National Health (Claims and under co‑payment data) Amendment (Medication Chart Prescriptions) Rule 2015 (PB 19 of 2015)
I, Felicity McNeill, First Assistant Secretary, Pharmaceutical Benefits Division, Department of Health, delegate of the Minister for Health, make the following rule.
Dated 26 March 2015
Felicity McNeill
First Assistant Secretary
Pharmaceutical Benefits Division
Department of Health
Contents
1............ Name............................................................................................................................. 1
2............ Commencement............................................................................................................. 1
3............ Authority....................................................................................................................... 1
4............ Schedules...................................................................................................................... 1
Schedule 1—Amendments 2
National Health (Claims and under co‑payment data) Rules 2012 2
1 Name
(1) This is the National Health (Claims and under co‑payment data) Amendment (Medication Chart Prescriptions) Rule 2015.
(2) This instrument may also be cited as PB 19 of 2015.
2 Commencement
This instrument commences on 1 April 2015.
3 Authority
This instrument is made under subsections 98AC(4) and 99AAA(8) of the National Health Act 1953.
4 Schedules
Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.
Schedule 1—Amendments
National Health (Claims and under co‑payment data) Rules 2012
1 Rule 4 (after the heading)
Insert:
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
Before “In these Rules”, insert “(1)”.
3 Rule 4 (paragraph (a) of the definition of A section)
Omit “an prescriber”, substitute “a prescriber”.
4 Rule 4 (definition of CTS claim)
Repeal the definition.
5 Rule 4 (definition of CTS non‑online claim)
Repeal the definition.
6 Rule 4 (definition of diskette)
Repeal the definition.
7 Rule 4
Insert:
electronic prescription has the same meaning as in the Regulations.
8 Rule 4 (definition of ePrescription)
Repeal the definition.
9 Rule 4 (definition of medication chart prescription)
Repeal the definition, substitute:
medication chart prescription has the same meaning as in the Regulations.
10 Rule 4 (definition of online claim)
Repeal the definition.
11 Rule 4 (definition of original authority prescription and original prescription)
Repeal the definition.
12 Rule 4 (definition of paperless claim for payment)
Repeal the definition.
13 Rule 4 (definition of PBS prescriber)
Repeal the definition, substitute:
PBS prescriber, in relation to a prescription, means the PBS prescriber (within the meaning of Part VII of the Act) who wrote or prepared the prescription.
14 Rule 4
Insert:
pharmaceutical benefit has the same meaning as in Part VII of the Act.
15 Rule 4 (definition of prescriber bag supply form)
Repeal the definition, substitute:
prescriber bag supply form means:
(a) an order form for the purpose of regulation 16 of the Regulations; or
(b) a form for the purpose of an approved medical practitioner giving notice of obtaining a pharmaceutical benefit when making a claim using the manual system, as mentioned in subregulation 18A(3) of the Regulations; or
(c) a form for the purpose of an approved medical practitioner creating a written record of obtaining a pharmaceutical benefit if he or she makes a CTS claim in relation to obtaining the benefit, as mentioned in subregulation 18A(5A) of the Regulations.
16 Rule 4 (definition of prescription)
Repeal the definition, substitute:
prescription includes the following:
(a) the Medicare Australia/DVA copy of a paper‑based prescription;
(b) a copy of a medication chart prescription that is not an electronic prescription;
(c) an electronic prescription in printed form;
(d) a repeat authorisation, a deferred supply authorisation, or a prescriber bag supply form, including such an authorisation or form in printed form if it was written or prepared by means of an electronic form.
17 Rule 4 (definition of print‑outs)
Repeal the definition.
18 Rule 4 (paragraph (a) of the definition of S section)
Omit “an prescriber”, substitute “a prescriber”.
19 Rule 4 (definition of supply certification form)
Repeal the definition.
20 Rule 4 (second note at the end of the definition of under co‑payment data)
Repeal the note.
21 At the end of rule 4
Add:
(2) A reference in these Rules to the supply of a pharmaceutical benefit includes a reference to the obtaining of a pharmaceutical benefit by an approved medical practitioner for the purpose of the supply of the benefit under section 93 of the Act.
22 After subrule 5(1)
Insert:
Certification
(1A) The approved supplier must certify:
(a) that each pharmaceutical benefit to which the information relates was supplied by, or on behalf of, the approved supplier in accordance with the National Health Act 1953 and the instruments made under it, or the RPBS; and
(b) that the information is correct.
Note: Paragraph 6(3)(d) sets out requirements for the Claims Transmission System about warnings and notifications that apply if the certification is not included in a form mentioned in paragraph (1)(a).
(1B) The approved supplier may make the certification in a form mentioned in paragraph (1)(a) or in another manner.
(1C) In certifying for the purposes of paragraph (1A)(a), the approved supplier must:
(a) identify the range of the serial numbers for each payment category referred to in Schedule 1 allotted in respect of the pharmaceutical benefits; and
(b) specify the total number of pharmaceutical benefits for each of those payment categories; and
(c) identify the claim period number, and the claim reference, referred to in Schedule 1 in relation to which the information is given.
Additional procedure if claim made using the manual system
23 Subrule 5(2)
Omit “Except when providing under co‑payment data, or making a claim for payment to which subrule 5(3) applies, the information shall be given accompanied by the original prescriptions”, substitute “If the approved supplier is making a claim using the manual system, the information must be accompanied by the prescriptions”.
24 Paragraph 5(2)(b)
Omit “an prescriber”, substitute “a prescriber”.
25 Paragraph 5(2)(c) (note)
Repeal the note, substitute:
Note: The expressions prescription and repeat authorisation have extended meanings under subrule 4(1).
26 Paragraph 5(2)(f)
Omit “control; and”, substitute “control.”.
27 Paragraph 5(2)(g)
Repeal the paragraph.
28 Subrule 5(2) (first note at the end of the subrule)
Omit “RPBS prescriptions are also given”, insert “If an RPBS claim is made using the manual system, RPBS prescriptions relating to the claim are given”.
29 Subrule 5(2) (second note at the end of the subrule)
Repeal the note.
30 Subrule 5(3)
Repeal the subrule, substitute:
(3) The prescriptions mentioned in subrule (2) must be grouped according to whether they are covered by subparagraph (2)(c)(i), (ii), (iii) or (iv), with the prescriptions in each group sorted in accordance with the serial numbers allotted under that subparagraph, starting with the first number allotted.
Note: The RPBS also requires an approved supplier to create a group of RPBS prescriptions sorted in accordance with the “R” serial numbers allotted to the prescriptions, starting with the first number allotted.
Additional procedure if claim made using the Claims Transmission System
(4) If the approved supplier is making a claim using the Claims Transmission System, the approved supplier must comply with the requirements of subrules (2) and (3) in relation to the prescriptions upon the presentation of which the pharmaceutical benefits that are the subject of the claim were supplied, except that those prescriptions need not accompany the information given in accordance with subrule (1).
Exception for medication chart prescriptions
(5) For subrules (2) to (4), a reference to a prescription does not include a reference to a medication chart prescription.
Note: If the information is given using the Claims Transmission System, Schedule 1 has the effect that a serial number is still allotted in relation to the supply of each pharmaceutical benefit on the basis of a medication chart prescription.
31 Rules 6 and 7
Repeal the rules, substitute:
6 Claims Transmission System—procedures
(1) For paragraphs 98AC(4)(b) (under co‑payment data) and 99AAA(8)(c) (claims for payment) of the Act, this rule defines the procedures to be followed by an approved supplier in giving information to the Secretary by electronic means.
Note 1: The procedures defined in this rule constitute the Claims Transmission System.
Note 2: The Claims Transmission System may contain modifications due to the effect of special arrangements under section 100 of the Act, or to facilitate the payment of additional fees to approved suppliers that are not paid as a claim under section 99AAA of the Act.
(2) The approved supplier must give the information to the Chief Executive Medicare, on behalf of the Secretary:
(a) in writing; and
(b) by means of an electronic communication; and
(c) in accordance with any other requirements that would need to be met in order for the requirement to give the information in writing to be taken to have been met under the Electronic Transactions Act 1999.
Note: Under that Act, the Chief Executive Medicare may require the information to be given in accordance with particular information technology requirements or by means of a particular kind of electronic communication (or both).
(3) The information must be generated using one or more computer programs that ensure the following:
(a) that the approved supplier is prevented from altering the description in the computer program of the pharmaceutical benefit or its PBS item code under Schedule 1;
(b) that the information in the computer program for each pharmaceutical benefit is:
(i) in accordance with the Act, and instruments made under the Act, as in force at the time the pharmaceutical benefit was supplied; and
(ii) encrypted when it is given to the Chief Executive Medicare;
(c) that the approved supplier is able to take all reasonable precautions to ensure that information relating to the supply of a substance that was not, in the circumstances, a pharmaceutical benefit, or that was a pharmaceutical benefit but was supplied contrary to section 89 of the Act, is not included;
(d) that, if the approved supplier makes the certification required by subrule 5(1A) otherwise than in a form mentioned in paragraph 5(1)(a):
(i) the Chief Executive Medicare is notified of the certification; and
(ii) the approved supplier is warned, before the certification is made, that giving false or misleading information is a serious offence under section 137.1 of the Criminal Code.
7 Information about supplies
For paragraphs 98AC(4)(a) (under co‑payment data) and 99AAA(8)(b) (claims for payment) of the Act, the information that is to be given to the Secretary by an approved supplier in relation to the supply of a pharmaceutical benefit by the approved supplier is as follows:
(a) the approved supplier’s approval number allotted under regulation 8A of the Regulations;
(b) if the approval number is to be given using the manual system and the approved supplier is an approved pharmacist:
(i) the pharmacist’s name; and
(ii) the address of the premises to which the approval number relates;
(c) if the approval number is to be given using the manual system and the approved supplier is an approved medical practitioner:
(i) the medical practitioner’s name; and
(ii) the address to which the medical practitioner wishes correspondence to be directed;
(d) if the approval number is to be given using the manual system and the approved supplier is an approved hospital authority:
(i) the approved hospital authority’s name; and
(ii) the address of the hospital to which the approval number relates;
(e) if the approval number is to be given using the Claims Transmission System—the information required under Schedule 1 to be given in relation to the supply of the pharmaceutical benefit.
Note: Under rule 6, the information is to be given to the Chief Executive Medicare on behalf of the Secretary.
32 Rule 8 (note)
Omit “7(1)(a), (b) and (c)” substitute “7(a), (b), (c) and (d)”.
33 Paragraph 10(a)
After “a claim”, insert “made using the manual system”.
34 Rule 10 (note)
Omit “online claims”, substitute “claims made using the Claims Transmission System”.
35 Rule 12
Repeal the rule, substitute:
12 Application and transitional provisions for the National Health (Claims and under co‑payment data) Amendment (Medication Chart Prescriptions) Rule 2015
Removal of requirement to send prescriptions and introduction of electronic certification
(1) If:
(a) an approved supplier gives information for the purposes of subsection 98AC(1) or section 99AAA of the Act on or after 1 April 2015 in relation to the supply of a pharmaceutical benefit; and
(b) at least one of the supplies to which the information relates was made before that date;
the approved supplier must give the information in accordance with the old Claims Rules (subject to subrule (4)), except to the extent to which the information relates to a medication chart prescription of a kind mentioned in subrule (5).
(2) 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) none of the supplies to which the information relates was made before 1 April 2015; and
(c) at least one of the supplies to which the information relates was made before 1 July 2015 or a later date determined for the approved supplier under subrule (3);
then, except to the extent to which the information relates to a medication chart prescription of a kind mentioned in subrule (5), the approved supplier may give the information:
(d) in accordance with the old Claims Rules (subject to subrule (4)); or
(e) in accordance with the new Claims Rules.
(3) For paragraph (2)(c), 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 April 2017.
Removal of CTS non‑online claiming
(4) The old Claims Rules continue to apply for the purposes of subrule (1) and paragraph (2)(d) in relation to information given in relation to a pharmaceutical benefit that is supplied on or after 1 April 2015 as if paragraphs 6(3)(b) and (4)(b), subparagraph 7(1)(d)(ii), and paragraph 7(2)(b), were omitted.
Note: This means that information relating to a pharmaceutical benefit supplied on or after 1 April 2015 that is given to the Chief Executive Medicare using the Claims Transmission System must be given using a computer system and cannot be given by forwarding a diskette.
Medication chart prescriptions—approved hospitals
(5) Information that relates to a medication chart prescription written for a person who is receiving treatment in or at an approved hospital must be given in accordance with the new Claims Rules.
Definitions
(6) In this rule:
new Claims Rules means these Rules as in force on 1 April 2015.
old Claims Rules means these Rules as in force immediately before 1 April 2015.
36 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
Authority Prescription Number
Only required if the approved form for the prescription requires an authority prescription number to be entered.
2
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.
3
Claim Period Number
Indicates the sequential order and calendar year of the claim submitted by the approved supplier during that calendar year.
4
Claim Reference
Sequential number generated for each claim submitted within a claim period.
5
Date of Dispensing
Date the prescription was dispensed.
6
Date of Prescribing
Date the PBS prescriber signed the prescription.
Not required for continued dispensing.
7
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.
8
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.
9
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.
10
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
11
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.
12
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.
13
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.
14
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.
15
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 falls under the Safety Net 20 day rule.
16
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.
17
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
18
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.
19
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.
20
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.
21
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
22
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
23
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 if RPBS, there is no RPBS item code, and the Veterans’ Affairs Department has given prior approval.
24
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.
25
Pharmacy Processing Code
Only required if the approved supplier’s dispensing software has no real time response from Chief Executive Medicare.
26
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.
27
Previous Supplies
Number of times (including the original supply) the pharmaceutical benefit has previously been supplied under the prescription.
28
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 when giving under co‑payment data.
29
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.
30
Regulation 24
Only required if first supply and all repeats were supplied all on the one occasion under regulation 24.
31
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.
32
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.
33
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).
34
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.
35
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.
