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Troubleshooting Medicare claims

Error codes on bulk bill or patient claims

Updated over a week ago

Claims can occasionally get rejected by Medicare. When this happens, Medicare will respond with an error code that can help in diagnosing what needs to be corrected in order to submit the claim successfully.

How to troubleshoot Medicare claims

1. From the client's file, click on Invoicing 
2. You can now view any error codes from the status column OR you can hover over the Actions button on the relevant invoice and select Bulk Bill (BB)/Patient Claim (PCI)/DVA depending on your claim type

3. Use your error code to correct the details and then resubmit the claim to Medicare.

💡 You can find claims that have been rejected by running the Claim Status Report (Reports > Medicare > Claim Status)

Most common error codes from Medicare

Understanding what these responses and messages mean can sometimes be tricky. 

So, below is a glossary of the more common messages from Medicare as well as what needs to be done in order to re-submit the claim successfully;

137: Details of requesting provider not shown on account/receipt

Details of the referral provider were not included on the invoice when submitted.

Action: Unlock the invoice and under Referral \ Request information ensure there is a start date, Referring Period and provider number entered.

💡 Due to the transition to PRODA, it's recommended to have the Request Type set to Specialist and Referral Override code set to N/A and Referral Period to 12 months under Referral/Request Information.

160: Maximum number of services for this item already paid

This means that Medicare has already paid the maximum number of items for the current referral or for the year.

Action: Check the item number is correct (psychology sessions 1-10 use a different item number to sessions 11-20), or seek a new referral for your client and add the referral to your client's file. Then recreate the invoice and submit to Medicare.

162: Benefit has been previously paid for this service

The rebate for this service has already been paid. This may have likely occurred because the invoice was submitted to Medicare more than once.

Action: Contact the Medicare processing line on 132 150 to confirm if the invoice has actually been paid. If not, resubmit the claim to Medicare, and in a few days check the Medicare report to see if the claim has been processed

255: Benefit assigned has been increased

The Medicare/DVA benefit schedule has changed, and as a result, the item codes benefit has increased

Action: Confirm the correct amount on the Medicare MBS then you can adjust your item code fees within the Setup > Settings > Service Types and resubmit the claim

Locked - Medicare error - 267: Service not payable - associated service not present

Medicare has not paid for this service. This can be due to the associated service not being included in this claim. This means that there is a second service that needs to be on the invoice to be able to claim that item.

Action: Please, call Medicare to troubleshoot this. The Medicare eBusiness phone number is 1800 700 199 and they’re open Monday – Friday between 8am – 5pm local time.

8005 - The individual has been matched using the submitted data however differences were identified. Please check the information returned and update your records.

One or more of the client's details (Name, Address, D.O.B, etc.) must be updated to match Medicare's files before resubmitting the claim.

You are able to confirm what is incorrect by running a Medicare OPV

9006 - The Provider [ ] is not authorised to undertake this

This is an issue related to the provider's registration with Medicare.

Action: Please, call Medicare to enquire what may be preventing the practitioner from claiming with Medicare.

9619: Check postcode and locality. This is not a recognised combination OR a PO Box type locality has been entered.

The suburb and the postcode entered under the Residential Address of the client's file do not match.

Action: Go to Client file > Details/Referrer and check if the suburb has been misspelled or if the wrong suburb has been entered for the postcode. If the suburb is correct, then check if the postcode matches the suburb. If both the suburb and the postcode are correct, then remove the state at the end of the suburb. Then click on Update Client and resubmit the claim to Medicare.

9309: Referral issue date must be supplied, and must be prior to, or the same as, the date of the medical service, cannot be before the date of birth, nor after the referral start date

This usually means there's an issue with the referral or consult date.

Action: Check the date of the referral, the date of the consult, and the client's birthdate to ensure the referral is dated before the consult and the referral and consult dates are after the date of birth. For 12-month referrals, check that the consult date is no more than 12 months after the referral date.

After checking all the details, resubmit the claim to Medicare.

9342: The Payee Practitioner supplied is the same as the Servicing Provider

This means that servicing provider number (in Consultation Information) is different to the payee provider number (in Claim Information), but the two different provider numbers belong to the same person. This usually occurs when your Medicare defaults are set so that one particular provider number is the payee provider for all claims.

Action: To process your claim simply change the payee provider number to match the servicing provider number and submit the invoice again.

💡 If you can't see the Payee Provider Number option in Claim Information on the invoice, you'll need to check User can change this when claiming under Principal Provider Number (payment directed to) for the relevant claim type in your claiming defaults

9601 - Claim successfully transmitted and pended for further assessment by a Customer Support Officer. The claimant will be advised of the outcome by mail.

This is an error between the patient & Medicare, as the patient cannot have their claims automatically processed.

Action: Advise the client of the above and they will either need to wait for the outcome or contact Medicare directly.

9602 - This claim cannot be lodged through this channel. Please submit the claim via an alternative Medicare claiming channel.

This error can relate to a few different issues, firstly confirm the following are all correct.

  1. Patient info such as name, D.O.B, address, and Medicare card number are all correct.

  2. Claim information is all correct, such as service type, date of service, and provider number.

  3. Ensure the referral details are listed and are all correct (if the patient has a referral)

  4. Check that Service Category is set to Specialist and you have selected the correct Medicare claim type.

Action: Advise the client their claim cannot be lodged through online claiming, and print their invoice to claim at a Medicare branch directly.

9605/9606 - Another Medicare Card may have been issued to the patient/claimant or the details you entered do not match those held by Medicare. Please update your records and resubmit the claim.

Action: Verify that the patient's Medicare card number, first name, last name, and D.O.B are all correct and up to date, you can do this by running a Medicare OPV. If any information is wrong, then please reach out to the client and correct it. Then submit the claim again to Medicare.

9617 - The referral has expired.

The referral is no longer valid and will not be accepted.

Action: Either seek another referral or if appropriate, update their current referral with new dates

9625 - Claimant address needs to be updated with Medicare, Issue account/receipt for the claimant to submit via an alternative Medicare claiming channel.

Action: The claimant's physical address will need to be updated with Medicare, you will need to print the claim out and have the patient take it to a Medicare branch.

9630: Please check the request or referral details.

Action: This may mean that the referral details are incorrect, the referral has exceeded the number of appointments, or the referral date has expired. Because the Claim was immediately rejected, Medicare may have no record of this Claim. Once checked you will need to resubmit the claim or edit the referral or if no issues, you will need to contact Medicare 132 011.

9632 - Duplicate of service already paid. If not duplicate resubmit with appropriate indication.

This error relates to the claim being sent to Medicare multiple times and was rejected as the first successful submission was paid and processed.

Action: Try submitting the claim with a Duplicate Service Override. This article will guide you through the whole process: Duplicate Service Override

If this doesn't go through and you cannot find the original claim, contact Medicare on 132150.

9633/9634 - A new Medicare card has been issued. Please update your records and ask the patient/claimant to use the new card number for any future claims.

Please, reach out to the patient/claimant to confirm their new Medicare card number.

Action: Update the client's Medicare details and then resubmit the claim.

9635 - Check Servicing Provider. May not be able to provide the service for this item at the date of service on the invoice

Servicing provider is not eligible to claim for this item number at the date of service.

Action: Select a more appropriate item number and resubmit the claim to Medicare.

9641 - A restrictive condition exists.

The restrictive condition exists error relates to an issue between the patient and Medicare, typically it will require the patient to take the claim into a Medicare branch, however, it'd be worth confirming the following are all correct:

  1. The patient's details are all up to date and valid (E.g name, d.o.b, Medicare card number).

  2. The item code is correct, and the referral details are all listed and valid.

If all the above are correct and the 9641 error code is still being received after recreating the invoice, the claim will need to be printed out for the patient to take into a Medicare branch.

9650 - The card number and/or patient details submitted did not match Medicare Australia's checks. Please verify the details and resubmit with additional information if available.

Action: The client's card number and/or address must be updated to match Medicare's files before the claim will be accepted. Please, reach out to the client and confirm the details. Then you'll have to update the client details and resubmit the claim to Medicare.

9675 - Current Medicare card has expired. Patient must contact Medicare as claims using this Medicare card may be rejected.

Action: The client's Medicare card has expired. You can check your client's Medicare eligibility by running a Medicare OPV

9701 - The maximum number of services for this item have been paid, if this service is not a duplicate please resend with correct item numbers as per MBS.

The client has already claimed the maximum number of services for this item.

Action: Obtain a new referral or contact Medicare directly.

9204 - Date in future. The date supplied must not be in the future.

The consultation date, date of birth, and or referral start date are in the future.

Action: Make sure the consultation date, date of birth or referral start date are not in the future

9616 - The BSB supplied is invalid, unknown or cannot be used for Medicare payments.

Check the client's bank details on the claim before recreating the invoice.

9006 - The Provider [Provider Number] is not authorised to undertake this.

It's very likely that the practitioner may not have been approved by Medicare for claiming or they haven't been added to your PRODA organisation.

Action: You can see here how to add members to your organisation: Add your practitioners to your PRODA organisation

223: Service not payable - specified item not claimed or present

Action: Make sure you're using the correct item number. Best to call Medicare if you're unsure about which item number to use.

If the practitioner is present in your PRODA organisation, then you'll need to reach out to Medicare to troubleshoot this issue. Medicare may have entered the wrong Minor ID.

The Medicare eBusiness phone number is 1800 700 199 and they’re open Monday – Friday between 8am – 5pm local time.

💡 In order to resubmit a claim, you'll need to go into the invoice via Client file > Invoicing > Actions > Edit > under Claim Information, set Send request now to Yes and then Update Invoice.

💡The full list of possible Medicare error codes can be found below:

The 4 digit codes (DB4 - Client) - 4 Digit Codes

These will be downloaded as a .csv file and can be opened in Microsoft Excel

You can call Medicare's processing line on 132 150 for further assistance with rejected claims. You are also welcome to contact our Customer Service Team.

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