Medicare Benefits Schedule - Note CN.0.6

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Category 7 - CLEFT LIP AND CLEFT PALATE SERVICES

CN.0.6

Claiming of Benefits

Claiming Benefits

The patient, upon receipt of a practitioner's account, has three courses open for paying the account and receiving benefits as outlined below. 

Paid Accounts

The patient may pay the account and subsequently present the receipt at a Medicare customer service centre for assessment and payment of the Medicare benefit in cash.  In these circumstances, where a claimant personally attends a customer service centre, the claimant is not required to complete a Medicare Patient Claim Form (PC1). 

In circumstances where the claimant is seeking a cheque payment of the Medicare benefit or is arranging for an agent to receive the Medicare benefit on the claimant's behalf, completion of a Medicare Patient Claim Form (PC1) is still required. 

Unpaid and Partially Paid Accounts

Where the patient has not paid the account, the unpaid account may be presented to Medicare with a Medicare claim form. In this case Medicare will forward to the claimant a benefit cheque made payable to the practitioner. 

It will be 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 cannot be sent direct to practitioners or to patients at a practitioner's address (even if requested by the patient to do so). "Pay doctor" cheques will be forwarded to the claimant's last known address. 

When issuing a receipt to a patient in respect of 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. 

Assignment of Benefits (Direct-Billing) Arrangements

Under the Health Insurance Act 1973 the Assignment of Benefit (direct‑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 a practitioner direct-bills, the practitioner undertakes 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 card number must be quoted on all direct‑bill forms for that patient.

· The basic 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 Subsection 19(6) of the Health Insurance Act 1973.

· The practitioner must cause the particulars relating to the professional service to be set out on the assignment 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 form:

·   the signature of the patient's parent, guardian or other responsible person (other than the doctor, doctor's staff, hospital proprietor, hospital staff, residential aged care facility proprietor or residential aged care facility staff) is acceptable; or

·   In the absence of a "responsible person" the patient signature section should be left blank. 

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 doctor.  If in the opinion of the practitioner 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. 

The administration of the direct‑billing arrangements under Medicare as well as the payment of Medicare benefits on patient claims is the responsibility of Services Australia. Any enquiries in regard to these matters should therefore be directed to Medicare offices or enquiry points. 

Under Medicare any eligible dental practitioner can accept assignment of benefit and direct‑bill for any eligible person. 

Use of Medicare Cards in Direct Billing

An eligible person who applies to enrol for Medicare benefits (using a Medicare Enrolment/Amendment Application) 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 plays an important part in direct billing as it can be used to imprint the patient details (including Medicare number) on the basic direct‑billing forms. A special Medicare imprinter has been developed for this purpose and is available free of charge, on request, from Medicare. 

The patient details can of course be entered on the direct‑bill forms by hand, but the use of a card to imprint patient details assists practitioners and ensures accuracy of information. The latter is essential to ensure that the processing of a claim by Medicare is expedited. 

The Medicare card number must be quoted on direct‑bill forms. If the number is not available, then the assignment of benefit facility 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 that he/she has been issued with a card but does not know the details, the practitioner may contact a Medicare telephone enquiry number to obtain the number. 

Assignment of Benefit Forms

To meet varying requirements the following types of stationery are available from Medicare. Note that these forms are approved forms under the Health Insurance Act, and no other forms can be used to assign benefits without the approval of Services Australia.

(a)        Form DB2. This form is used to assign benefits for services other than requested pathology. It is loose leaf for imprinting and comprises a throw away cover sheet (after imprinting), a Medicare copy, a Patient copy and a Practitioner copy.

(b)        Form DB4. 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)

Practitioners who accept assigned benefits must claim from Medicare 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 a practitioner 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 doctor and setting the locum up with a provider number and pay‑group link for the principal doctor's practice is impractical. Practitioners should note that this facility cannot be used to generate payments to or through a person who does not have a provider number. 

The DB1N and DB1H are also loose leaf to enable imprinting of practitioner details using the special Medicare imprinter. For this purpose, practitioner cards, showing the practitioner's name, practice address and provider numbers are available from Medicare on request. 

Direct‑Bill Stationery

Medical practitioners and eligible dental practitioners wishing to direct‑bill may obtain information on direct‑bill stationery by telephoning 132150. Information on the completion of the forms and direct‑bill procedures are provided with the forms. Information on direct‑billing is available from any Medicare office. 

Time Limits Applicable to Lodgement of Claims for Assigned Benefits

A time limit of two years applies to the lodgement of claims with Medicare under the direct‑billing (assignment of benefit) 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 Medicare. 

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 processing centre to which assigned claims are directed.


Legend

  • Assist - Addition/Deletion of (Assist.)
  • Amend - Amended Description
  • Anaes - Anaesthetic Values Amended
  • Emsn - EMSN Change
  • Fee - Fee Amended
  • Renum - Item Number Change (renumbered)
  • New - New Item
  • NewMin - New Item (previous Ministerial Determination)
  • Qfe - QFE Change