6. Department of Human Services Entitlement Checks

General Patients

The Department of Human Services validates a patient's entitlement to pharmaceutical benefits by checking the Department of Human Services and/or Veteran file numbers in pharmacist's claims. If a number is not recorded correctly, a patient cannot be identified against the Department of Human Services' Pharmaceutical Benefits Entitlement File and entitlement cannot be established.

If the Medicare or Veteran file number provided in the pharmacists' claims is incorrect or the number and the name supplied do not match the Department of Human Services records to enable patient identification, an appropriate warning or rejection code will be returned to the pharmacy. These notifications of missing or incorrect Medicare or Veteran file numbers are provided to pharmacists in their reconciliation statement produced after the claim period has been paid by the Department of Human Services.

Special numbers are available for use in certain circumstances for eligible people who are unable to provide a Medicare number.

Concessional Patients

The Department of Human Services routinely validates a patient's entitlement to free or concessional benefits by checking concessional numbers in pharmacists' claims. If a number is not recorded correctly, a patient cannot be identified against the Department of Human Services' Pharmaceutical Benefits Entitlement File and entitlement cannot be established.

When a number is found to be from a card which was incorrect, expired at the time of supply or entitlement was withdrawn, warning or rejection codes will be returned to the pharmacy to assist with validation of concessional entitlement in relation to future claims from the same patient.

Entitlement checking procedures

General Patients

Once a pharmacist has been notified by the Department of Human Services of an incorrect Medicare or Veteran file number he/she should correct the number for future claims by:

  • updating his/her system to reflect the correct number provided by the Department of Human Services (if patient consent to do so has been obtained); or
  • speaking to the patient; or
  • obtaining patient consent and calling the Department of Human Services on the Improved Monitoring of Entitlements (IME) (132 290 — select option 1).

If the patient presents a Medicare card that appears correct, but according to the Department of Human Services is not a valid number, or not a valid number for that person, a pharmacist may use a special number. A photocopy of the card, or a form must accompany the use of this number. The form is available on the Department of Human Services' website or by calling 132 290.

Concessional Patients

Once a pharmacist has been notified by the Department of Human Services of an incorrect concessional entitlement number, he/she should view the entitlement card to confirm the entitlement number, and start and end dates, when the patient next presents a PBS prescription.

Step by step

Pharmacists should take the following steps where concession entitlement does not appear to be valid or current:

  • Re-confirm entitlement with the cardholder/customer;
  • Contact the Department of Human Services on 132 290, with consent, to confirm the cardholder/customer concession status;
  • If the Department of Human Services advises that the cardholder/customer is concessionally entitled to receive the PBS medicines on that day, supply the prescription as a concessional entitlement;
  • If the Department of Human Services advises that the cardholder/customer is not concessionally entitled to receive the PBS medicines on that day, supply as a general prescription. Provide the customer with the information sheet "Your entitlement card" which explains entitlement checking to the customer and the steps they can follow if they are concessionally entitled.