Patient Claim Process 

There are 3 payment options for patient claims that can be lodged through Medicare Online.

• Fully paid account - patient or claimant has paid their account in full.
• Part paid account - patient or claimant has paid a contribution toward the settlement of the account.
• Unpaid account - account has not been paid.

Fully paid:

• where the account has been paid in full, payment will be made to the claimant's nominated bank account almost immediately.

Part paid:

• where a claimant has made a part payment contribution towards the account
  
• where Medicare benefits are assessed as payable for a claim, a statement or cheque in the health professional's name will be sent to the claimant's address recorded by Medicare. The cheque is then sent by the claimant to the health professional with any outstanding balance
• where no benefit is payable, a statement will be sent to the claimant's address recorded by Medicare
• where a Medicare Safety Net threshold has been reached and the patient is entitled to an additional safety net benefit, the amount will be either paid by cheque to the claimant or by EFT if this information is stored by Medicare

Unpaid:

• where the account is unpaid
• where Medicare benefits are assessed as payable for a claim, a statement or cheque in the health professional's name will be sent to the claimant's address recorded by Medicare. The cheque is then sent by the claimant to the health professional with any outstanding balance.
• where no benefit is assessed as payable, a statement will be sent to the claimant's address recorded by Medicare

When the Medicare Patient Claim Billing Process has been completed - there are 3 options presented.

1. Print Invoice
2. Pay Now
3. Continue

[Print Invoice] prints a standard invoice. You can print this now before continuing if required

[Pay Now] allows patient receipting

[Continue] to proceed with with the Medicare Claim Process for an Unpaid Account

(1) Payment Type (Select from drop-down list)

(2) Enter Amount (If not fully paid - or the the payment is composed of multiple parts)

(3) Add this payment - will be shown on the summary line (4)

You can add multiple payment parts - when completed you can Print the Receipt if required (5)

For full details of patient claim payments and receipting -

refer to the Medicare Online Patient Claim Payments Guide

`When payment details have been entered - click on [Continue] - the Medicare Patient Claim - Start Claim Process screen will be displayed.

Click [Start Claim Process]

Start the Claim Process 

The Start the Claim process presents 2 options:-

Start Claim Process

or

Save Patient Voucher for later claim

Start Claim Process will send the claim now

As SAAS Web is always on-line - this is the easiest process for most practices.

Save Patient Voucher for later claim

This method only creates the Invoice/Voucher `which may be processed later, or included with other voucher(s) for the same patient for claiming at a later date.

Patient Claim Payment Instructions 

Medicare's Response Status to a Patient Claim will be one of the following :-

• MEDICARE_ASSESSED 
• MEDICARE_REJECTED 
• MEDICARE_PENDABLE 
• MEDICARE_PENDED

MEDICARE_ASSESSED

When a claim has a response status of MEDICARE_ASSESSED, each service will also have an Assessment Code.

The Assessment Code will be either a Medicare assessment explanation code, commonly referred to as the Medicare Reason Code or an Assessment Value.

An Assessment Value may be: 

• ASSESSED 
• NOT_ASSESSED 
• ACCEPTABLE_ERROR 

If the claim is successful (Assessed by Medicare) - you need only print the Statement of Claim & Benefit Payment and give it to the patient.

When the Claim has been ASSESSED, a Statement of Claim & Benefit Payment will be produced. Click on the Print Claim Benefit Payment button.

If you don't print it now - it can be printed at any time.

To print or re-print the Statement of Claim & Benefit Report (or the Lodgement Advice in the case of a PENDED claim) - navigate to the Medicare Online Menu (from the Home Page) - then select the Patient Claims TAB).

You can also view the Patient Claim Response Details for this claim (as received from Medicare).

If Medicare returns a status of MEDICARE_PENDABLE - first view the Detailed Response.

(In this example - Medicare says this is a duplicate service which has already been paid.)

There are 3 options when the claim is MEDICARE_PENDABLE.

Option 1 : Refer Claim to Medicare Operator

Option 2 : Go Back to the Patient Billing Screen and resolve the issues

Option 3 : Cancel the claim.

If the Medicare Claim Response is Pendable - then you can refer the claim to the Medicare Operator.

The claim will then be re-sent to Medicare with a notation that it should be reviewed by the Medicare Operator.

Medicare will acknowledge this and return a PENDED status for the claim.

A Patient Claim Lodgement Advice can then be printed.

Refer Claim to Operator must be done straight away (there is a 1 hour window). If you do not respond to a Pendable notice within the hour, the claim will automatically be cancelled by Medicare.

View the detailed response. The issue may be easily resolved - so you can simply return to the Patient Billing screen - make any modification or notation required - then resubmit the claim.

Note that this creates a new claim. The Pendable Claim that was NOT referred to the Medicare Operator will automatically be cancelled by Medicare within an hour.

First - click on View Detailed Response.

This will show full details of the information returned from Medicare, and the status of each service item within the claim.

If the issue can be resolved, click on the Go Back to the Patient Billing Screen button and resolve the issues (as shown below).

In this example, the issue may be resolved by adding the Not Duplicate Service (NDS) notation to the service item (or adding the Service Time).

You will now be returned to the billing screen for the Medicare Patient Claim.

You can now select the Invoice Item (Service Item) - and add the NDS notation.

Select the Invoice Item and add the NDS notation.

Refer to the guide for Medicare Online Patient Billing - Item Overrides 

Re-Submit the Claim 

• Click on [Continue] - the Medicare Patient Claim - Start Claim Process screen will be displayed.
• Click on [Start Claim Process]

As there is no explicit definition of Error 9641 - it is recommended that the claim is referred to the Medicare Operator.

This will change the status of the claim from PENDABLE to PENDED

You can then print the Lodgement Advice

If the claim is MEDICARE_REJECTED or MEDICARE_PENDABLE - and you want to Cancel the Claim - just click on the Cancel Claim button.

The Patient Billing screen will be re-displayed.

Medicare will automatically cancel the claim on their side.

You then have options:- 

• Print a standard Invoice/Receipt for the patient.
• Delete/Cancel the Invoice if it is in error.

A Statement of Claim and Benefit Payment is provided to the claimant when a Patient Claim has been lodged in real time, processed by the agency and a benefit amount returned to the claimant. 

A Lodgement Advice is provided to the claimant when a Patient Claim has been lodged in real time and referred to an agency operator for action

When the Claim has been ASSESSED, a Statement of Claim & Benefit Payment will be produced.

When the Claim is PENDED (referred to the Medicare Operator), a Lodgement Advice  will be produced.

You can re-print the Statement of Claim & Benefit Payment or the Lodgement Advice at any time.

The Reprint screen allows you to Search or Sort by any of the displayed fields.

Highlight the required Patient Claim - then click on either Lodgement Advice or Statement of Claim Print.

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