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PB 19 of 2012 Rules/Other as amended, taking into account amendments up to National Health (Claims and under co-payment data) Amendment (Electronic Prescriptions) Rules 2019
Administered by: Health
Registered 14 Jan 2020
Start Date 31 Oct 2019
Table of contents.

Commonwealth Coat of Arms of Australia

National Health (Claims and under co-payment data) Rules 2012 (PB 19 of 2012)

made under subsections 98AC(4) and 99AAA(8) of the

National Health Act 1953

Compilation No. 7

Compilation date:                              31 October 2019

Includes amendments up to:            F2019L01383

Registered:                                         14 January 2020

 

About this compilation

This compilation

This is a compilation of the National Health (Claims and under co-payment data) Rules 2012 (PB 19 of 2012) that shows the text of the law as amended and in force on 31 October 2019 (the compilation date).

The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.

Uncommenced amendments

The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register (www.legislation.gov.au). The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.

Application, saving and transitional provisions for provisions and amendments

If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.

Editorial changes

For more information about any editorial changes made in this compilation, see the endnotes.

Modifications

If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.

Self-repealing provisions

If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.

  

  

  


Contents

1............ Name of Instrument....................................................................................................... 1

4............ Definitions..................................................................................................................... 1

5............ Procedures..................................................................................................................... 5

6............ Claims Transmission System—procedures................................................................... 7

7............ Information about supplies............................................................................................ 8

8............ Manual System—procedures........................................................................................ 9

9............ Manual System—under co‑payment data...................................................................... 9

10.......... Claim processing procedures......................................................................................... 9

11.......... Claim payment procedures.......................................................................................... 10

12.......... Application and transitional provisions for the National Health (Claims and under co‑payment data) Amendment (Medication Chart Prescriptions) Rule 2015.............................................................. 10

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....................................... 11

Schedule 1—Information required when using Claims Transmission System 13

1............ Information required when using Claims Transmission System................................. 13

2............ Extra information required when using Claims Transmission System in relation to supply of pharmaceutical benefits upon electronic prescriptions....................................................................................... 17

Endnotes                                                                                                                                                               20

Endnote 1—About the endnotes                                                                                                      20

Endnote 2—Abbreviation key                                                                                                          21

Endnote 3—Legislation history                                                                                                       22

Endnote 4—Amendment history                                                                                                     23

 


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.

4  Definitions

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;

(c)    special patient contribution

             (1)  In these Rules:

Act means the National Health Act 1953.

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.

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

A section means:

                     (a)  in respect of an authority prescription, a repeat authorisation, a deferred supply authorisation, or a prescriber bag 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.

approved private hospital means a private hospital that has an approved hospital authority.

approved public hospital means a public hospital that has an approved hospital authority.

approved supplier has the same meaning as in Part VII of the Act.

authority prescription means a prescription that prescribes a pharmaceutical benefit and that has been authorised:

                     (a)  in accordance with subsection 30(4) of the Regulations; or

                     (b)  in accordance with authority required procedures that:

                              (i)  are part of the circumstances determined by the Minister under paragraph 85(7)(b) of the Act for the pharmaceutical benefit; or

                             (ii)  are part of the conditions determined by the Minister under subsection 85A(2A) of the Act for the pharmaceutical benefit; or

                            (iii)  are incorporated by reference into the circumstances determined for the pharmaceutical benefit under subsection 85B(4) of the Act.

Note:          A Streamlined Authority Code appearing in the prescription may satisfy subparagraph (b)(i), (ii) or (iii) of the definition of authority prescription.

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.

continued dispensing means a supply of a pharmaceutical benefit by an approved pharmacist in accordance with subsection 89A(1) of the Act and the Regulations.

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.

deferred supply authorisation means a deferred supply authorisation prepared under section 53 of the Regulations upon which a pharmaceutical benefit has been supplied.

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

electronic communication has the meaning given by subsection 5(1) of the Electronic Transactions Act 1999.

electronic prescription has the same meaning as in the Regulations.

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.

healthcare identifier has the same meaning as in the Healthcare Identifiers Act 2010.

healthcare provider organisation has the same meaning as in the Healthcare Identifiers Act 2010.

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’.

medication chart prescription has the same meaning as in the Regulations.

paper‑based prescription has the same meaning as it does in the Regulations.

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.

pharmaceutical benefit has the same meaning as in Part VII of the Act.

prescriber bag supply form means:

                     (a)  an order form for the purpose of section 33 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 subsection 36(4) 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 subsection 36(7) of the Regulations.

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.

Regulations means the National Health (Pharmaceutical Benefits) Regulations 2017.

RPBS means the:

                     (a)  Repatriation Pharmaceutical Benefits Scheme, a legislative instrument made under section 91 of the Veterans’ Entitlements Act 1986; or

                     (b)  Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006, a legislative instrument made under section 18 of the Australian Participants in British Nuclear Tests (Treatment) Act 2006; or

                     (c)  MRCA Pharmaceutical Benefits Scheme, a legislative instrument made under paragraph 286(1)(c) of the Military Rehabilitation and Compensation Act 2004.

repeat authorisation means:

                     (a)  a repeat authorisation prepared under section 52 of the Regulations using a repeat authorisation form; or

                     (b)  continued dispensing using a repeat authorisation form prepared by an approved pharmacist;

upon which a pharmaceutical benefit has been supplied.

repeat authorisation form has the meaning given in the Regulations.

S section means:

                     (a)  in respect of an authority prescription, a repeat authorisation, a deferred supply authorisation or a prescriber bag 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) of the Act 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.

             (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.

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.

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

             (2)  If the approved supplier is making a claim using the manual system, the information must be accompanied by the 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 a prescriber bag 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 prescriber bag supply forms—commencing at “1” in each claim and continuing consecutively in respect of that claim; and

Note:          The expressions prescription and repeat authorisation have extended meanings under subrule 4(1).

.                    (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.

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). If an RPBS claim is made using the manual system, RPBS prescriptions relating to the claim are 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.

             (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.

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 section 16 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.

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(a), (b), (c) and (d) 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 made using the manual system 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 claims made using the Claims Transmission System.

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  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 February 2018.

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.

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:

                     (c)  in accordance with the old Claims Rules; or

                     (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 February 2018.

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.

 


Schedule 1Information 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.

Note 3:       Clause 2 requires the approved supplier to give extra information in relation to the supply of a pharmaceutical benefit upon an electronic prescription.

 

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.

9A

Drug Item Start Date

The date the PBS prescriber started prescribing the drug.

Only required for a medication chart prescription in or at an approved private hospital or approved public hospital.

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

The hospital’s provider number.

Only required if the prescription originated in or at an approved public hospital or if the patient category is:

Medication chart private hospital patient

Medication chart public hospital patient

Private PBS HMC Inpatient prescription

Private PBS HMC discharge prescription

Private PBS HMC outpatient prescription

Public PBS HMC Inpatient prescription

Public PBS HMC discharge prescription

Public PBS HMC outpatient prescription

17

Immediate Supply Necessary

Required if prescription supplied within the 4 or 20 day period in accordance with section 51 of the Regulations 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

19A

Medication Chart Start Date

The date the medication chart prescription commences.

Only required for a medication chart prescription in or at an approved private hospital or approved public hospital.

20

Number of Repeats

Number of repeats prescribed, including number of repeats prescribed if original and repeats supplied all on the one occasion under section 49 of the Regulations.

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 section 16 of the Regulations.

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

Community patient = 0 (zero)

Medication chart public hospital patient = M

Medication chart private hospital patient = P

Paperless private hospital patient = H

Paperless public hospital patient = C

Private PBS HMC Inpatient prescription = V

Private PBS HMC discharge prescription = W

Private PBS HMC outpatient prescription = X

Public hospital patient = B

Public PBS HMC Inpatient prescription = S

Public PBS HMC discharge prescription = T

Public PBS HMC outpatient prescription = U

Residential aged care facility patient (PBS NRMC prescription) = R

Residential aged care facility patient (prescription that is not a PBS NRMC prescription) = N

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.

25A

PBS Prescriber Number

The number (if any) allotted to the approval of the PBS prescriber under section 16 of the Regulations.

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.

28A

Prescription Format

Claim from a paper‑based prescription, including one that is a medication chart prescription = P

Claim from an electronic prescription, including one that is a medication chart prescription = E

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 section 49 of the Regulations.

32

Regulation 24

Only required if first supply and all repeats were supplied all on the one occasion under section 49 of the Regulations.

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.

2  Extra information required when using Claims Transmission System in relation to supply of pharmaceutical benefits upon electronic prescriptions

             (1)  For the purposes of paragraph 7(e) of these Rules, an approved supplier must give, in relation to the supply of a pharmaceutical benefit upon an electronic prescription, 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 in relation to supply of pharmaceutical benefits upon electronic prescriptions

Item

Column 1

Information

Column 2

Details

1

Approved Supplier Healthcare Provider Identifier—Individual (HPI‑I)

The healthcare identifier (if any) assigned to:

(a) if the supplier is an individual—the supplier; or

(b) otherwise—the individual who supplied the pharmaceutical benefit on behalf of the supplier.

2

Approved Supplier Healthcare Provider Identifier—Organisation (HPI‑O)

The healthcare identifier assigned to a healthcare provider organisation to which the supplier, or the individual who supplied the pharmaceutical benefit on behalf of the supplier, is linked (within the meaning of the Healthcare Identifiers Act 2010).

3

Dispensing Software Conformance Identifier

A valid conformance identifier provided to the Australian Digital Health Agency in relation to the software used to dispense the pharmaceutical benefit.

4

Intermediary Systems Conformance Identifiers

A valid conformance identifier provided to the Australian Digital Health Agency in relation to any software used to store or transmit the prescription until the pharmaceutical benefit is dispensed.

5

Patient Date of Birth

The date of birth of the person for whom the pharmaceutical benefit is prescribed.

Only required if included in the electronic prescription.

6

PBS Dispensing Notes

Notes of any clarification of the prescription at the time of the supply.

7

PBS Prescriber Healthcare Provider Identifier—Individual (HPI‑I)

The healthcare identifier (if any) assigned to the PBS prescriber who wrote the electronic prescription.

Only required if included in the electronic prescription.

8

PBS Prescriber Healthcare Provider Identifier—Organisation (HPI‑O)

The healthcare identifier assigned to a healthcare provider organisation to which the PBS prescriber who wrote the electronic prescription is linked (within the meaning of the Healthcare Identifiers Act 2010).

9

PBS/RPBS Item Receipt Flag

An indication that the person to whom the pharmaceutical benefit was supplied, or an agent of that person, has acknowledged receiving the benefit.

10

Prescribed Pharmaceutical Benefit

The code, in Australian Medicines Terminology, for the pharmaceutical benefit that is prescribed.

Only required if included in the electronic prescription.

11

Prescribing Software Conformance Identifier

A valid conformance identifier provided to the Australian Digital Health Agency in relation to the software used to prepare the prescription.

12

Reason for Prescription

The code, in SNOMED CT‑AU clinical terminology, for the clinical condition for which the pharmaceutical benefit is prescribed.

Only required if included in the electronic prescription.

13

Reason for Supply

The code, in SNOMED CT‑AU clinical terminology, for the clinical condition for which the pharmaceutical benefit is supplied.

Optional.

14

Supplied Pharmaceutical Benefit

The code, in Australian Medicines Terminology, for the pharmaceutical benefit that is supplied.

Optional.

15

Unique PBS Electronic Prescription Number

A unique identifier for the prescription generated by the software used to prepare the prescription.

 

             (2)  This clause has effect in addition to clause 1.


Endnotes

Endnote 1—About the endnotes

The endnotes provide information about this compilation and the compiled law.

The following endnotes are included in every compilation:

Endnote 1—About the endnotes

Endnote 2—Abbreviation key

Endnote 3—Legislation history

Endnote 4—Amendment history

Abbreviation key—Endnote 2

The abbreviation key sets out abbreviations that may be used in the endnotes.

Legislation history and amendment history—Endnotes 3 and 4

Amending laws are annotated in the legislation history and amendment history.

The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.

The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.

Editorial changes

The Legislation Act 2003 authorises First Parliamentary Counsel to make editorial and presentational changes to a compiled law in preparing a compilation of the law for registration. The changes must not change the effect of the law. Editorial changes take effect from the compilation registration date.

If the compilation includes editorial changes, the endnotes include a brief outline of the changes in general terms. Full details of any changes can be obtained from the Office of Parliamentary Counsel.

Misdescribed amendments

A misdescribed amendment is an amendment that does not accurately describe the amendment to be made. If, despite the misdescription, the amendment can be given effect as intended, the amendment is incorporated into the compiled law and the abbreviation “(md)” added to the details of the amendment included in the amendment history.

If a misdescribed amendment cannot be given effect as intended, the abbreviation “(md not incorp)” is added to the details of the amendment included in the amendment history.

 

Endnote 2—Abbreviation key

 

ad = added or inserted

o = order(s)

am = amended

Ord = Ordinance

amdt = amendment

orig = original

c = clause(s)

par = paragraph(s)/subparagraph(s)

C[x] = Compilation No. x

    /sub‑subparagraph(s)

Ch = Chapter(s)

pres = present

def = definition(s)

prev = previous

Dict = Dictionary

(prev…) = previously

disallowed = disallowed by Parliament

Pt = Part(s)

Div = Division(s)

r = regulation(s)/rule(s)

ed = editorial change

reloc = relocated

exp = expires/expired or ceases/ceased to have

renum = renumbered

    effect

rep = repealed

F = Federal Register of Legislation

rs = repealed and substituted

gaz = gazette

s = section(s)/subsection(s)

LA = Legislation Act 2003

Sch = Schedule(s)

LIA = Legislative Instruments Act 2003

Sdiv = Subdivision(s)

(md) = misdescribed amendment can be given

SLI = Select Legislative Instrument

    effect

SR = Statutory Rules

(md not incorp) = misdescribed amendment

Sub‑Ch = Sub‑Chapter(s)

    cannot be given effect

SubPt = Subpart(s)

mod = modified/modification

underlining = whole or part not

No. = Number(s)

    commenced or to be commenced

 

Endnote 3—Legislation history

 

Name

Registration

Commencement

Application, saving and transitional provisions

PB 19 of 2012

30 Mar 2012 (F2012L00726)

1 Apr 2012 (r 2)

 

PB 49 of 2012

29 June 2012 (F2012L01456)

1 July 2012 (r 2)

PB 79 of 2012

27 Sept 2012 (F2012L01951)

1 Oct 2012 (r 2)

PB 19 of 2015

1 Apr 2015 (F2015L00437)

1 Apr 2015 (r 2)

PB 128 of 2015

17 Dec 2015 (F2015L02061)

1 Jan 2016 (r 2)

PB 60 of 2016

30 June 2016 (F2016L01127)

1 July 2016 (r 2)

PB 24 of 2017

15 Mar 2017 (F2017L00225)

16 Mar 2017 (r 2)

National Health (Claims and under co-payment data) Amendment (Electronic Prescriptions) Rules 2019

30 Oct 2019 (F2019L01383)

31 Oct 2019 (s 2(1) item 1)

Endnote 4—Amendment history

 

Provision affected

How affected

 

r 2.............................................

rep LA s 48D

 

r 3.............................................

rep LA s 48C

 

r 4.............................................

am PB 49 and 79 of 2012; PB 19 and 128 of 2015; PB 60 of 2016; F2019L01383

 

r 5.............................................

am PB 49 and 79 of 2012; PB 19 of 2015

 

r 6.............................................

rs PB 19 of 2015

 

r 7.............................................

rs PB 19 of 2015

 

 

am F2019L01383

 

r 8.............................................

am PB 19 of 2015

 

r 10...........................................

am PB 19 of 2015

 

r 12...........................................

rs PB 19 of 2015

 

 

am PB 24 of 2017

 

r 13...........................................

ad PB 128 of 2015

 

 

am PB 60 of 2016; PB 24 of 2017

 

Schedule...................................

am PB 49 and 79 of 2012

 

 

rep PB 19 of 2015

 

Schedule 1

 

 

Schedule 1................................

ad PB 19 of 2015

 

 

rs PB 128 of 2015

 

c 1.............................................

ad PB 19 of 2015

 

 

rs PB 128 of 2015

 

 

am PB 60 of 2016; F2019L01383

 

c 2.............................................

ad F2019L01383