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:

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

· the forms include all patient and services details as listed on the form. This is required under subsection 19(6) of the Health Insurance Act 1973; and

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

• the signature of the patient's parent, guardian or other responsible person (other than the practitioner, practitioner'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 parent, guardian or other responsible person, leave the ‘patient signature’ section 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" in the 'Practitioner's Use' section, the reason why the patient was unable to sign, for example ‘unconscious’, ‘injured hand’ or ‘verbal consent obtained’. 

If the practitioner assesses the reason is of such a highly 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, the reason "due to medical condition" or “due to 

sensitive condition” 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. “Extenuating circumstances” cannot be used as a reason for no patient signature.

The practitioner and the patient must have entered into a bulk bill agreement at the time of service. This must include having the patient sign the assignment of benefit form. If the patient is deceased and had not signed the form, a signature from a responsible person is acceptable. A responsible person can be either the executor of the will or an appointed administrator.

You must not write ‘patient deceased’ as a reason for not getting a signature on the assignment of benefit form.

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 Medicare.

For pathology, the patient ‘pre-assign’ 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 forms. 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 Medicare to obtain the number. 

Assignment of benefit forms

These forms are approved under the Health Insurance Act 1973, and no other forms can be used to assign benefits without approval of Services Australia.

 (a)              Forms DB4E
Use this form to claim assigned benefits for electronically transmitted claims.
These services can be claimed through HPOS Bulk Bill Webclaim capability.
This form is interactive. It has 2 copies, one for the health professional and one for the patient.

(b)              Forms DB020
Use this form in conjunction with HPOS Medicare Bulk Bill Webclaims only. It cannot be submitted to Services Australia for manual processing.
This form is interactive. It has 2 copies, one for the health professional and one for the patient.

The Claim for Assigned Benefits (Form DB1N, DB1H)

Practitioners who accept assigned benefits must claim from Services Australia 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 practitioner and setting the locum up with a provider number and pay‑group link for the principal practitioner'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. 

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

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

Claims for bulk billed (assignment of benefits) 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.

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