8. How Pharmacists Claim Reimbursement: Documents to be Submitted

Page last updated: 1 January 2016

A claim for pharmaceutical benefits consists of:

  • the original and duplicate of a completed Claim for Payment Form;
  • the original orders for prescriber bag supplies in a separate bundle;
  • the originals of all old format PBS prescriptions and authority PBS prescriptions, the Department of Human Services/DVA copies of new format PBS prescriptions and authority PBS prescriptions, and all repeat authorisations, separated into four bundles for benefits supplied to the general public; concessional beneficiaries/Safety Net Concession Card holders; Safety Net Entitlement Card holders and RPBS patients.

In order to satisfy auditing/spot check compliance measures, PBS prescriptions in each bundle should be in serial number order, with serial number 1 at the top of the bundle.

PBS prescriptions subject to the Safety Net early supply rule are handled according to the resulting payment category. For prescription forms with multiple PBS items, where the Safety Net early supply rule would result in different payment categories for different items, dispensing via 'deferred supply' should be used where necessary to allow all items to be grouped correctly.

PBS prescriptions in the incorrect category may be returned to the pharmacist for clarification. If appropriate, they can be resubmitted in the correct category in the next claim period.

Completing the claim form

The claimant's name, address of the pharmacy from which the pharmacist is approved to supply pharmaceutical benefits, approval number, and claim period number should be entered on the Claim for Payment Form. These details should match the latest written information held by the Department of Human Services, or payments can be delayed while clarification is sought.

The claim period number should state how many claims have been submitted so far in a calendar year, e.g., the sixth claim submitted by an approved pharmacist in 2005 should have a claim period number of 0506.

The first and last serial numbers given to items in each bundle are to be entered on the Claim for Payment Form.

A total claim amount is not required – this will be calculated by the Department of Human Services after the PBS prescriptions have been individually priced.

The declaration must be signed by the pharmacist approved to supply pharmaceutical benefits, unless he/she has made arrangements through the Department of Human Services for another pharmacist to sign it.

Lodging claims

A claim may be lodged at any time during the month at the relevant the Department of Human Services State office. Unless other arrangements have been made with the Department of Human Services, the following conditions apply:

  • only one claim period can exist and only one claim can be lodged per month;
  • the claim period shall cover pharmaceutical benefits supplied during one month; and
  • the claim shall be sent within 30 days from when the benefits were supplied.

Claims for pharmaceutical benefits supplied over 18 months earlier may not be accepted for computer processing. Pharmacists with such claims should contact the Department of Human Services.

Reconciliation statements

As mentioned earlier, a pharmacist will receive a PBS reconciliation statement after a claim period has been processed. It provides details of each prescription for each brand of each pharmaceutical benefit item supplied in that claim period.

Reasons for non-payment of any item are coded, with the code numbers explained in the statement.

PBS prescriptions and repeat authorisations not accepted for payment will be returned, with the exception of PBS prescriptions with a dispensed price equal to or less than the patient contribution. Any other items on those PBS prescriptions that have been paid will have been cancelled.

If a PBS prescription was not accepted and can be re-submitted, it must be given a new serial number and included in a subsequent claim period.

If a PBS prescription is finally rejected for payment and a pharmacist is not satisfied with the decision, he/she may apply to the Administrative Appeals Tribunal for a review of that decision.