REJECTION OF HMR CLAIMS SOME REASONS WHY A FULL CLAIM IS REJECTED IN SOME INSTANCES AND NOT PROCESSED: The claim has been signed and dated by the wrong person. The form must be signed by either an approved or authorised person. Usually the pharmacist has not been authorised by the owner. MEDICARE AUSTRALIA do check with the relevant state’s approval clerk (to ensure the system has been updated) before rejecting. Often the full name of the accredited pharmacist has been omitted. From time to time there is no name quoted on the claim form, often only an initial. MEDICARE AUSTRALIA does not expect all Given names to be supplied, but do expect at least one. The date of the consumer review is omitted or the date is incomplete. Often on the claim form the pharmacist will write the month and year, but no day (eg: 11/02). The claim is only rejected when all dates are omitted or incomplete. No prescriber number quoted for the referring medical practitioner or just the surname given and no first name. The full name of the consumer is not given. In many cases MEDICARE AUSTRALIA receive the surname or a surname with an initial of the patient’s given name. This is insufficient data to identify the patient where the Medicare number is not supplied. The pharmacy is not registered to perform HMR’s. Some pharmacists believe that once they receive accreditation for QCPP that they do not have to register with the MEDICARE AUSTRALIA. It would appear that the pharmacy does not read the information supplied to them by the MEDICARE AUSTRALIA and Guild. This also includes pharmacies that have changed approval number and have not re- registered. The claim form has not been signed. The claim forms received are not originals. The MEDICARE AUSTRALIA will only accept original claim forms, not photocopies or faxes. SOME REASONS WHY A SERVICE IS REJECTED The pharmacy was not approved at the date of review. Duplicate services. Pharmacies claim services that have already been processed Some of the duplicate services result from pharmacies misreading a statement for a previous claim that has a warning on the statement. Pharmacies incorrectly believe the claim has been rejected and then re-claim. When a second review is done within the 12 month period, the pharmacist should write on the claim form that the prescriber has requested another review or otherwise the service is automatically rejected MEDICARE AUSTRALIA does check the previous service and it is also common for the incorrect Medicare number to be quoted (eg: quoting the Medicare number for the wife instead of the husband. This will result in confusion when the husband has a review at a later date). Prescriber name mismatch. The pharmacist provides the incorrect provider number for the GP named on the claim form When a pharmacy’s approval has been revoked and the new approval has been registered, pharmacists tend to claim all services under the new approval number. Services performed before the new approval date need to be claimed using the revoked (previous) approval number. SITUATIONS WHERE PHARMACIES ARE REJECTED Pharmacists frequently quote the Centrelink numbers instead of Medicare Numbers Often Medicare numbers quoted are incorrect or are not a complete number (ie: they do not include a patient reference number). Pharmacists should use the patient’s name as per the Medicare card Where the patient’s known name is different to their correct name, this can result in name mismatches (eg: Bill v’s William) Prescriber number- transposing numbers Using provider numbers instead of prescribing numbers, this results in additional processing time to identify the correct prescriber number. Use of the prescribers known given name instead of the prescribers registered name is essential if the correct medical practitioner is to be identified as the referring practitioner. Pharmacies lodging claims using the incorrect approval number (revoked number) In these instances, the MEDICARE AUSTRALIA will ring the pharmacy and advise them of the error. Pharmacies claiming for a HMR service using a Special Number (Medicare number) for a patient instead of using the patient’s Medicare number.
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