Medicare Benefits Schedule - Note AN.0.12

There are three ways benefits may be paid for professional services:

(a)              the claimant may pay the practitioner's account in full and then claim benefits from Services Australia by submitting the account and the receipt;

(b)              the claimant may submit the unpaid account to Services Australia who will then send a cheque in favour of the practitioner, to the claimant; or

(c)              the practitioner may direct-bill Medicare instead of the patient for the consultation. This is known as bulk billing.  If a practitioner direct-bills, they undertake to accept the relevant Medicare benefit as full payment for the consultation.  Additional charges for that service (irrespective of the purpose or title of the charge) cannot be raised against the patient. 

Claiming of benefits

The patient, upon receipt of an practitioner's account, has two options open for paying the account and receiving benefits. 

Paid accounts

If the account has been paid in full a claimant can claim Medicare benefits in a number of ways:

• Electronically if the claimant's doctor offers this service and the claimant has completed and lodged bank account details with Medicare.
• Online through Medicare Online Services.
• At the claimant's local Services Australia Service Centre.
• By mail by sending a completed Medicare claim form (MS014) with the original accounts and/or receipts to:

Services Australia

Medicare

GPO Box 9822

In the claimant's capital city

• Over the phone by calling 132 011 and giving the claim details and then sending the accounts and/or receipts to:

Services Australia

Medicare

GPO Box 9822

In the claimant's capital city

Practitioners seeking information regarding registration to allow EFT payments and other E-Business transactions, can do so by viewing the Health Professionals section at Services Australia's website. 

Unpaid and partially paid accounts

Where the patient has not paid the account in full, the unpaid account may be presented to Medicare with a completed Medicare Claim form (MS014). In this case Medicare will forward to the claimant a benefit cheque made payable to the practitioner. 

It is the patient's responsibility to forward the cheque to the practitioner and make arrangements for payment of the balance of the account, if any. "Pay doctor" cheques involving Medicare benefits not be sent direct to practitioner, or to the claimant at an practitioner's address (even if requested by the claimant to do so). "Pay doctor" cheques are required to be forwarded to the claimant's last known address. 

When issuing a receipt to a patient for an account that is being paid wholly or in part by a Medicare "pay doctor" cheque the practitioner should indicate on the receipt that a "Medicare cheque for $..... was involved in the payment of the account". The receipt should also include any money paid by the claimant or patient. 

Itemised accounts

When a practitioner bills a patient for a service, the patient should be issued with a correctly itemised account and receipt to enable the patient to claim Medicare benefits.  Where both a consultation and another service occur these may be itemised on the same account. 

Medicare benefits are only payable in respect of professional services where it is recorded on the account setting out the fee for the service or on the receipt for the fee in respect of each service to each patient, the following information:

(a)              patient's name;

(b)              date on which the service(s) was rendered;

(c)              a description of the service(s) (e.g. "initial consultation," "subsequent consultation" or "contact lens consultation" and/or "computerised perimetry" in those cases where it is performed);

(d)              Medicare Benefits Schedule item number(s);

(e)              the name and practice address or name and provider number of the practitioner who actually rendered the service(s). Where the practitioner has more than one practice location, the provider number used should be that which is applicable to the practice location where the service(s) was given;

(f)               the fee charged for the service(s); and

(g)              the time each service began if the practitioner attended the patient on more than one occasion on the same day and on each occasion rendered a professional service relating to an MBS item, except where a perimetry item is performed in association with a consultation item, where times do not need to be specified. 

The practitioner billing for the service bears responsibility for the accuracy and completeness of the information included on accounts, receipts and assignment of benefits forms even where such information has been recorded by an employee of the practitioner. 

Payment of benefits could be delayed or disallowed if the account does not clearly identify the service as one which qualifies for Medicare benefits or that the practitioner is a registered practitioner practising at the address where the service was rendered. It is important to ensure that an appropriate description of the service, the item number and the practitioner's provider number are included on accounts, receipts and assignment of benefit forms. 

Details of any charges made other than for services, e.g. a dispensing charge, a charge for a domiciliary visit, should be shown separately either on the same account or on a separate account. 

Patients must be eligible to receive Medicare benefits and must also meet the clinical requirements outlined in the relevant item descriptors. 

Duplicate accounts

Only one original itemised account per service should be issued, except in circumstances where both a consultation and computerised perimetry occur, in which case these may be itemised on the same original account. Duplicates of accounts or receipts should be clearly marked "duplicate" and should be issued only where the original has been lost. Duplicates should not be issued as a routine system for "accounts rendered". 

Assignment of benefit (bulk billed) arrangements

Under the Health Insurance Act 1973 an Assignment of Benefit (bulk-billing) for professional services is available to all persons in Australia who are eligible for benefit under the Medicare program. This is not confined to pensioners or people in special need. 

If a practitioner bulk-bills, they undertake to accept the relevant Medicare benefit as full payment for the service. Additional charges for that service (irrespective of the purpose or title of the charge) cannot be raised against the patient. Under these arrangements:

• a patient’s assignment of benefit can be obtained before or after a service is rendered; it must be obtained by a provider before a claim is made;
• the assignment agreement must include the ‘data set’ as outlined in the Health Insurance Regulation 2018;
• the practitioner must cause the particulars relating to the professional service to be set out in the agreement before the patient signs the agreement, and if requested provide the patient with a copy of the completed agreement form as soon as practicable; and,
• the practitioner must retain a copy of the competed assignment agreement for up to 2 years following the making of a related claim.

Where a patient is unable to sign the form through either a wet or electronic signature:

• an assignor (for example a parent, partner, carer, relative, individual with power of attorney, or friend) may be requested to sign the agreement.
• should neither the patient nor an assignor provides a signature, the assignment of benefit agreement remains incomplete, and a bulk billed claim must not be submitted.

The administration of bulk billing arrangements under Medicare as well as the payment of Medicare benefits on patient claims is the responsibility of Services Australia and any enquiries in regard to these matters should therefore be directed to Services Australia.

For pathology, the patient ‘pre-assigns’ their benefits at the time of consultation/request is made, but the date of service for pathology is reported as the date of the specimen collection or, where multiple samples are taken for a single Medicare-billed test, the date of the first specimen collection.

Use of Medicare cards in bulk-billing

An eligible person who applies to enrol for Medicare benefits will be issued with a uniquely numbered Medicare card which shows the Medicare card number, the patient identification number (reference number), the applicant's first given name, initial of second given name, surname and an effective "valid to" date. These cards may be issued on an individual or family basis. Up to 5 persons may be listed on the one Medicare card, and up to 9 persons may be listed under the one Medicare card number. 

The Medicare card number must be quoted on bulk bill agreements. If the number is not available, then assignment of benefit arrangements should not be used. To do so would incur a risk that the patient is not eligible and Medicare benefits not payable.

Where a patient presents without a Medicare card and indicates they have been issued with a card but do not know the details, the patients may present a digital copy of their Medicare card from their Medicare app, providing they have a myGov account and have linked to Medicare from this account. The practitioner may also contact Services Australia to obtain the number. 

Assignment of benefit forms

From 1 July 2026, the assignment of benefit approved form (for example DB4e or DB020) will no longer be required.

Instead, assignment agreements must include the required ‘data set’ as specified in the Health Insurance Regulations 2018, ensuring patients are adequately informed when making decisions.

Services Australia has downloadable assignment agreement templates available on its website for pre and post assignment agreements for different medical specialities.  These are available for use where practitioners do not wish to create their own agreement based on the Regulations or use agreements generated by medical software.

Time limits applicable to lodgement of bulk bill claims for assigned benefits

Claims for bulk billed services rendered may be paid if the claim is made up to 1 year from the date of service. For services rendered prior to 5 September 2025, this timeframe is up to 2 years from the date of service.

Provision exists whereby in certain circumstances (e.g. hardship cases), the Minister may waive the time limits. More information is available on the Services Australia website.

Related Items: 12218 12219

• Previous - Note AN.0.11
• Next - Note AN.0.13

Overnight investigation of sleep, for at least 8 hours, for a patient aged at least 3 years but less than 12 years, if:

(a) the patient is referred by a medical practitioner to a qualified paediatric sleep medicine practitioner; and

(b) following professional attendance on the patient (either face-to-face or by video conference), the qualified paediatric sleep medicine practitioner determines that:

(i) the investigation is necessary for a purpose mentioned in paragraph (c); and

(ii) an unattended sleep study is appropriate for the investigation; and

(c) the purpose of the investigation is documented and is any of the following:

(i) to confirm diagnosis of sleep apnoea;

(ii) as a repeat investigation to assess treatment effectiveness;

(iii) as a repeat investigation to determine respiratory support needs following a significant change in clinical status; and

(d) during a period of sleep, there is continuous monitoring and recording of at least the following measures:

(i) airflow;

(ii) EMG;

(iii) ECG or heart rate;

(iv) EEG;

(v) EOG;

(vi) oxygen saturation;

(vii) respiratory effort; and

(e) the investigation is provided:

(i) under the supervision of a qualified paediatric sleep medicine practitioner; and

(ii) in accordance with current professional guidelines (including in relation to interpreting polygraphic data and preparing a report); and

(f) before the investigation commences, a parent or caregiver of the patient is given:

(i) written or video instructions on how to monitor the patient overnight; and

(ii) a way of contacting a sleep technician to enable trouble shooting overnight; and

(g) the equipment is applied to the patient by:

(i) a sleep technician; or

(ii) the parent or caregiver of the patient if:

(A) before the set-up process commences, the parent or caregiver is given written or video instructions for how to apply the equipment; and

(B) there is continuous telehealth support from a sleep technician throughout the set-up process; and

(C) the use of telehealth is documented; and

(h) polygraphic records are:

(i) analysed (for assessment of sleep stage, arousals, respiratory events and cardiac abnormalities) using manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and

(ii) stored for interpretation and preparation of a report; and

(i) interpretation and preparation of a permanent report are provided by a qualified paediatric sleep medicine practitioner with personal direct review of raw data from the original recording of polygraphic data from the patient

Applicable in relation to the first 3 investigations to which this item or item 12210 applies in any 12 month period

Fee: $489.90 Benefit: 85% = $416.45

(See para AN.0.12, DN.1.37 of explanatory notes to this Category)

Overnight investigation of sleep, for at least 8 hours, for a patient aged at least 12 years but less than 18 years, if:

(a) the patient is referred by a medical practitioner to a qualified sleep medicine practitioner; and

(b) following professional attendance on the patient (either face-to-face or by video conference), the qualified sleep medicine practitioner determines that:

(i) the investigation is necessary for a purpose mentioned in paragraph (c); and

(ii) an unattended sleep study is appropriate for the investigation; and

(c) the purpose of the investigation is documented and is any of the following:

(i) to confirm diagnosis of sleep apnoea;

(ii) as a repeat investigation to assess treatment effectiveness;

(iii) as a repeat investigation to determine respiratory support needs following a significant change in clinical status; and

(d) during a period of sleep, there is continuous monitoring and recording of at least the following measures:

(i) airflow;

(ii) EMG;

(iii) ECG or heart rate;

(iv) EEG;

(v) EOG;

(vi) oxygen saturation;

(vii) respiratory effort; and

(e) the investigation is provided:

(i) under the supervision of a qualified sleep medicine practitioner; and

(ii) in accordance with current professional guidelines (including in relation to interpreting polygraphic data and preparing a report); and

(f) before the investigation commences, a parent or caregiver of the patient is given:

(i) written or video instructions on how to monitor the patient overnight; and

(ii) a way of contacting a sleep technician to enable trouble shooting overnight; and

(g) the equipment is applied to the patient by:

(i) a sleep technician; or

(ii) the parent or caregiver of the patient if:

(A) before the set-up process commences, the parent or caregiver is given written or video instructions for how to apply the equipment; and

(B) there is continuous telehealth support from a sleep technician throughout the set-up process; and

(C) the use of telehealth is documented; and

(h) polygraphic records are:

(i) analysed (for assessment of sleep stage, arousals, respiratory events and cardiac abnormalities) using manual scoring, or manual correction of computerised scoring in epochs of not more than 1 minute; and

(ii) stored for interpretation and preparation of a report; and

(i) interpretation and preparation of a permanent report are provided by a qualified sleep medicine practitioner with personal direct review of raw data from the original recording of polygraphic data from the patient

Applicable in relation to the first 3 investigations to which this item or item 12210, 12213 or 12218 applies in any 12 month period

Fee: $455.25 Benefit: 85% = $387.00

(See para AN.0.12, DN.1.37 of explanatory notes to this Category)