Medicare Benefits Schedule - Note AN.0.12

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

(a)              the claimant may pay the optometrist's account in full and then claim benefits from the Department of Human Services office by submitting the account and the receipt;

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

(c)              the optometrist may bill Medicare instead of the patient for the consultation. This is known as bulk billing.  If an optometrist 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 optometrist'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 a Bank account details collection form with Medicare.
• Online through Medicare Online Services.
• At the claimant's local Department of Human Services Service Centre.
• By mail by sending a completed Medicare claim form with the original accounts and/or receipts to:

Department of Human Services

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:

Telephone Claiming

Department of Human Services

GPO Box 9847

                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 the Department of Human Services at www.humanservices.gov.au. 

Unpaid accounts

Where the patient has not paid the account in full, the unpaid account may be presented to the Department of Human Services with a completed Medicare claim form. In this case the Department of Human Services will forward to the claimant a benefit cheque made payable to the optometrist. 

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

When issuing a receipt to a patient for an account that is being paid wholly or in part by a Medicare "pay optometrist" cheque the optometrist 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 an optometrist 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, for example computerised perimetry occur, these may be itemised on the same account. 

Medicare benefits are only payable in respect of optometric 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 optometrist who actually rendered the service(s). Where the optometrist 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 optometrist attended the patient on more than one occasion on the same day and on each occasion rendered a professional service relating to an optometric item, except where a perimetry item is performed in association with a consultation item, where times do not need to be specified. 

The optometrist 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 optometrist. 

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 optometrist 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 optometrist'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) facility for professional services is available to all persons in Australia who are eligible for benefit under the Medicare program. This facility is NOT confined to pensioners or people in special need. 

If an optometrist 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:

· the patient's Medicare number must be quoted on all bulk‑bill assignment of benefit forms for that patient;

· the assignment of benefit forms provided are loose leaf to enable the patient details to be imprinted from the Medicare Card;

· the forms include information required by Regulations under Section 19(6) of the Health Insurance Act 1973; and

· the optometrist must cause the particulars relating to the professional service to be set out on the assignment of benefit form, before the patient signs the form and cause the patient to receive a copy of the form as soon as practicable after the patient signs it. 

Where a patient is unable to sign the assignment of benefit form, the signature of the patient's parent, guardian or other responsible person (other than the optometrist, optometrist's staff, hospital proprietor, hospital staff, residential aged care facility proprietor or residential aged care facility staff)) is acceptable. 

Where the signature space is either left blank or another person signs on the patient's behalf, the form must include:

• the notation "Patient unable to sign" and 
• in the section headed 'Practitioner's Use', an explanation should be given as to why the patient was unable to sign (e.g. unconscious, injured hand etc.) and this note should be signed or initialled by the optometrist.  If in the opinion of the optometrist the reason is of such a "sensitive" nature that revealing it would constitute an unacceptable breach of patient confidentiality or unduly embarrass or distress the recipient of the patient's copy of the assignment of benefits form, a concessional reason "due to medical condition" to signify that such a situation exists may be substituted for the actual reason.  However, this should not be used routinely and in most cases it is expected that the reason given will be more specific. 

Use of Medicare cards in bulk-billing

Where a patient presents without a Medicare card and indicates that they have been issued with a card but does not know the details, the optometrist may contact the Department of Human Services on 132 150 to obtain the number. 

It is important for the optometrist to check the eligibility of their patients for Medicare benefits by reference to the card, as entitlement is limited to the "valid to" date shown on the bottom of the card. Additionally the card will show if a person is enrolled through a Reciprocal Health Care Agreement. 

Assignment of benefit forms

Only the approved assignment of benefit forms available from the Department of Human Services website, www.humanservices.gov.au, can be used to bulk-bill patients for optometric services and no other form can be used without its approval.

(a)              Form DB2-OP
This form is designed for the use of optical scanning equipment and is used to assign benefits for optometrical services.  It is loose leaf to enable imprinting of patient details from the Medicare card and comprises a throw away cover sheet (after imprinting), a Medicare copy, a Practitioner copy and a Patient copy.        

(b)              Form DB4
This is a continuous stationery version of Form DB2 and has been designed for use on most office accounting machines. 

The Claim for Assigned Benefits (Form DB1N, DB1H)

Optometrists who accept assigned benefits must claim from the Department of Human Services using either Claim for Assigned Benefits form DB1N or DB1H.  The DB1N form should be used where services are rendered to persons for treatment provided out of hospital or day hospital treatment.  The DB1H form should be used where services are rendered to persons while hospital treatment is provided in a hospital or day hospital facility (other than public patients).  Both forms have been designed to enable benefit for a claim to be directed to an optometrist other than the one who rendered the services.  The facility is intended for use in situations such as where a short term locum is acting on behalf of the principal optometrist and setting the locum up with a provider number and pay‑group link for the principal optometrist's practice is impractical.  Optometrists should note that this facility cannot be used to generate payments to or through a person who does not have a provider number. 

Each claim form must be accompanied by the assignment of benefit forms to which the claim relates. 

Time limits applicable to lodgement of bulk bill claims for benefits

A time limit of two years applies to the lodgement of claims with the Department of Human Services under the bulk billed (assignment of benefits) arrangements. This means that Medicare benefits are not payable for any service where the service was rendered more than two years earlier than the date the claim was lodged with the Department of Human Services. 

Provision exists whereby in certain circumstances (e.g. hardship cases), the Minister may waive the time limits. Special forms for this purpose are available, if required, from the Department of Human Services website at www.humanservices.gov.au or the processing centre to which bulk-bill claims are directed.

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