National Health (Claims and under co-payment data) Rules 2012 (No. PB 19 of 2012)

Link to law: https://www.comlaw.gov.au/Details/F2012L00726

PB 19 of 2012
National Health (Claims and under           co-payment data) Rules 20121
National Health Act 1953
I, TRACEY DUFFY, Acting Assistant Secretary, Pharmaceutical Policy Branch, Pharmaceutical Benefits Division, Department of Health and Ageing, delegate of the Minister for Health, make these Rules under subsections 98AC(4) and 99AAA(8) of the National Health Act 1953.
Dated   27.03.12
 
TRACEY DUFFY
Acting Assistant Secretary
Pharmaceutical Policy Branch
Pharmaceutical Benefits Division
Department of Health and Ageing
 
 
 
 
 
 
 
 
1.         Name of Instrument
 
(1)   These Rules are the National Health (Claims and under co-payment data) Rules 2012.
 
(2)   These Rules may also be cited as PB 19 of 2012.
 
 
2.         Commencement
 
            These Rules commence on 1 April 2012.
 
 
3.         Revocation
 
The Rules under subsection 99AAA(8) (PB 49 of 2008) are revoked.
 
 
4.         Definitions
 
            In these Rules:
 
           Act means the National Health Act 1953.
 
           A section means:
      
              (a)   in respect of an authority prescription, a repeat authorisation, a deferred supply authorisation, or an emergency drug supply form – the section of the form upon which the prescription is written that is provided for the purpose of recording the information required in the provision in these Rules in which the expression occurs; and
 
(b)   in respect of a prescription other than a prescription specified in paragraph (a) - the section of the stamp format marked “A” appearing on the prescription.
 
authority prescription means a prescription that prescribes a pharmaceutical benefit and that has been authorised:
 
              (a)   in accordance with subregulation 13(5) of the Regulations; or
 
(b)   under authority required procedures that are part of the circumstances determined by the Minister for paragraph 85(7)(b) of the Act for the pharmaceutical benefit.
 
Note: A determination under subsection 85(7) of the Act contains procedures that are called ‘authority required procedures’ that are part of the circumstances determined by the Minister for paragraph 85(7)(b) of the Act and that only apply to certain pharmaceutical benefits specified in the determination. A PBS prescription is also taken to be authorised under authority required procedures if a prescription contains the Streamlined Authority Code required by a paragraph 85(7)(b) circumstance for a pharmaceutical benefit.
 
claim means information given, and procedures followed by, an approved supplier to make a claim for payment under section 99AAA of the Act for the supply of a pharmaceutical benefit.
 
Claims Transmission System has the same meaning as in subsection 99AAA(1) of the Act. It means the procedures defined in rule 6 of these Rules, to be followed by approved suppliers in providing information by electronic means to the Secretary in relation to the supply by them of pharmaceutical benefits.
 
CTS claim has the same meaning as in section 84 of the Act. It means a claim made to the Chief Executive Medicare using the procedures of the Claims Transmission System provided for in section 99AAA of the Act.
 
CTS non-online claim means a CTS claim that is not an online claim which is made by diskette forwarded to the Chief Executive Medicare.
 
deferred supply authorisation means a deferred supply authorisation prepared under regulation 26A of the Regulations upon which a pharmaceutical benefit has been supplied.
 
diskette means a data storage medium for use with a computer system where the medium is compatible with the MS-DOS operating system and, unless otherwise agreed with the Chief Executive Medicare, the format is a 3.5 inch, 1.44 megabyte floppy diskette.
 
electronic communication has the meaning given by subsection 5(1) of the Electronic Transactions Act 1999.
 
emergency drug supply form means an order form for the purpose of regulation 16 of the Regulations or a notification form for the purpose of regulation 18A of the Regulations.
 
ePrescription means an electronic prescription as defined under the Regulations, and for the purposes of the Rules, includes an electronic authority prescription.
 
exceptional prescription means a prescription for an extemporaneously-prepared pharmaceutical benefit that is not a standard formula preparation and for which the price of the ingredients calculated in accordance with sections 19 to 21 of the determination made under paragraph 98B(1)(a) of the Act is not less than twice the amount calculated in accordance with section 30 of that determination, excluding the container price and dispensing fee.
 
extemporaneously-prepared pharmaceutical benefit means a pharmaceutical benefit in respect of which there is not in force a determination under subsection 85(6) of the Act.
 
information technology requirements has the meaning given by subsection 5(1) of the Electronic Transactions Act 1999.
 
manual system has the same meaning as in subsection 99AAA(1) of the Act. It means the procedures defined in rule 8 of these Rules, to be followed by approved suppliers in providing information otherwise than by electronic means to the Secretary in relation to the supply by them of pharmaceutical benefits.
 
Medicare Australia/DVA copy, for a paper-based prescription, means the duplicate of the prescription on which appear the words ‘Medicare Australia/DVA copy’.
 
online claim means a CTS claim by means of a method of transmitting encrypted data to the Chief Executive Medicare by a kind of electronic communication using a computer system.  
 
original authority prescription and original prescription includes the Medicare Australia/DVA copy of a paper-based prescription, and print-outs of the ePrescription.
 
paper-based prescription has the same meaning as it does in the Regulations.
 
PBS prescriber means the PBS prescriber who wrote or prepared the prescription.
 
prescription includes a paper-based prescription, an ePrescription, a repeat authorisation, a deferred supply authorisation and an emergency drug supply form.
 
print-outs for the purposes of the Rules, refer to the printed form of an ePrescription.
 
Regulations means the National Health (Pharmaceutical Benefits) Regulations 1960 made under the Act.
 
RPBS means the Repatriation Pharmaceutical Benefit Scheme, being a legislative instrument made under section 91 of the Veterans’ Entitlements Act 1986.
 
repeat authorisation means a repeat authorisation prepared under regulation 26 of the Regulations upon which a pharmaceutical benefit has been supplied.
 
S section means:
 
(a)   in respect of an authority prescription, a repeat authorisation, a deferred supply authorisation or an emergency drug supply form, the section of the form upon which the prescription is written that is provided for the purpose of recording the information required in the provision in these Rules in which the expression occurs; and
 
(b)   in respect of a prescription other than a prescription specified in paragraph (a), the section of the stamp format marked “S” appearing on the prescription.
 
stamp format means the following format, whether made by stamp or otherwise and whether or not the lines are omitted:
 
S

A

 
standard formula preparation means an extemporaneously-prepared pharmaceutical benefit that is listed in Schedule 5 to the determination in force under paragraph 98C(1)(b) of the Act.
 
under co-payment data means information relating to a supply of a pharmaceutical benefit by:
(a)      an approved supplier where subsection 99(2A), 99(2AB) or 99(2B) applies; and
(b)     an approved hospital authority where the amount payable by the Commonwealth in accordance with a subsection 99(4) determination is nil due to the dispensed price not exceeding the applicable patient co-payment, as defined in the subsection 99(4) determination.  
 
Note: When subsection 99(2A), 99(2AB) or 99(2B) of the Act applies, no claim is payable under section 99AAA of the Act.
 
Note: Terms used in these Rules have the same meaning as in the Act – see section 13 of the Legislative Instruments Act 2003. These terms include:
·         Chief Executive Medicare
·         Health Department
·         Human Services Department
·         PBS prescriber
·         pharmaceutical benefit
·         Veterans’ Affairs Department
 
 
5.         Procedures
 
(1)   For the purposes of paragraphs 99AAA(8)(a) and 98AC(4)(b) of the Act, an approved supplier, when providing information to the Chief Executive Medicare on behalf of the Secretary, whether making a claim under section 99AAA, or, providing under co-payment data in accordance with subsection 98AC(1), is to follow these procedures: 
 
       (a)   the information shall be given in accordance with the relevant form approved by the Chief Executive Medicare (if any); and
 
       (b)   except as provided in subparagraph (d), the information shall be given in respect of pharmaceutical benefits supplied during a period not exceeding 35 days; and
 
       (c)   except as provided in subparagraph (d), the information shall be furnished to the Chief Executive Medicare not more than 30 days after the last day of the period in respect of which previous information was supplied; and
 
       (d)   where the Chief Executive Medicare is satisfied that an approved supplier was unable, through circumstances outside the approved supplier’s control, to comply with paragraphs (b) or (c), the information may be given outside the requirements of those paragraphs; and
 
       (e)   except as provided in paragraph (f), the information shall not be furnished to the Chief Executive Medicare during the same calendar month as any previous information relating to supplies of pharmaceutical benefits; and
 
(f)    notwithstanding paragraph (e), the information may be given to the Chief Executive Medicare  in the same calendar month as the previous information in accordance with an arrangement between the approved supplier and the Chief Executive Medicare in which the approved supplier has proposed that additional information be accepted in a calendar month and which the Chief Executive Medicare, provided that he or she is satisfied that the arrangement will not impose additional administrative expenses on the  Chief Executive Medicare, has accepted.
 
(2)   Except when providing under co-payment data, the information shall be given accompanied by the original prescriptions:
 
(a)    upon the presentation of which the pharmaceutical benefits that are the subject of the claim were supplied; and
 
(b)    on each of which that is not an authority prescription, a repeat authorisation, a deferred supply authorisation or an emergency drug supply form, shall be marked a stamp format in the area on the extreme left of the prescription, horizontally aligned with the pharmaceutical benefit to which it relates in such a way as to avoid obliterating any other information on the prescription; and
 
(c)    on each of which shall be marked in the S section or S sections one or more serial numbers by the approved supplier, allotted in respect of each pharmaceutical benefit as follows:
 
(i)    in respect of general benefit prescriptions — commencing at “1” in each claim and continuing consecutively in respect of that claim; and
 
(ii)   in respect of concessional benefit prescriptions and concession card prescriptions — commencing at “C1” in each claim and continuing consecutively in respect of that claim; and
 
(iii)  in respect of entitlement card prescriptions — commencing at “E1” in each claim and continuing consecutively in respect of that claim; and
 
(iv)  in respect of emergency drug supply forms – commencing at “1” in each claim and continuing consecutively in respect of that claim; and
 
 
(d)   on each of which that is an authority prescription or a repeat authorisation relating to an authority prescription shall be marked as a prefix to the serial number allocated under paragraph (2)(c) the letter “A”; and
 
(e)    on each of which that is a deferred supply authorisation shall be marked as a prefix to the serial number allocated under paragraph (2)(c) the letter “D”; and
 
(f)    on each of which shall be marked in the A section or A sections:
 
(i)    where the approved supplier has made an election pursuant to subsection 31(1) of the determination made under paragraph 98B(1)(a) of the Act and the prescription is in respect of an extemporaneously-prepared pharmaceutical benefit that is not a standard formula preparation, the price calculated by the approved supplier in accordance with section 18 of that Determination; or
 
(ii)   where the approved supplier has not made an election pursuant to subsection 31(1) of the determination made under paragraph 98B(1)(a) of the Act and the prescription is an exceptional prescription, the price calculated by the approved supplier in accordance with section 18 of that Determination; or 
 
(iii)        where the prescription is in respect of extemporaneously-prepared ear drops, eye drops or nasal instillations and the supply of the benefit in a glass bottle container is specified by the PBS prescriber or considered necessary by the approved supplier, the words ‘glass bottle’;
 
except for those prescriptions that were not in the possession of the approved supplier for reasons which are, in the opinion of the Chief Executive Medicare, outside the supplier’s reasonable control; and
 
(g)   the information shall be divided into four bundles in accordance with the categories set out in paragraph (2)(c), with the prescriptions in each bundle sorted into the order of the serial numbers allocated under that paragraph with the least serial number at the top of each bundle.
 
Note: The RPBS provides that a RPBS claim is to be made in accordance with section 99AAA of the Act and these Rules (except where the RPBS otherwise provides). RPBS prescriptions are also given to the Chief Executive Medicare on behalf of the Secretary. The RPBS requires the provision of a serial number that uniquely identifies the RPBS benefit within the category ‘R’, being a serial number marked on the ‘S’ section of the prescription by the approved supplier, commencing at ‘R1’ in each claim and continuing consecutively in respect of that claim made in accordance with rule 5 of these Rules.
 
Note: The RPBS also requires an approved supplier to create a bundle of RPBS prescriptions sorted into the order of the ‘R’ serial numbers, with the least serial number at the top of the bundle.
 
 
6.         Claims Transmission System – procedures
 
  (1) For the purposes of paragraphs 99AAA(8)(c) and 98AC(4)(b) of the Act, an approved supplier, when providing information by electronic means to the Chief Executive Medicare on behalf of the Secretary, whether making a claim under section 99AAA, or, providing under co-payment data in accordance with subsection 98AC(1), is to follow these procedures: 
 
(a)  provide information to the Chief Executive Medicare in accordance with the Electronic Transactions Act 1999, including information technology requirements and the kind of electronic communication used; and
 
(b) in accordance with the procedures defined in subrules 6(2) and (3).
 
Note: Rule 4 provides that ‘information technology requirements’ and ‘electronic communication’ have the meaning given by the Electronic Transactions Act 1999.
 
Note: The Claims Transmission System may contain modifications due to the effect of s.100 special arrangements under the Act, or to facilitate the payment of additional fees to approved suppliers which are not paid as a claim under section 99AAA of the Act.
 
Note: Subrule 6(1) applies in addition to the procedures in Rule 5.
 
(2) The information must be produced by a computer program that:
 
(a)    does not allow the approved provider to alter the description of the pharmaceutical benefit or its PBS item code (within the meaning of the Schedule to these Rules) in the program; and
 
(b)   ensures that the information in the computer program in respect of each pharmaceutical benefit is in accordance with the Act and instruments made under the Act as they applied at the time the pharmaceutical benefit was supplied; and
 
(c)    takes 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.
 
(3)  A procedure is defined in the Schedule to these Rules in the column headed ‘Element’, as described in the column headed ‘Description of Element’, if activated opposite the Element for (as applicable) the column headed:
 
(a) ‘Online claim’; or
(b) ‘CTS non-online claim’.
 
       (4)   Under co-payment data is not required for a procedure defined in the Schedule to these Rules in the column headed ‘Element’, as described in the column headed ‘Description of Element’, unless activated opposite the Element for (as applicable) the column headed:
 
(a) ‘Under Co-payment data provided with online claims’; or
 
(b) ‘Under Co-payment data provided with CTS non-online claims.’
 
7.         Information
 
  (1) For the purposes of paragraphs 99AAA(8)(b) and 98AC(4)(a) of the Act, an approved supplier, when providing information, is required to give the following information to the Chief Executive Medicare on behalf of the Secretary in relation to the supply by the approved supplier of a pharmaceutical benefit, whether making a claim under section 99AAA, or providing under co-payment data in accordance with subsection 98AC(1):
 
       (a)   the name of the approved supplier;
 
       (b)   the approval number of the approved supplier allotted under regulation 8A of the Regulations;
 
       (c)   the address:
 
(i)                 where the approved supplier is an approved pharmacist — of the premises in respect of which the pharmacist is approved under section 90 of the Act; or
 
(ii)               where the approved supplier is an approved medical practitioner – to which the medical practitioner would seek correspondence to be directed; or
 
(iii)             where the approved supplier is an approved hospital authority – of the hospital; and
      
       Note: Paragraphs 7(1)(a) and (b) are not limited to the manual system.
 
       (d)   when providing information by electronic means, the  information specified in the Schedule in the column headed ‘Element’, as described in the column headed ‘Description of Element’, is to be given to the Chief Executive Medicare on behalf of the Secretary if activated opposite the Element for (as applicable) the column headed:
 
(i)         ‘Online claim’; or
                       
(ii)        ‘CTS non-online claim’.
 
      
       (2)   Under co-payment data is not required for information specified in the Schedule in the column headed ‘Element’, as described in the column headed ‘Description of Element’ unless activated opposite the Element for (as applicable), the column headed:
 
(a)  ‘Under Co-payment data provided with online claims’; or
                       
(b) ‘Under Co-payment data provided with CTS non-online claims’.
 
 
 
8.         Manual System - procedures
 
For the purpose of paragraph 99AAA(8)(d) of the Act, the procedures to be followed by an approved supplier in providing information otherwise than by electronic means in relation to the supply by the approved supplier of pharmaceutical benefits are to forward a claim to the Chief Executive Medicare on behalf of the Secretary in accordance with rule 5.
 
Note: Paragraphs 7(1)(a), (b) and (c) of these Rules also apply.
 
9.         Manual System – under co-payment data
 
For the purpose of paragraph 98AC(4)(b) of the Act, an approved supplier who is permitted to claim by the manual system in accordance with section 99AAB of the Act is not required to provide under co-payment data when claiming by the manual system.
 
Note: Subsections 99AAA(4) and (5) and section 99AAB of the Act provide that an approved supplier must use the Claims Transmission System, unless permitted to use the manual system under section 99AAB of the Act.
 
 
10.       Claim processing procedures
 
       For the purpose of subparagraph 99AAA(8)(e)(i) of the Act, the procedures to be followed by the Chief Executive Medicare, on behalf of the Secretary, in processing and determining claims by an approved supplier for payment relating to the supply of pharmaceutical benefits, are to institute reasonable checks to satisfy him or herself that:
 
 
              (a)      the information provided by the approved supplier in respect of a claim accurately reflects the information recorded on the prescriptions submitted in support of the claim; and
 
              (b)     the approved supplier is entitled to be paid in accordance with the Act and instruments under the Act an amount in respect of the claim.
 
            Note:    Advance payments are permitted in accordance with subsection 99AB(1) of the Act. Advance payments are associated with online claims.
 
 
 
11.       Claim payment procedures
 
       For the purpose of subparagraph 99AAA(8)(e)(ii) of the Act, the procedures to be followed by the Chief Executive Medicare, on behalf of the Secretary, in making payments in respect of claims by an approved supplier in relation to the supply of pharmaceutical benefits, are that:
 
              (a)      payment shall be made by an electronic funds transfer from the Commonwealth to the account at a financial institution nominated in writing by the approved supplier; and
 
              (b)     a statement of account shall be forwarded to the approved supplier in respect of each claim for payment.
 
 
12.       Transitional
 
(1)     If a matter specified in this subrule was in effect under a specified rule of the former claims rules immediately prior to the commencement of these Rules, it is taken to have effect under a specified provision of these Rules:
 
matter
provision of former claims rules
provision of these Rules

approved diskette format
definition of ‘diskette’ rule 2
definition of ‘diskette’ rule 4

approved form for claim
paragraph 3(a)
paragraph 5(a)

approval about claim period and time period for submission of claim
paragraph 3(d)
paragraph 5(1)(d)

approval about re-submission within same calendar month
paragraph 3(f)
paragraph 5(1)(f)

nominated financial institution
paragraph 10(a)
paragraph 11(a)

 
 
(2)     In subrule 12(1) the former claims rules means the Rules under subsection 99AAA(8) (PB 49 of 2008).
Schedule        Information and Procedures – Claims Transmission System
(rules 6 and 7)  
 
Element  
Online claim
Under co-payment data provided with online claims
CTS non-online claim
Under co-payment data
provided with CTS non-online claims
Description of Element

PRESCRIPTION
RECORD
 
 
 
 
 

Authority Prescription Number
yes
yes
yes
yes
Required for original authority prescription and authority repeat authorisation relating to an authority prescription. It is the number that appears at the top right of the original authority prescription and is transferred to the authority repeat authorisation.

Brand
yes
yes
yes
yes
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.

Date of Dispensing
yes
yes
yes
yes
The date the prescription was dispensed.

Date of Prescribing
yes
yes
yes
yes
Date the PBS prescriber signed the prescription, or date of regulation 22(1)(a) authorisation (if applicable).

Date of Previous Supply
yes
yes
yes
yes
The 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’)

Date of Supply
yes
yes
yes
yes
Date the pharmaceutical benefit was supplied.

 
 
 
 
 
 

Element 
Online claim
Under co-payment data provided with online claims
CTS non-online claim
Under co-payment data
provided with CTS non-online claims
Description of Element

Entitlement ID
yes
yes
yes
yes
The 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 emergency drug supply form.

Family Name
yes
yes
yes
yes
The surname of the person for whom the prescription was written sourced from the Medicare or equivalent DVA card.
Not for emergency drug supply form.

Form Category
yes
yes
yes
yes
Identifies:
original prescription = 1
repeat authorisation = 2
original authority prescription = 3
repeat authorisation relating to authority prescription = 4
deferred supply authorisation = 5
prescription written by a participating dental practitioner = 6
emergency drug supply form = 7
DVA authority original form = 8
DVA authority repeat form = 9

Given Name
yes
yes
yes
yes
The given name of the person for whom the prescription was written sourced from the Medicare or equivalent DVA card.
Not for emergency drug supply form.

 
 
 
 
 
 

 
 
 
 
 
 

 
 
 
 
 
 

Element 
Online claim
Under co-payment data provided with online claims
CTS non-online claim
Under co-payment data
provided with CTS non-online claims
Description of Element

Glass Bottle
yes
yes
yes
yes
Indicates 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.

Hospital Provider Number
yes
yes
yes
yes
Provider number of the public hospital where the prescription originated.

Immediate Supply Necessary
yes
yes
yes
yes
Indicates if prescription supplied within the 4 or 20 day period in accordance with regulation 25 as ‘immediate supply necessary’.
Online claiming only must also indicate if prescription falls under the Safety Net 20 day rule.

Medicare Number
yes
yes
yes
yes
The 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 for emergency drug supply form or RPBS prescriptions where entitlement number supplied.

Number of Repeats
yes
yes
yes
yes
The number of repeats prescribed, including number of repeats prescribed if Regulation 24 supply all on one occasion.

Original PBS Approval Number
yes
yes
yes
yes
Approval number allocated to approved supplier who supplied the original prescription, being approval number allocated under regulation 8A. Appears on repeat authorisation.

Original Unique Pharmacy Prescription Number
yes
yes
yes
yes
Prescription number allocated to prescription by approved supplier who supplied on original prescription. Appears on original prescription and repeat authorisation.

 
 
 
 
 
 

Element 
Online claim
Under co-payment data provided with online claims
CTS non-online claim
Under co-payment data
provided with CTS non-online claims
Description of Element

Patient Category
yes
yes
yes
yes
For all prescriptions identifies the patient category type:
paperless private hospital patient = H
public hospital patient = B
nursing home patient = N
paperless public hospital patient = C
community patient = 0 (zero)
hospital patient (not identified by any of the above) = 1* (CTS non-online claim only)

Payment Category
yes
yes
yes
yes
For all prescriptions identifies:
general  benefit = 1
entitlement card/PBS Safety Net (free) = 2
concessional benefit and concession card = 3
repatriation = 4 (RPBS)
emergency drug supply form = 5

PBS item code
yes
yes
yes
yes
Code for the pharmaceutical benefit that appears in the Schedule of Pharmaceutical Benefits published by the Health Department. RPBS item codes also appear in this Schedule.
Not required if RPBS and no RPBS item code but prior approval from the Veterans’ Affairs Department.

PBS Reference Number
yes
yes
yes
yes
A number created by Chief Executive Medicare when a pre-assessment was requested by approved supplier.

Pharmacy Processing Code
yes
yes
yes
yes
Indicates the approved supplier’s dispensing software has no real time response from Chief Executive Medicare.  

Prescriber ID
yes
yes
yes
yes
The prescriber number of the PBS prescriber issued by the Chief Executive Medicare, except where prescription written by medical practitioner and the prescriber number was not available to the approved supplier at the time of supply.

 
 
 
 
 
 

Element 
Online claim
Under co-payment data provided with online claims
CTS non-online claim
Under co-payment data
provided with CTS non-online claims
Description of Element

Previous Supplies
yes
yes
yes
yes
Number of times (including the original supply) the pharmaceutical benefit has previously been supplied under the prescription.

Price
yes
no
yes
no
For prescriptions priced by the approved supplier in accordance with an election pursuant to subsection 31(1) of the determination under paragraph 98B(1)(a) of the Act or priced by an approved supplier as an exceptional prescription.
If RPBS, no RPBS item code, and prior approved by Veterans’ Affairs Department must be priced.

Quantity
yes
yes
yes
yes
The quantity of the pharmaceutical benefit supplied. Must be total quantity supplied (original and all repeats) if Regulation 24 supply all on one occasion.

Record Type
no
no
yes
yes
For all prescriptions indicates that “P” is a claiming record, or “U” to identify the prescription data relates to an under co-payment data record.

Regulation 24
yes
yes
yes
yes
Indicates whether supply of the original and all repeats made on the one occasion under Regulation 24.

Resubmission Flag
yes
yes
yes
yes
Indicates information relating to the prescription was previously submitted (whether by way of claim or under co-payment data) and rejected.

Serial Number
yes
yes
yes
yes
Number that uniquely identifies the pharmaceutical benefit within the payment category, marked on the prescription by the approved supplier. The number must run sequentially within that claim period for each payment category.

Element  
Online claim
Under co-payment data provided with online claims
CTS non-online claim
Under co-payment data
provided with CTS non-online claims
Description of Element

Streamlined Authority Code
yes
yes
yes
yes
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. If the element is not provided, claim not rejected on that basis.

Unique Pharmacy Prescription Number
yes
yes
yes
yes
Unique number allocated by the approved supplier’s pharmacy dispensing software which stays with prescription throughout its lifecycle. An individual prescription will only ever have one number allocated to it and that number will not be re-allocated to other prescriptions.

 
 
 
 
 
 

HEADER – ONLINE CLAIM ONLY
 
 
 
 
 

 
 
 
 
 
 

Approval Number
yes
yes
 
 
The approved supplier’s approval number.

Claim period number
yes
yes
 
 
Indicates the sequential order and calendar year of the claim submitted by the approved supplier during that calendar year.

Claim reference
yes
yes
 
 
A sequential number generated for each claim submitted within a claim period.

 
 
 
 
 
 

CLAIM HEADER RECORD
CTS non-online claim only
 
 
 
 
 

Record Type
 
 
yes
yes
‘H’ to identify record as a claim header record.

Element 
Online claim
Under co-payment data provided with online claims
CTS non-online claim
Under co-payment data
provided with CTS non-online claims
Description of Element

Human Services Department File Format Specification Version Number
 
 
yes
yes
Identification of Human Services Department File Format Specifications version number.

Approval Number
 
 
yes
yes
The approved supplier’s approval number.

Claim Period Number
 
 
yes
yes
The last 2 digits of the year followed by the sequential number of the claim submitted by the approved supplier during that calendar year.

Claim Reference
 
 
yes
yes
The number of claims within the claim period.

Pharmacy Software Name
 
 
yes
yes
Identifies the pharmacy software system used by the approved supplier. This allows for more efficient help desk support.

Pharmacy Software Version Number
 
 
yes
yes
Identifies the pharmacy software system version. This allows for more efficient help desk support.

 
 
 
 
 
 

CLAIM TRAILER RECORD
CTS non-online claim only
 
 
 
 
 

 
 
 
 
 
 

Record Type
 
 
yes
yes
‘Z’ to identify this record as a claim trailer record.

The total number of record types marked “P”
 
 
yes
yes
The total number of record types marked “P” in the claim period.

The total number of record types marked “U”
 
 
yes
yes
The total number of record types marked “U” in the claim period.

Note
1.       All legislative instruments and compilations are registered on the Federal Register of Legislative Instruments kept under the Legislative Instruments Act 2003. See http://www.frli.gov.au.
 
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