National Health (Claims and under co‑payment data) Rules 2012

1 Rule 4 (after the heading)

Repeal the note, substitute:

Note: A number of expressions used in these Rules are defined in the Act, including the following:

(a) Chief Executive Medicare;

(b) Veterans’ Affairs Department;

2 Rule 4

Insert:

actual contribution means the actual amount a patient pays for each prescription, including a special patient contribution.

Note: Does not include any charge for delivery, or for supply of a pharmaceutical benefit outside normal trading hours.

3 Rule 4

Insert:

allowable discount has the meaning given by subsection 87(2AAAA) of the Act.

4 Rule 4

Insert:

contribution discount means the amount of the allowable discount for a supply other than an early supply of a specified pharmaceutical benefit.

Note: The contribution discount may be greater than one dollar in the limited cases where subsection 92A(2) of the Act applies to a supply of a pharmaceutical benefit by a friendly society or a friendly society body to an eligible member.

5 Rule 4

Insert:

early supply of a specified pharmaceutical benefit has the same meaning as in subsection 84AAA(1) of the Act.

6 After Rule 12

Insert:

13 Application and transitional provisions for the National Health (Claims and under co‑payment data) Amendment (Discount co-payment and patient charges data) Rule 2015

(1) If:

(a) an approved supplier gives information for the purposes of subsection 98AC(1) or section 99AAA of the Act in relation to the supply of a pharmaceutical benefit; and

(b) at least one of the supplies to which the information relates was made on or after 1 January 2016, but before 1 March 2016, by an approved pharmacist or approved medical practitioner, or before 1 July 2016 by an approved hospital authority, or a later date determined for the approved supplier under subrule (2);

then, the approved supplier may give the information:

(d) in accordance with the new Claims Rules.

(2) For paragraph (1)(b), the Chief Executive Medicare may, by writing, determine a later date for an approved supplier if the Chief Executive Medicare is satisfied that exceptional circumstances exist in relation to the approved supplier. The date must be before 1 January 2017.

Definitions

(3) In this rule:

new Claims Rules means these Rules as in force on 1 January 2016.

old Claims Rules means these Rules as in force immediately before 1 January 2016.

7 Schedule

Repeal the Schedule, substitute:

Schedule 1—Information required when using Claims Transmission System

Note: See paragraph 7(e).

1 Information required when using Claims Transmission System

For paragraph 7(e) of these Rules, an approved supplier must give, in relation to the supply of a pharmaceutical benefit, the information referred to in an item in the following table in accordance with that item.

Note 1: The table applies for the purposes of an approved supplier giving under co‑payment data (see subsection 98AC(1) of the Act) or information required to be given because the approved supplier is making, or proposing to make, a claim (see subsection 99AAA(3) of the Act).

Note 2: The details in column 2 of an item in the table may have the effect that information is not required to be given under that item in relation to a particular supply.

Information to be given when using the claims transmission system
Item	Column 1 Information	Column 2 Details
1	Actual contribution	The actual contribution paid by the patient or their agent.
2	Authority Prescription Number	Only required if the approved form for the prescription requires an authority prescription number to be entered.
3	Brand	Manufacturer’s code that represents the listed brand of the pharmaceutical item in the determination under subsection 85(6) of the Act supplied by the approved supplier. An extemporaneously‑prepared pharmaceutical benefit will not have a listed brand.
4	Claim Period Number	Indicates the sequential order and calendar year of the claim submitted by the approved supplier during that calendar year.
5	Claim Reference	Sequential number generated for each claim submitted within a claim period.
6	Contribution discount	The contribution discount (if any) applied by the approved pharmacist or approved medical practitioner. Not required for approved hospital authority or when giving under co-payment data.
7	Date of Dispensing	Date the prescription was dispensed.
8	Date of Prescribing	Date the PBS prescriber signed the prescription. Not required for continued dispensing.
9	Date of Previous Supply	Date printed on a repeat authorisation in the box “Name and PBS Approval number of pharmacist issuing this authorisation” (where it is called “Date this authorisation prepared”). Not required for continued dispensing or medication chart prescription.
10	Entitlement ID	Number from the Health Care Card, Pensioner Concession Card, Commonwealth Seniors Health Card, Safety Net Entitlement Card, Safety Net Concession Card, Repatriation Health Card (Specific or All Conditions), or Repatriation Pharmaceutical Benefits Card, that applies to the person for whom the prescription was written. Not required for payment category general benefit or prescriber bag supply form.
11	Family Name	Surname of the person for whom the prescription was written sourced from the Medicare or equivalent DVA card. Not required for prescriber bag supply form.
12	Form Category	Prescription not covered by another form category = 1 Repeat authorisation not relating to authority prescription = 2 Authority prescription = 3 Repeat authorisation relating to authority prescription = 4 Deferred supply authorisation = 5 Prescription written by a participating dental practitioner = 6 Prescriber bag supply form = 7 DVA authority form = 8 DVA authority repeat form = 9
13	Given Name	Given name of the person for whom the prescription was written sourced from the Medicare or equivalent DVA card. Not required for prescriber bag supply form.
14	Glass Bottle	Only required if, in a prescription for extemporaneously‑prepared ear drops, eye drops or nasal instillations, a glass bottle is ordered by the PBS prescriber or considered necessary by the approved supplier.
15	Health Practitioner (AHPRA) Number	Only required for continued dispensing. Registration number published by the Australian Health Practitioner Regulation Agency. Number required for the individual pharmacist who personally dispensed the pharmaceutical benefit.
16	Hospital Provider Number	Only required if patient category is “medication chart public hospital patient” or “medication chart private hospital patient”, or if prescription originated in a public hospital. The hospital’s provider number.
17	Immediate Supply Necessary	Required if prescription supplied within the 4 or 20 day period in accordance with regulation 25 as “immediate supply necessary”. Must also indicate if prescription is an early supply of a specified pharmaceutical benefit.
18	Medicare Number	Medicare card number (including card issue number and individual reference number) of the person for whom the prescription was written. The number can also be a special number which applies to the person. Not required for prescriber bag supply form or RPBS prescriptions where entitlement number supplied.
19	Medication Chart Period of Validity	Only required for medication chart prescription. Patient receiving treatment in or at a residential care service = 4 Patient receiving treatment in or at an approved hospital = 1, 4 or 12
20	Number of Repeats	Number of repeats prescribed, including number of repeats prescribed if original and repeats supplied all on the one occasion under regulation 24.
21	Original PBS Approval Number	Approval number allotted to approved supplier who made the first supply on the prescription, being the approval number allotted under regulation 8A. Not required for continued dispensing or medication chart prescription.
22	Original Unique Pharmacy Prescription Number	Prescription number allotted to prescription by approved supplier who made the first or only supply on the prescription. Appears on original prescription and any subsequent repeat authorisations. Not required for continued dispensing or medication chart prescription.
23	Patient Category	Continued dispensing patient = D Paperless private hospital patient = H Public hospital patient = B Nursing home patient = N Paperless public hospital patient = C Community patient = 0 (zero) Residential aged care facility patient (medication chart prescription) = R Medication chart public hospital patient = M Medication chart private hospital patient = P
24	Payment Category	General benefit = 1 Entitlement card/PBS Safety Net (free) = 2 Concessional benefit and concession card = 3 Repatriation = 4 (RPBS) Prescriber bag supply form = 5
25	PBS Item Code	Code for the pharmaceutical benefit that appears in the Schedule of Pharmaceutical Benefits published by the Department. RPBS item codes also appear in this Schedule. Not required for RPBS, if there is no RPBS item code, and the Veterans’ Affairs Department has given prior approval.
26	PBS Reference Number	Only required if a pre‑assessment was requested by approved supplier. Number created by Chief Executive Medicare in relation to pre‑assessment.
27	Pharmacy Processing Code	Only required if the approved supplier’s dispensing software has no real time response from Chief Executive Medicare.
28	Prescriber ID	Prescriber number of the PBS prescriber issued by the Chief Executive Medicare. Not required for continued dispensing, or if prescription written by medical practitioner and the prescriber number was not available to the approved supplier at the time of supply.
29	Previous Supplies	Number of times (including the original supply) the pharmaceutical benefit has previously been supplied under the prescription.
30	Price	Required for a prescription priced by the approved supplier in accordance with an election under subsection 31(1) of the determination under paragraph 98B(1)(a) of the Act or priced by an approved supplier as an exceptional prescription. Required if RPBS, no RPBS item code, and the Veterans’ Affairs Department has given prior approval. Not required if the price for a prescription priced by the approved supplier is under co-payment.
31	Quantity	Quantity of the pharmaceutical benefit supplied. Must be total quantity supplied (first supply and all repeats) if supplied all on the one occasion under regulation 24.
32	Regulation 24	Only required if first supply and all repeats were supplied all on the one occasion under regulation 24.
33	Residential Aged Care Facility ID	Only required if pharmaceutical benefit supplied to resident receiving residential care within the meaning given by section 41‑3 of the Aged Care Act 1997, including if medication chart prescription. Also known as Residential Aged Care Service identification number.
34	Resubmission Flag	Only required if information relating to the prescription was previously submitted (whether by way of claim or under co‑payment data) and rejected.
35	Serial Number	Number that uniquely identifies the pharmaceutical benefit within the payment category, marked on the prescription by the approved supplier. The number runs sequentially, within a range, for that claim period, for each payment category, or, at times, for a type of prescription for each payment category (for example medication chart prescriptions).
36	Streamlined Authority Code	Only required for authority prescriptions, if the type of authority is streamlined authority code. The streamlined authority code is written on the prescription by the PBS prescriber. It is also written on the repeat authorisation by an approved supplier.
37	Unique Pharmacy Prescription Number	Unique number allotted by the approved supplier’s pharmacy dispensing software to a supply of the pharmaceutical benefit. Each individual supply will only ever have one number allotted to it and that number will not be re‑allotted to other prescriptions supplied by the approved supplier.