Information to help you understand your legal obligations if you choose to privately bill a patient.
When you choose to privately bill a patient for a medical or allied health service, make sure you understand and meet the requirements under the Health Insurance Regulations 1975. This will help us pay the Medicare benefit to the claimant.
A Medicare benefit is not payable for a professional service unless it’s on an account or receipt that sets out the fee and includes:
- the name of the patient who got the service
- the date the service was given
- the amount charged for the service
- the total amount paid for the service
- any amount outstanding for the service
- an item number and/or a description that identifies the service
If an employee of the health professional records the information on accounts or receipts, the health professional claiming payment for the service is responsible for the accuracy and completeness of the information.
Provider details required on account or receipt
Under Regulation 13 of the Health Insurance Regulations 1975 certain information is needed on an account or receipt.
You can provide either or both:
- the name and the address of the medical practitioner, and
- the provider number of the medical practitioner
If you have more than one practice location recorded with us, use the provider number that applies to the practice location where the service was performed.
When a locum renders a service on behalf of another provider, the account documents must use the word 'Locum' or the letters 'LT' (Locum Tenens) to show it is a locum service.
Referral details required on account or receipt
If you’re referring a patient to a service, you need to include the following referral information on the account and/or receipt:
- the name of the referring practitioner
- the address or provider number of the referring practitioner
- the date on which the patient was referred
- the period of the validity of the referral - where this is for other than for 12 months, this should be expressed in months, for example 3, 6 or 18 months, or indefinitely
Multiple attendances on same day
Medicare benefits can be paid for several attendances on a patient on the same day, by the same health professional, as long as the subsequent attendances aren’t a continuation of the initial or earlier attendances.
Where 2 or more attendances are made on the same day by the same health professional, you need to include the time of each attendance on the account. This will help with the assessment of benefits.
Services given to in-patients
You should mark the patient account with an asterisk * for professional services provided or requested while the patient was admitted as a patient:
- of a hospital, or
- at an approved day hospital facility
Where services are given as part of a privately insured episode of hospital-substitute treatment and the patient who gets the treatment chooses to receive a benefit from a private health insurer, the claim should include the words:
- ‘hospital-substitute treatment’ directly after an item number, or
- ‘hospital-substitute treatment’ followed by a description of the professional service that identifies the item that relates to that service account reference
You can ask for account reference details to be included in your Medicare statement of benefit.
This will help you work out which account the Medicare benefit has been paid for. The account can hold up to 11 alpha and numeric characters.
Where we can’t clearly identify the service as one that qualifies for Medicare benefits we may delay or not allow claims to be paid.
Benefits for professional services
The claimant is the person who incurred or is liable for the expense for services provided. We pay Medicare benefits to the claimant as the claimant and patient aren’t always the same - for example, a parent.
The claimant may pay your account and then claim the Medicare benefit with Medicare. There are a number of ways they can do this.
Unpaid and partially paid accounts
Where the claimant hasn’t paid your account at all or in full, they can present the unpaid or partially paid account to Medicare.
In this case, Medicare will forward to the claimant a Medicare benefit cheque made payable to you, the service provider.
The claimant is responsible for forwarding the cheque to you and for paying the balance of the account.
This is known as Pay Doctor via Claimant Cheque (PDVC).
For eligible health professionals, the 90 day pay doctor cheque scheme lets us cancel a PDVC cheque and pay you the Medicare schedule fee by Electronic Funds Transfer (EFT).
Read more about the 90 day pay doctor cheque scheme.