Medicare, Bulk Bill and DVA Claims Process

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This article outlines how a Medicare claim goes from Halaxy to Medicare and what information you need to provide to successfully process a claim.

Patient-paid Medicare rebates process

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When you submit a patient-paid Medicare rebate claim to Medicare, the following happens in sequence:

  1. Halaxy checks the following:

    • patient date of birth

    • patient Medicare card number

    • servicing practitioner's provider number

    If there is a problem, you will see an error message in Halaxy advising you of the missing information. If everything seems valid, the claim is submitted to Medicare.

  2. Medicare checks the following:

    • patient date of birth

    • patient Medicare card number

    • referral date

    • referrer's details and provider number

    • the provider number (or payee provider number) is registered with the Minor ID/Location ID

    Medicare also provides a Lodgement Advice that can be accessed from the invoice by clicking View Statement. The Lodgement Advice contains the Claim Reference ID. Note that the claim status shown in the Lodgement Advice is based on the status of the claim at the time of submission and is not updated afterwards.

    If you entered "Additional Information" when submitting the claim, a Medicare officer will review the claim.

    The day after submitting the claim, Halaxy requests reports from Medicare in relation to the claim status; Halaxy has no control of when these reports are received. You can attempt to retrieve a report by clicking Get Report from the invoice. If the claim has the same status for a number of days and "the report is not available", you should contact Medicare. The claim status will automatically be set to "Failed" after 7 days, allowing you to resubmit the claim.

  3. Based on the above, there are three possible outcomes:

    • Success: The claim is successful and Medicare pays the rebate into the registered bank account. Medicare supplies the Statement of Claim and Benefit Payment, which states the Claim Amount and the Claim Reference ID. This is accessible from the invoice by clicking View Statement. Halaxy updates the claim status to "Successful" and then "Completed" on the invoice.

      Note that the rebate amount that Medicare pays is based on its own schedule, regardless of what you set as the rebate amount on the invoice.

    • Failure: The claim failed Medicare's validation process, or the benefit is not payable for another reason. Halaxy updates the claim status to "Rejected" on the invoice. If you are using batch processing or automatic Medicare processing, the status is set to "Scheduled failed". Medicare provides an error code on the report, accessible from the invoice by clicking Get Report or View Report. You can use the report to identify and fix problems with the claim and then resubmit it. Note that you are not charged Halaxy credits for failed claims.

    • Uncertain: Medicare is unsure and will review the claim further. Halaxy updates the claim status to "Lodged", "Incomplete" or "Cancelled" on the invoice. At this point, Halaxy is not informed about the status of the claim. Clicking the claim status or the statement on the invoice will give you the option of cancelling the claim or pushing the claim through for further processing; if you choose to push the claim through, the status is set to "Submitted" in Halaxy. Halaxy is not informed about the further status of the claim. You will need to contact Medicare and may need to reset and resubmit the claim manually based on Medicare's advice.

      Note

      Uncertain claims are considered lodged, so they do not appear on the unprocessed Medicare report.

Bulk bill and DVA claims process

Medicare_BulkBillDVA.png

When you submit a bulk bill or DVA claim to Medicare, the following happens in sequence:

  1. Halaxy checks the following:

    • patient date of birth

    • patient Medicare or DVA card number

    • servicing practitioner's provider number

    If there is a problem, you will see an error message in Halaxy advising you of the missing information. If everything seems valid, the claim is submitted to Medicare.

  2. Medicare checks the following:

    • patient date of birth

    • patient Medicare/DVA card number

    • referral date

    • referrer's details and provider number

    • the provider number (or payee provider number) is registered with the Minor ID/Location ID and there is a registered bank account to receive the rebate

    Medicare supplies the Assignment of Benefits statement or the DVA Service Treatment Voucher, which can be provided to the patient.

    Medicare also provides a Lodgement Advice that can be accessed from the invoice by clicking View Statement. The Lodgement Advice contains the Claim Reference ID. Note that the claim status shown in the Lodgement Advice is based on the status of the claim at the time of submission and is not updated afterwards.

    If you entered "Additional Information" when submitting the claim, a Medicare officer will review the claim.

    The day after submitting the claim, Halaxy requests reports from Medicare in relation to the claim status; Halaxy has no control of when these reports are received. DVA claims usually take an extra day to receive an update. You can attempt to retrieve a report by clicking Get Report from the invoice. If the claim has the same status for a number of days and the "report is not available", you should contact Medicare. The claim status will automatically be set to "Failed" after 7 days, allowing you to resubmit the claim.

  3. Based on the above, there are two possible outcomes:

    • Success: The claim has passed Medicare's validation. Halaxy updates the claim status to "Lodged" on the invoice; the claim is not yet fully processed. When the claim is fully processed, payment is made into the registered bank account and Halaxy updates the claim status to "Completed" on the invoice.

      For bulk bill claims, Medicare supplies the Statement of Claim and Benefit Payment, which states the Claim Amount and the Claim Reference ID. For DVA claims, Medicare supplies the DVA Processing & Payments Report, which states the Claim Amount and the Claim Reference ID. These are accessible from the invoice by clicking View Statement.

      Note that the claim status shown in the statement/report is based on the status of the claim at the time of issuing and is not updated afterwards.

    • Failure: The claim has failed Medicare's validation. Halaxy updates the claim status to "Failed" on the invoice. The claim is NOT submitted for further review. Medicare provides an error code on the report, accessible from the invoice by clicking Get Report or View Report. You can use the report to fix problems with the claim and then resubmit it.

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