or paper form.

Benefits of online claiming

Claiming PBS medicines online is fast and easy. With online claiming you’ll: 

  • be paid more frequently - we’ll pay you each week
  • know how much we’ll pay before you supply the medicine to the customer
  • see potential rejections at the point of dispensing, so you can correct errors before the customer leaves
  • get electronic statements that your PDS automatically reconciles.

Register for online claiming for PBS

To register for online claiming for PBS, you need a pharmacy or hospital approval number. Once you have your approval number:

  1. Complete the online claiming for Pharmaceutical Benefits Scheme application and terms and conditions form.
  2. Make sure all approved pharmacy owners sign the agreement.
  3. Return the completed agreement to the email address on the form.

We’ll finalise your registration and issue you with a digital certificate. Read more about Public Key Infrastructure (PKI) and digital certificates.

You’ll need to apply for a new approval number and digital certificate to claim online if you:

  • relocate your pharmacy, or
  • add or remove a business partner.

Check for a concessional entitlement

When you claim PBS medicines online, we check your customer’s concessional entitlement with Centrelink in real-time. You need to check your customer’s concession card before supplying medicine. This is to validate your customer's entitlement to the PBS and RPBS.

You can use PBS Online Claims Processing to validate your customer's entitlement to subsidised 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.

If a customer isn’t entitled to PBS or RPBS medicine at the subsidised rate, they should pay:

  • an increased contribution, or
  • a private rate.

The rate type will depend on their level of entitlement.

You can give your customers information about why we haven’t applied the PBS concessional rate.

Owing prescriptions

The National Health (Pharmaceutical Benefits) Regulations allow pharmacists to dispense medicine before the customer has supplied a written prescription. In urgent cases, a prescriber may tell you the details of the prescription or send a fax of the written and signed prescription.

Prescriptions requiring prior authority approval still need approval before you can dispense them. You’ll need to ask the prescriber for the authority approval number to ensure they have approval.

After contacting you, the prescriber has to give you the original PBS or RPBS prescription within 7 days. When you have the prescription, use the owing mark-off function to enter the prescribing date. Mark-off the prescription recorded in your PDS. You shouldn’t amend the date of supply.

You can’t claim an owing prescriptions until you have the paper prescription.

When you get the prescription, make sure the prescribing date is the date the prescriber requested the prescription. If you get the prescription more than 7 days after the date of supply, it is still payable as long as all other requirements including authority approval are met.

If you don’t have the patient's signature the normal receipting rules apply. You must certify on the prescription the date of supply and the reason you couldn’t get the patient's signature.

PBS claim statements

Pharmacies who claim PBS medicines online will receive:

  • payment correspondence
  • PBS reconciliation statements.

Payment correspondence

You’ll get hard copy payment correspondence about your PBS medicine claims each week. You’ll find information about your payments and any associated tax or fee information. Use this correspondence to reconcile payments made into your bank account.

Payment correspondence may include:

  • a payment advice note with details about payments we made to your bank account
  • a tax invoice detailing any fees that we have charged. We will only issue this if we have charged fees. Only pharmacists who submit their claims manually will receive a tax invoice
  • a recipient created tax invoice (RCTI) detailing the payments that we have made under the RCTI agreement. We will only issue this as required for payments that include GST.

PBS reconciliation statement

There are 2 types of PBS reconciliation statements you can get through your PDS:

  • interim reconciliation statements - provided weekly
  • final PBS reconciliation statements - produced after each claim period closes.

These statements help you reconcile your online claims with the prescription details in your PDS. The statements have 4 parts:

  • The prescription summary and adjustments shows an overview of all prescriptions you processed or adjusted in the claim period. The summary shows totals relevant to the prescriptions you submitted in the claim. The adjustments detail information relating to prescriptions you adjusted since the previous statement.
  • The prescription details show each prescription you submitted during the claim period. The table lists each prescription, price, if it was accepted, and relevant reason codes.
  • PBS entitlement errors is a table of each prescription where there was an associated entitlement error. It details the relevant rejects, warnings or information and provides the pharmacist with details of the entitlement errors.
  • The explanation of reason codes explains the reason your PDS returned for prescriptions within the claim period. Your PDS provides reason codes to explain warnings or rejected prescriptions.

Compliance

We perform data mining on all prescriptions you claim. We also do audit checks.

At any time, we may refer your pharmacy to the Department of Health (Health) who do compliance checks. They may ask you for a copy of prescription and claim paperwork. You can provide this in electronic or paper form.

Pharmacies should document prescriptions and medication charts. Health may ask for a copy of this documentation. In some situations they may keep these documents.

Approved suppliers must keep all prescriptions and claim paperwork for 2 years from the date of supply.

More information

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

Page last updated: 12 October 2018