Medicare Easyclaim Business Rules
This information should assist vendors in building PMS workflows that meet Medicare business rule requirements regarding what item numbers can and can't be sent via the Easyclaim channel. We suggest all vendors also familiarise themselves with the following Medicare website page http://www.medicareaustralia.gov.au/provider/medicare/claiming/easyclaim/reference-guide.jsp#N10054 that provides more vendor specific detail on the General Rules associated with Medicare Easyclaim.
| Rule Number | Service Not Accepted Through Easyclaim | Medicare Clarification of Business Rule and Interpretation |
|---|---|---|
| 1 | - in-hospital items | |
| 2 | - Australian Childhood Immunisation Register (ACIR) information | |
| 3 | - bulk bill claims more than two years from date of service | |
| 4 | - patient claims more than two years from date of service | |
| 5 | - time duration dependent items | Time dependent duration item numbers relate to the Relative Value Guide (RVG) structure, which is based on a unit system to reflect the complexity of the service and the time taken in a procedure. Eg, Anaesthetic items, 21482, 23043, 22031 If your require further information, please see the Medicare Benefits Schedule link. http://www.mbsonline.gov.au/ |
| 6 | - notional charges (e.g. provider has raised a total charge to cover a group of services) | |
| 7 | - patient claims for pathology items excepting Group 9 items/td> | Item numbers 73801-73837 are claimable through Medicare Easyclaim, all other pathology item numbers in category 6 are not claimable through Medicare Easyclaim Self-deemed code SD = self-deemed SS = substituted service SD is an optional element. However, conditions apply depending on the SD value selected. SD applies to both pathology and diagnostic claims. When the SD value is present, request details cannot be set. Pathology claims may only have an SD indicator. SS only applies to diagnostic claims. When the SS value is present, request details are required. There may be claims where neither the request details nor request override type code are set, instead a self-deemed value of SD applies. Pathology item numbers 73801-73837 are basic simple tests that can be performed at the premises of the practice. As they are simple basic tests Tyro does not need to be accredited for these item numbers (Category 6 Pathology Services, Group 9 Simple Basic Pathology tests). However for all other pathology item numbers that can be transmitted through Medicare Easyclaim, Tyro will need to obtain accreditation for pathology. |
| 8 | - bulk bill pathology items which are self deemed or Rule 3 exemptions | See response above for Rule Number 7 |
| 9 | - patient claims and bulk bill claims with non-standard referrals | A 'Standard referral' is a current and valid referral from a GP which has a 12 month/Indefinite duration or from a Specialists which has a 3 month referral period. To claim through Medicare Easyclaim the referring Dr must have a current and valid registration and provider number at the date of referral. Other referral types such as Emergency, Lost, etc are accepted just not the one called 'Non-standard'. e.g. An Emergency referral is used for patients who were seen in hospital and who requires an urgent outpatient appointment with either a Specialist, Allied Health professional or a consulting physician. An emergency referral must have 'emergency' stated on the referral letter or discharge letter. A lost referral would be used in conjunction with a standard referral where the original referral was lost. A 'non-standard' referral is a referral letter without any referral periods. A 'non-standard' referral letter will not be accepted through Medicare Easyclaim as the referral has no date and duration of referral. |
| 10 | - tems where the charge exceeds $9999.99 | |
| 11 | - GP multiple attendance items (e.g. MBS item 24, 35 etc) | Any GP consult item number that requires the number of patients seen is not claimable through Medicare Easyclaim. Example: If a GP visits a nursing home and sees 10 patients on the one occasion they will not be able to transmit those claims through Medicare Easyclaim. |
| 12 | - Separate sites override—unless the item is listed under Restrictive override code in the ‘General terms explained’ list. | Under certain circumstances, providers are required to provide additional information on an account to enable assessment of a service. Omission of this information would result in either a rejection or further contact with the practice for clarification. The restrictive override code will enable providers to submit the additional information, for specific situations, through a two character indicator that will enable the correct assessment and payment for the service. Separate sites—when this indicator is set, item numbers 30071, 30061, 30192 and 30195 will automatically override where: - the services are within one claim and are for the same patient, provider and date of service - there are combinations of items 30071 and 30061 plus only 1 x 30195 and/or only 1 x 30192 - there are multiples of items 30071 and 30061 within one claim. Note: the time dependency restrictions for items 30192 and 30195 will continue to apply. Q:Does this mean that only items 30071, 30061, 30192 and 30195 can be sent with Override codes via Easyclaims and all other item numbers will be rejected? No, as per the below description, any procedural item numbers that can be performed by a GP or a specialist in their consulting rooms that requires additional information for a specific situation the provider can use the restrictive override code to allow payment and correct assessment of the service provided. Item numbers 30071, 30061, 30192 and 30195 are very common procedural items used by practitioner’s. estrictive override codes: NC=Not for comparison SP=Separate sites NR=Not related (care plans for allied health) NC is only used for diagnostic claims only, this override code will not apply to Tyro SP & NR indicator is normally used at general practices, specialist practices etc Scenario 1: Separate sites—when the indicator SP is set, item numbers 30071, 30061, 30192 and 30195 will automatically override where: - the services are within one claim and are for the same patient, provider and date of service - there are combinations of items 30071 and 30061 plus only 1 x 30195 and/or only 1 x 30192 - there are multiples of items 30071 and 30061 within one claim. Note: the time dependency restrictions for items 30192 and 30195 will continue to apply. Scenario 2: Not related (care plans for allied health) This indicator/override code is used for GP’s who completes 2 separate care plans for a patient where the care plans are not related to the same condition. |
| 13 | - Assisted Reproductive Technology (ART) services | Items 13200 - 13221 All Assisted Reproductive Technology (ART) Services cannot be claimed through Medicare Easyclaim. To define the ART services they are located in the online Medicare Benefits Schedule under Category 3, Group T1, Miscellaneous Therapeutic Procedures under Sub Group 3 – Assisted Reproductive services. These items are unable to be transmitted through Medicare Easyclaim |
| 14 | Claims requiring text | Claims requiring free-form text cannot be sent through Easyclaim. Claims with standard text can be processed through Easyclaim e.g. Not Duplicate Service, Not Normal Aftercare. This uses the item override codes, Values AO = not normal aftercare and AP = not duplicate service (am/pm) |