Patient Claim(PCI)
Medicare PCI Claim
Kavanii allows users to process Interactive Patient Claims (PCI) that allows real-time processing of a single claim, and is available during Medicare Australia operating hours. PCI allows claims to be transmitted and assessed at the time of billing, and will return an outcome immediately.
PCI claims are generally sent to Medicare at the time of billing or receipting the patient, but a claim can be submitted to Medicare up to 2 years after the treatment date.
Note: Medicare Australia operating hours are: 7am to 9pm (AEST), Monday to Friday (except National Public Holidays)
PCI claims are generally sent to Medicare at the time of billing or receipting the patient, but a claim can be submitted to Medicare up to 2 years after the treatment date.
To process a Patient Claim (PCI) for Medicare, Create the patient’s invoice as you normally would, and select to process PCI Claim Edit Patient > Billing Tab > Add Invoice – Select ‘Bill To Medicare’ as PCI Claim (PCI)
Who will claim the MBS Benefit?
If the patient will not be the one claiming the rebate from Medicare, then select Claimant details. This will automatically display claimant details. If they have been entered on the patient’s details > Health Fund section. This would typically be used in the case where a child is the patient, and the rebate will be sent to a parent.
Bank & Address
This section also allows the patient to select whether they would prefer the benefit to be paid using details registered with Medicare or if they would like an EFT payment directly into their specified bank account if they have been entered on the patient’s Bank account section.
Fill in all the appropriate Medicare services and necessary information then Submit the claim. The claim will then be sent to Medicare Australia. If the claim is accepted, a Statement of Claim and Benefit Payment will be printed. If the claim is rejected, then the following error message will be displayed. You can download/print the benefit form to provide it the patient, and you can also give the patient a copy of their invoice, which should have all their Medicare claim details.
Services
These are the services that are being claimed. This will automatically display what was on the invoice:
Referral details
This is where you’ll include everything about the referral. The referrer type, referring doctor provider number, referral date and referral period are all required fields. You don’t need to include the referring doctor’s name if you don’t want to.
Statement of claim and claimant benefits:
When printing patient claims in Kavanii – there are two types of documents that Medicare can generate.
- Statement of Claim & Benefits Payment – Medicare assessed the claim in real-time.
- Lodgement Advice – claim was stored for later transmission and assessment by Medicare
A Statement of Claim and Benefit is a document that
Medicare Australia provides to you once your Medicare claim has been processed. It shows the details of the services you received, the amount that Medicare has paid, and the amount you may need to pay yourself.
Statement of Claim and Benefit
The Statement of Claim and Benefit will include the following information:
Your Medicare number
The date you received the service
The type of service you received
The name of the healthcare provider who provided the service
The amount that Medicare has paid for the service
The amount that you may need to pay yourself
You can use the Statement of Claim and Benefit to keep track of your Medicare claims and to check how much Medicare has paid for the services you have received.
Statement of Claim and Benefit (SCB):
The Statement of Claim and Benefit is a document used in the Australian healthcare system, particularly within Medicare, to detail the services rendered by healthcare providers (such as doctors, hospitals, or clinics) to patients covered by Medicare.
It includes information about the medical services provided, the corresponding Medicare item numbers, and the fees charged by the healthcare provider.
The SCB serves as a claim for reimbursement from Medicare for the eligible portion of the healthcare costs. Medicare typically covers a portion of the fees associated with eligible medical services.
After receiving the SCB, Medicare reviews the claim, determines the benefit amount the patient is entitled to, and processes the payment to the healthcare provider and the patient accordingly.
Medicare Claim Statement:
A Medicare Claim Statement is a document that provides details about a patient’s Medicare claim. It typically includes information about the medical services or treatments received by the patient, the healthcare provider who rendered the services, and the associated costs.
The statement will also outline the Medicare benefits that will be paid for the services and any out-of-pocket expenses for which the patient may be responsible.
Patients receive Medicare Claim Statements after seeking medical services, and their healthcare provider submits a claim to Medicare Australia for reimbursement.
If the claim is able to be assessed by Medicare (Services Australia) in real-time, a Statement of Claim & Benefit Payment will be generated that will show Medicare have assessed the claim and the benefit amount they will provide to the patient.
An example of the format of a Statement of Claim can be found below. You will notice the Statement of Claim can flow onto a second page. This is expected due to the additional information from Medicare that is required to be included on the Statement of Claim.
On real time the statement of claim can be viewed from the following steps on the application:
Click on billing:
Click on Insurance claims:
Click on benefit form near status paid, the form will be opening:
The benefit form for a claimant patient:
We can also check the statement from patient details:
Click on patients -> billing -> insurance claims. Then click on print option near payment status the form can be viewed.
Medicare Benefits:
Medicare Benefits are government payments made to eligible individuals to help cover the cost of healthcare services. In Australia, Medicare provides access to various medical services, including doctor visits, hospital care, and prescription medications.
Medicare Benefits are typically paid directly to healthcare providers as a contribution toward the cost of services. Patients may still be required to pay a portion of the fees as a co-payment or gap payment.
In summary, the Statement of Claim and Benefit is a document healthcare providers submit to request reimbursement from Medicare for services provided to eligible patients. At the same time, the Lodgement Advice is the acknowledgment and status update Medicare provides to healthcare providers regarding the submitted claims. These documents are crucial in reimbursement and help ensure that Medicare in Australia covers eligible healthcare expenses.
An example of a Statement of Claim format can be found below. You will notice the Statement of Claim can flow onto a second page. It is expected due to the additional information from Medicare that must be included in the Statement of Claim.
Lodgement Advice
A Lodgement Advice is a document Medicare Australia provides you when you submit a Medicare claim online. It confirms that your claim has been received and is being processed.
The Lodgement Advice will include the following information:
Your Medicare number
The date you submitted your claim
The number of services you claimed for
The total amount you claimed for
You can use the Lodgement Advice to check that your Medicare claim has been received and is being processed.
Benefits of using the Statement of Claim and Benefit and the Lodgement Advice
The Statement of Claim and Benefit and the Lodgement Advice can be helpful for many reasons, including:
Keeping track of your Medicare claims: You can use the Statement of Claim and Benefit to keep track of all of the Medicare claims you have submitted and the amount that Medicare has paid for each service. It can be helpful for budgeting and tax purposes.
Checking your Medicare eligibility: If you are unsure whether you are eligible for Medicare benefits, check your Statement of Claim and Benefit to see if Medicare has paid for any services you have received.
Identifying errors in your Medicare claims: If you notice any errors on your Statement of Claim and Benefit, you can contact Medicare to have them corrected.
Resolving billing disputes: If you have a billing dispute with a healthcare provider, you can use your Statement of Claim and Benefit to show how much Medicare has paid for the service.
How to access the Statement of Claim and Benefit and the Lodgement Advice
You can access your Statement of Claim and Benefit and Lodgement Advice online through your myGov account.
To access your Statement of Claim and Benefit:
Log in to your myGov account.
Select Medicare.
Select Statements.
Select the Statement of Claim and Benefit you want to view.
To access your Lodgement Advice:
Log in to your myGov account.
Select Medicare.
Select Lodgement History.
Select the Lodgement Advice you want to view.
If you do not have a myGov account, you can contact Medicare to request a copy of your Statement of Claim and Benefit or Lodgement Advice.
The Lodgement Advice acknowledges the receipt of the SCB and provides information regarding the claim’s status.
It may include details such as the claim reference number, the date of lodgment, and a summary of the services claimed.
Healthcare providers can use the Lodgement Advice as a reference to track the progress of their claims with Medicare. It helps them ensure that their claims have been received and are in the process of being reviewed.
Please note that the terminology and specific documents associated with Medicare may vary over time, and it’s essential to refer to the latest information provided by Medicare Australia or relevant authorities for the most up-to-date details on their processes and documents.
If Medicare cannot assess the claim in real-time, a Lodgement Advice will print instead, stating that the claim has been “STORED FOR LATER TRANSMISSION”. This document will show the claim has been submitted to Medicare for processing. However, Medicare has not yet assessed the claim.
It may be because the claim needs to be manually assessed by a Medicare agent before a benefit can be issued. The rebate amount is included on the form as an estimate of the expected rebate, depending on how Medicare assess the claim.
An example of the Lodgement Advice form can be seen below. You will notice the Lodgement Advice should fit onto one page.
Resubmit rejected claim:
The submitted claim has been rejected:
The claim has been resubmitted:
Now the claim has been resubmitted and it has been successfully paid.
Please do not hesitate to contact Kavanii support for any issue that pertains or anything else that might concern you:
Email to support@kavanii.com.au