Claiming Procedures

The administration of payments for claims by Medicare Australia to state and territory health departments for HSDs and PBS trastuzumab commenced on 1 July 2009 for any claims with a supply date of 1 July 2009 onwards.

From this time, under the offline solution (Phase 1), payments will occur monthly in arrears after Medicare Australia receives HSD and PBS trastuzumab claiming information from state and territory health departments. 

Monthly updated HSD and PBS trastuzumab claim forms will be emailed out by Medicare Australia to state and territory health departments before the commencement of each month.

Claim form information

The offline claim form must include the following data:

• PBS item name
• PBS code
• form
• pack size
• total cost
• total number of patients

All HSDs and PBS trastuzumab are to be claimed on the spreadsheet that relates to the month in which they are dispensed. For example, if a drug is dispensed in July 2009, then it must to be claimed in the July 2009 spreadsheet.

State and territory health departments must complete the columns stating the number of packs dispensed and the total number of patients for each item claimed.

The format of the claim spreadsheet is not to be altered.

Failure to provide complete information will delay payment for that item.

The spreadsheet has been formatted to show the amount claimed based on the packs dispensed multiplied by the price. The state or territory is entitled to claim that amount less 0.8%. This is shown in the 'Claimable amount (cost less 0.8%)' column.

Information about the identification of the patient is not required under the offline solution.

For more information on the spreadsheet please see Payment for approved CAR HSDs dispensed by public hospital pharmacies.

Certification

By submitting the claim form, you will be deemed to agree and certify that the HSDs and PBS trastuzumab were supplied from1 July 2009 and that the items have not been included in any separate claim made directly by the approved HSD public hospital or by any agent of the hospital to Medicare Australia.

Submission of claim form

Under the offline solution, state and territory health departments are to forward their claim form (as an Excel spreadsheet in electronic form (email or CD)) each month to claim for eligible HSD and PBS trastuzumab medications that have been dispensed. 

State and territory health departments are responsible for collating their respective state/territory claims and submitting one (1) collated claim form per month.

More than one claim form per month is allowed where the other claim forms are for HSDs and PBS trastuzumab dispensed in different months.

Claim forms must be received by Medicare Australia no later than three (3) months from the end of the claim period. For example, all claims for items dispensed in the month of July 2009 will need to be received by 31 October 2009.

Claim forms should be submitted a minimum of two (2) weeks prior to the payment date to guarantee inclusion in the following payment run. Completed forms are to be returned to public.hospital.hsd@medicareaustralia.gov.au

Participating public hospitals—CAR HSDs and PBS trastuzumab

Participating public hospitals are able to claim CAR HSDs and PBS trastuzumab in their normal PBS claims to Medicare Australia.

State/territory health departments are to ensure that where a participating public hospital claims these items directly to Medicare Australia that the items are not to be included in the state/territory monthly claim form.

Last updated: 4 September, 2009