On occasion you may encounter issues with a claim, and your claim will be returned with exceptions. Most of the time you'll be able to determine how to resolve these exceptions by assessing the error code returned in the Processing Report, but sometimes you'll encounter issues with more complex exceptions where it isn't clear how best to deal with them. This article will cover some exceptions and how they can be resolved.

Please note that all exceptions are returned directly from Medicare Australia or the individual Health Fund, not from Gentu. 

Exception Types

Generally, exception types will fall under these two categories: Underpaid or Rejection. 

Underpaid exceptions are categorised by the account holder (Medicare, DVA, or the health fund) paying less than the amount owing. 

Underpaid exceptions are fixed by adjusting the charge of the item number to match the amount paid by the account holder. (Note that it is uncommon, but possible, for the account holder to overpay an item. This is also fixed by adjusting the item's fee to match what was paid. You may also wish to notify Medicare or the health fund of the overpayment, to ensure that you are charging the correct fees in future.)

Rejection type exceptions are categorised by Medicare or the health fund paying nothing against the claim or item. Usually the exception message will state ‘no benefit payable’ or ‘the claim was rejected’.

Rejection type exceptions are usually resolved by fixing any issues preventing payment and resubmitting the item. Alternatively, if the item is likely to never be paid, it can be adjusted to write off the balance.

Common Exceptions 

> A report for this claim has not been found on the Medicare servers for 14 or more days...

How it occurs:

This particular error is not an exception as such - instead, it occurs when you have successfully sent a claim, but Gentu does not receive the claim's Processing Report within the expected 14 day (2 week) period. 

How to fix this exception:

After 14 days have passed without receiving the electronic Processing Report, Gentu will present you with this error. As the error text clearly states, you must contact Medicare prior to resubmitting the claim.

Medicare will be able to tell you if the claim was received or not. It is very important to confirm whether Medicare received the claim: if you resubmit a claim which is currently being processed by Medicare, this will result in the duplicate claim being rejected with a "Benefit has previously been paid for this service" rejection and you will be required to manually receipt the claim.

• If Medicare states they did not received the claim, you can safely resubmit it by pressing the Resubmit button.
  
  
• If Medicare states they did receive the claim; then it is recommended that you request a manual statement of payment from Medicare, and once received, manually receipt the claim via Financials > Organisational Remittance.

Please note that Gentu Support cannot access Medicare's claims database, and therefore cannot advise whether the claim was received by Medicare or not. It is strongly recommended that you contact Medicare in the first instance to confirm they received the claim, as this will consistently be the advice provided by the Gentu Support team in order to fix this error. 

> Benefit has been previously paid for this service

If you have submitted duplicate claims for the same service; the second invoice, item or claim will be rejected with the exception "Benefit has been previously paid for this service".

How it occurs:

This error most typically occurs after receiving the "A report for this claim has not been found on the Medicare servers for 14 or more days..." error, described above. If the claim is resubmitted without confirming it was received by Medicare, and Medicare have actually successfully received and processed the claim, then this exception will reliably occur as they reject the "duplicate" claim.

On rare occasions, it can take several weeks for Medicare to return a claim's processing report/payment summary. This can result in the original claim being paid and auto receipted several weeks after it was sent, however any claims which were resubmitted will be rejected wtih the "benefit previously paid" exception.

How to fix this exception:

To resolve this, you must manually receipt the claim (via Financials > Organisational Remittance). You will first need to confirm it was actually paid, which you can do by contacting Medicare and requesting a manual statement of payment for your records before manually receipting. Alternatively, you can determine the original claim on which the benefit was paid, find it in Claims Control > Finalised, and check the payment advice. If you need assistance doing so, please contact Gentu Support. 

It is also possible for this error to occur if a second, duplicate invoice was accidentally created for the patient and submitted as a new claim. In the case of two identical invoices, you can resolve this exception by manually marking each item as resolved (open the invoice and tick "Mark as Resolved" for each item) and adjusting each item on the invoice to $0.

> Referral issues

Referral-related exceptions may include the following:

• Referral/request details not supplied - no benefit payable
• Referral date format is invalid
• Date of service outside of referral/request period
• 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
• Referring Practitioner's Provider Number must be supplied
• ReferringProviderNum is an invalid value

If a claim is submitted without a referral, or with incorrect or missing referral details, you may receive one of the exceptions above.

How to fix these exceptions:

To resolve referral detail issues, first open the patient's file and check their referral(s) within the Patient Details tab, ensuring all referral details are accurate. Next, open the invoice in question from the patient's Account tab, and ensure the correct referral has been selected from the drop down list.

If the invoice relates to an issue covered by an indefinite referral and it has been rejected, please click on the next to each item and note the indefinite referral details in the service text.

Once you have updated the referral details, you can then tick "Mark as resolved" and "Reclaim item" for each item on the invoice. Press Reclaim to resubmit the claim.

> 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.

How it occurs:

As the error states, this occurs when there is a discrepancy between the patient details submitted with the claim, and those held on record by Medicare Australia.

How to fix this exception:

It is recommended that you open Patient Details for that patient, and verify the patient's details electronically with Medicare using the Verify button. It may also be necessary to contact the patient and confirm their details. Amend the details as needed, then resubmit the claim.

> Check Servicing Provider. May not be able to provide the service for this item at date of service.

How it occurs:

This error indicates an issue with the servicing provider's details. For example, it may be that they have submitted a claim under a Site of Service-specific Provider Number which was not actively registered at the time the service was provided.

How to fix this exception:

In the absence of any apparent issues with the servicing provider's details, you will need to contact Medicare for more information.

> Service is within the required waiting period

How it occurs:

This error occurs when you claim from a private health fund for a service that the patient is not yet eligible for, and therefore the health fund will not honour the claim. 

How to fix this exception:

If this occurs for a Known Gap claim, then you can reassign the outstanding balance of the claim to the patient by opening the invoice and pressing the Transfer button. 

In the pop-up box, press Transfer again to confirm. The outstanding balance will be transferred into the patient's name, and the patient will be responsible for paying the balance. (You may also wish to adjust the fee at this stage, which you can do by pressing the Adjust icon next to each item on the claim, and making the necessary changes.) 

If this occurs for a No Gap claim, it will be necessary to cancel the invoice (by marking each item resolved, and adjusting each item's balance to $0), and then re-raise the invoice, addressed to the patient.

> In hospital services cannot be claimed as out of hospital

How it occurs:

As the error text suggests, this exception occurs when an inpatient service (typically a surgical item) is claimed as an Outpatient service. Normally this error will only occur for Bulk Bill/DVA claims.

How to fix this exception:

In this scenario, it is necessary to mark the exceptions resolved, and adjust the fee for each item down to $0, in order to finalise the claim. You can then re-raise an invoice with the correct details and submit it electronically.

> Service possibly aftercare

How it occurs:

This error normally occurs if the Medicare conditional override "Not normal aftercare" has not been set for this item.

How to fix this exception:

To fix this issue, open the invoice and click the + icon to the left of the item in question. The Overrides window will open. Tick the Not Normal Aftercare option (and any other options which are appropriate). Click Apply to save.

You can then tick Reclaim Item before pressing Reclaim to resubmit.

> Derived item assessed with other item on statement

How it occurs:

This exception is neither a rejection or an underpayment; rather it occurs when you claim a telehealth item (for example, MBS items 99 or 112) in addition to a consult item. As telehealth items are derived fees (calculated as half of the consult item fee), Medicare has an unusual method of paying the benefit.

The telehealth item will be shown in the Processing Report with a $0 charge and benefit amount. The consult item will have the telehealth item's fee added to its original fee, changing the total charge amount. Medicare will then pay the benefit for both items against the consult item.

In the example above; the base MBS rebate for the consult item is $112.30. Medicare calculates the telehealth item benefit by halving the consult item fee, giving the telehealth item a benefit amount of $56.15. This derived amount is added this to the consult item fee, for a total charge amount of $168.45, and Medicare pays the full benefit against the consult item. 

See also:

Resolving, Reclaiming & Manually Receipting