{"id":"F2022L00436","name":"National Health (Supply of Pharmaceutical Benefits—Under Co-payment Data and Claims for Payment) Rules 2022","slug":"national-health-supply-of-pharmaceutical-benefits-under-co-payment-data-and-claims-for-payment-rules","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":102350,"registerId":"commonwealth-F2022L00436-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Part 1","sectionType":"part","heading":"Preliminary","content":"## Part 1—Preliminary","sortOrder":0},{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n (1) This instrument is the National Health (Supply of Pharmaceutical Benefits—Under Co‑payment Data and Claims for Payment) Rules 2022.\n (2) This instrument may also be cited as PB 22 of 2022.","sortOrder":1},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n This instrument is made under subsections 98AC(4) and 99AAA(8) of the National Health Act 1953.","sortOrder":2},{"sectionNumber":"5","sectionType":"section","heading":"Definitions","content":"#### 5 Definitions\n\n> Note: A number of expressions used in this instrument are defined in the Act, including the following:\n\n (a) Chief Executive Medicare;\n (b) Veterans’ Affairs Department.\n (1) In this instrument:\n\n> Act means the National Health Act 1953.\n\n> actual contribution means the actual amount a patient pays for each prescription, including a special patient contribution.\n\n> Note: This amount does not include any charge for delivery, or for supply of a pharmaceutical benefit outside normal trading hours.\n\n> allowable discount has the meaning given by subsection 87(2AAAA) of the Act.\n\n> Note: The allowable discount may be greater than $1.00 in the limited cases where subsection 92A(2) of the Act applies to the supply of the pharmaceutical benefit by a friendly society, or by a friendly society body, to an eligible member.\n\n> approved private hospital means a private hospital that has an approved hospital authority.\n\n> approved public hospital means a public hospital that has an approved hospital authority.\n\n> A section means:\n\n (a) in respect of a prescription that is an authority prescription, a repeat authorisation, a deferred supply authorisation or a prescriber bag supply form—the section of the form on which the prescription is written that is provided for the purpose of recording the information required by the provision of this instrument in which the expression occurs; or\n (b) in respect of any other prescription—the section of the stamp format marked “A” on the prescription.\n\n> authority prescription has the meaning given by subsection 5(1) of the Regulations.\n\n> 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.\n\n> Claims Transmission System has the meaning given by subsection 99AAA(1) of the Act.\n\n> Note: See the procedures in section 8 of this instrument.\n\n> continued dispensing means a supply of a pharmaceutical benefit by an approved pharmacist without a prescription in accordance with subsection 89A(1) of the Act and the Regulations.\n\n> Note: See also the legislative instruments in force under subsection 89A(3) of the Act and Part 5 of the Regulations.\n\n> contribution discount for a supply of a pharmaceutical benefit (other than an early supply of a specified pharmaceutical benefit) means:\n\n (a) if the supply is not eligible for increased discounting—the amount of the allowable discount for the supply of the pharmaceutical benefit; or\n (b) if the supply is eligible for increased discounting—the amount worked out by reducing the general patient charge amount by the amount charged for the supply under paragraph 87(2)(e) of the Act.\n\n> deferred supply authorisation means a deferred supply authorisation prepared under section 53 of the Regulations on the basis of which a pharmaceutical benefit was supplied.\n\n> early supply of a specified pharmaceutical benefit has the meaning given by subsection 84AAA(1) of the Act.\n\n> electronic communication has the meaning given by the Electronic Transactions Act 1999.\n\n> electronic prescription has the meaning given by subsection 5(1) of the Regulations.\n\n> eligible for increased discounting has the meaning given by section 87AA of the Act.\n\n> exceptional prescription means a prescription for an extemporaneously‑prepared pharmaceutical benefit:\n\n (a) that is not a standard formula preparation; and\n (b) for which the price of the ingredients worked out in accordance with sections 19 to 21 of the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020 is not less than twice the amount worked out in accordance with section 30 of that determination, excluding the container price and dispensing fee.\n\n> extemporaneously‑prepared pharmaceutical benefit means a pharmaceutical item in respect of which no determination under subsection 85(6) of the Act is in force.\n\n> healthcare identifier has the meaning given by the Healthcare Identifiers Act 2010.\n\n> healthcare provider organisation has the meaning given by the Healthcare Identifiers Act 2010.\n\n> information technology requirements has the same meaning as in the Electronic Transactions Act 1999.\n\n> manual system has the meaning given by subsection 99AAA(1) of the Act.\n\n> Note: See the procedures in section 10 of this instrument.\n\n> Medicare Australia/DVA copy, for a paper‑based prescription, means the duplicate of the prescription that includes the words “Medicare Australia/DVA copy”.\n\n> medication chart prescription has the meaning given by the Regulations.\n\n> non‑ACSS payment means a payment to an approved supplier from the Commonwealth under Part VII of the Act in relation to the supply of a pharmaceutical benefit, other than an ACSS payment.\n\n> Note: Commonwealth payments to approved suppliers under Part VII of the Act that are not ACSS payments include payments under sections 93, 93AB and 99 of the Act.\n\n> paper‑based prescription has the meaning given by the Regulations.\n\n> PBS prescriber, in relation to a prescription, means the PBS prescriber who wrote or prepared the prescription.\n\n> prescriber bag supply form means:\n\n (a) an order form approved by the Secretary, as referred to in section 33 of the Regulations; or\n (b) a form approved by the Secretary, as referred to in paragraph 36(5)(a) of the Regulations, for the purpose of an approved medical practitioner giving notice of having obtained a pharmaceutical benefit when making a claim using the manual system, as required by paragraph 36(4)(c) of the Regulations; or\n (c) a form approved by the Secretary, as referred to in paragraph 36(8)(a) of the Regulations, for the purpose of an approved medical practitioner creating a written record of having obtained a pharmaceutical benefit if the practitioner makes a CTS claim in relation to obtaining the benefit, as required by paragraph 36(7)(c) of the Regulations.\n\n> prescription includes the following:\n\n (a) the Medicare Australia/DVA copy of a paper‑based prescription;\n (b) a copy of a medication chart prescription that is not an electronic prescription;\n (c) an electronic prescription.\n\n> Regulations means the National Health (Pharmaceutical Benefits) Regulations 2017.\n\n> repeat authorisation means:\n\n (a) a repeat authorisation prepared under subparagraph 52(3)(a)(i) of the Regulations using a repeat authorisation form; or\n (b) continued dispensing using a repeat authorisation form prepared by an approved pharmacist;\n on the basis of which a pharmaceutical benefit has been supplied.\n\n> repeat authorisation form has the meaning given by the Regulations.\n\n> RPBS means:\n\n (a) the Repatriation Pharmaceutical Benefits Scheme determined under subsection 91(1) of the Veterans’ Entitlements Act 1986; or\n (b) the Australian Participants in British Nuclear Tests and British Commonwealth Occupation Force (Treatment) (Modifications of the Repatriation Pharmaceutical Benefits Scheme) Instrument 2017 made under section 18 of the Australian Participants in British Nuclear Tests and British Commonwealth Occupation Force (Treatment) Act 2006; or\n (c) the MRCA Pharmaceutical Benefits Scheme (No. MRCC 44/2013) made under section 286 of the Military Rehabilitation and Compensation Act 2004.\n\n> S section means:\n\n (a) in respect of a prescription that is an authority prescription, a repeat authorisation, a deferred supply authorisation or a prescriber bag supply form—the section of the form on which the prescription is written that is provided for the purpose of recording the information required by the provision of this instrument in which the expression occurs; or\n (b) in respect of any other prescription—the section of the stamp format marked “S” on the prescription.\n\n> stamp format means the following format, whether made by stamp or otherwise and whether the lines are included or not:\n\n| S |\n| --- |\n| A |\n\n> standard formula preparation means an extemporaneously‑prepared pharmaceutical benefit described in an item of the table in clause 1 of Schedule 5 to the National Health (Commonwealth Price and Conditions for Commonwealth Payments for Supply of Pharmaceutical Benefits) Determination 2019.\n\n> under co‑payment data means information in relation to the supply of a pharmaceutical benefit:\n\n (a) by an approved supplier if subsection 99(2A), (2AB) or (2B) of the Act applies in relation to the supply; or\n (b) by an approved hospital authority if the amount payable by the Commonwealth in accordance with a determination made under subsection 99(4) of the Act is nil due to the dispensed price not exceeding the applicable patient co‑payment, as defined in the determination.\n\n> Note: If subsection 99(2A), (2AB) or (2B) of the Act applies in relation to the supply, no claim is payable under section 99AAA of the Act.\n\n (2) Where an expression that is used in this instrument is defined for the purposes of Part VII of the Act, it has the same meaning in this instrument as it has in that Part. Expressions used in this instrument that are defined in Part VII include the following:\n (a) ACSS eligible supply;\n (b) ACSS payment;\n (c) approved hospital authority;\n (d) approved supplier;\n (e) general patient charge amount;\n (f) pharmaceutical benefit;\n (g) special patient contribution.\n (3) A reference in this instrument 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.","sortOrder":3},{"sectionNumber":"Part 2","sectionType":"part","heading":"Information and procedures relating to supplies of pharmaceutical benefits","content":"## Part 2—Information and procedures relating to supplies of pharmaceutical benefits","sortOrder":4},{"sectionNumber":"6","sectionType":"section","heading":"Procedures for giving information—form and period for giving information and certification","content":"#### 6 Procedures for giving information—form and period for giving information and certification\n\n (1) For the purposes of paragraphs 98AC(4)(b) and 99AAA(8)(a) of the Act, this section defines procedures to be followed by an approved supplier in giving information to the Chief Executive Medicare, on behalf of the Secretary, in relation to the supply by the approved supplier of pharmaceutical benefits, whether the information is given:\n (a) under subsection 98AC(1) of the Act; or\n (b) in making a claim under section 99AAA of the Act.\n Form for giving information\n (2) If the Chief Executive Medicare has approved a form for giving the information, the information must be given in accordance with the approved form.\n Period for giving information etc.\n (3) The information must be given to the Chief Executive Medicare in relation to pharmaceutical benefits supplied by the approved supplier during a period not exceeding 35 days, unless the Chief Executive Medicare is satisfied that the approved supplier was unable, through circumstances outside the approved supplier’s control, to comply with that requirement.\n (4) The information must be given to the Chief Executive Medicare not more than 30 days after the last day of the period in respect of which previous information in relation to supplies of pharmaceutical benefits was given by the approved supplier, unless the Chief Executive Medicare is satisfied that the approved supplier was unable, through circumstances outside the approved supplier’s control, to comply with that requirement.\n (5) The information must not be given to the Chief Executive Medicare during the same calendar month as any previous information was given in relation to supplies of pharmaceutical benefits by the approved supplier, unless it is given in accordance with an arrangement proposed by the approved supplier and agreed to by the Chief Executive Medicare on the basis that the arrangement will not impose additional administrative expenses on the Chief Executive Medicare.\n Certification\n (6) The approved supplier must certify:\n (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\n (b) that the information is correct.\n (7) The approved supplier may make the certification in an approved form (if any) referred to in subsection (2) or in another manner.\n\n> Note: Paragraph 8(3)(d) of this instrument sets out requirements for the Claims Transmission System about warnings and notifications that apply if the certification is not included in a form referred to in subsection (2) of this section.\n\n (8) In certifying for the purposes of paragraph (6)(a), the approved supplier must:\n (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\n (b) specify the total number of pharmaceutical benefits for each of those payment categories; and\n (c) identify the claim period number, and the claim reference, referred to in Schedule 1 in relation to which the information is given.","sortOrder":5},{"sectionNumber":"7","sectionType":"section","heading":"Additional procedures for giving information","content":"#### 7 Additional procedures for giving information\n\n (1) For the purposes of paragraphs 98AC(4)(b) and 99AAA(8)(a) of the Act, this section defines additional procedures to be followed by an approved supplier in giving information to the Chief Executive Medicare, on behalf of the Secretary, in relation to the supply by the approved supplier of pharmaceutical benefits, whether the information is given:\n (a) under subsection 98AC(1) of the Act; or\n (b) in making a claim under section 99AAA of the Act.\n Claim made using manual system\n (2) Subsections (3) to (9) apply if the approved supplier’s claim is made using the manual system.\n (3) The information must be accompanied by the prescriptions on the presentation of which the pharmaceutical benefits that are the subject of the claim were supplied.\n (4) On each prescription (other than an authority prescription, a repeat authorisation, a deferred supply authorisation or a prescriber bag supply form), there must 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.\n\n> Note: For prescription and repeat authorisation, see subsection 5(1).\n\n (5) On each prescription, there must be marked in the S section (or each S section) one or more serial numbers by the approved supplier, allotted in respect of each pharmaceutical benefit as follows:\n (a) in respect of general benefit prescriptions—commencing at “1” in each claim and continuing consecutively in respect of that claim;\n (b) in respect of concessional benefit prescriptions and concession card prescriptions—commencing at “C1” in each claim and continuing consecutively in respect of that claim;\n (c) in respect of entitlement card prescriptions—commencing at “E1” in each claim and continuing consecutively in respect of that claim;\n (d) in respect of prescriber bag supply forms—commencing at “1” in each claim and continuing consecutively in respect of that claim.\n (6) On each authority prescription, or repeat authorisation relating to an authority prescription, there must be marked as a prefix to the serial number allotted under subsection (5) the letter “A”.\n (7) On each deferred supply authorisation, there must be marked as a prefix to the serial number allotted under subsection (5) the letter “D”.\n (8) On each prescription (other than a prescription that was not in the possession of the approved supplier for reasons that are, in the opinion of the Chief Executive Medicare, outside the approved supplier’s reasonable control), there must be marked in the A section (or each A section):\n (a) if an election by the approved supplier is in force under subsection 31(3) of the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020, and the prescription is in respect of an extemporaneously‑prepared pharmaceutical benefit that is not a standard formula preparation—the price worked out by the approved supplier in accordance with section 18 of that determination; or\n (b) if no election by the approved supplier is in force under subsection 31(3) of the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020, and the prescription is an exceptional prescription—the price worked out by the approved supplier in accordance with section 18 of that determination; or\n (c) if the prescription is in respect of an extemporaneously‑prepared pharmaceutical benefit that is 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”.\n\n> Note: The RPBS provides that an RPBS claim is to be made in accordance with section 99AAA of the Act and this instrument except if 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 this section.\n\n (9) The prescriptions referred to in subsections (3) to (8) must be grouped according to whether they are covered by paragraph (5)(a), (b), (c) or (d), with the prescriptions in each group sorted in accordance with the serial numbers allotted under the relevant paragraph, starting with the first number allotted.\n\n> 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.\n\n Claim made using Claims Transmission System\n (10) If the approved supplier’s claim is made using the Claims Transmission System, the approved supplier must comply with the requirements of subsections (3) to (9) in relation to the prescriptions on the presentation of which the pharmaceutical benefits that are the subject of the claim were supplied, except that the prescriptions need not accompany the information given in accordance with this section.\n Exception for medication chart prescriptions\n (11) For the purposes of this section, a reference to a prescription does not include a reference to a medication chart prescription.\n\n> 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.","sortOrder":6},{"sectionNumber":"8","sectionType":"section","heading":"Procedures for giving information using Claims Transmission System","content":"#### 8 Procedures for giving information using Claims Transmission System\n\n (1) For the purposes of paragraphs 98AC(4)(b) and 99AAA(8)(c) of the Act, this section defines procedures to be followed by an approved supplier in giving information to the Secretary by electronic means.\n\n> Note 1: The procedures defined in this section constitute the Claims Transmission System.\n\n> 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.\n\n (2) The approved supplier must give the information to the Chief Executive Medicare, on behalf of the Secretary:\n (a) in writing; and\n (b) by means of an electronic communication; and\n (c) in accordance with any other requirements that would need to be met for the requirement to give the information in writing to be taken to have been met under the Electronic Transactions Act 1999.\n\n> Note: Under the Electronic Transactions Act 1999, 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).\n\n (3) The information must be generated using one or more computer programs that ensure the following:\n (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;\n (b) that the information in the computer program for each pharmaceutical benefit is:\n (i) in accordance with the Act, and instruments made under the Act, as in force at the time the pharmaceutical benefit was supplied; and\n (ii) encrypted when it is given to the Chief Executive Medicare;\n (c) that the approved supplier is able to take all reasonable precautions to ensure that the following information is not included:\n (i) information relating to the supply of a substance that was not, in the circumstances, a pharmaceutical benefit;\n (ii) information relating to the supply of a substance that was a pharmaceutical benefit but was supplied contrary to section 89 of the Act;\n (d) that, if the approved supplier makes the certification required by subsection 6(6) of this instrument otherwise than in an approved form referred to in subsection 6(2):\n (i) the Chief Executive Medicare is notified of the certification; and\n (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.","sortOrder":7},{"sectionNumber":"9","sectionType":"section","heading":"Information about supplies","content":"#### 9 Information about supplies\n\n (1) For the purposes of paragraphs 98AC(4)(a) and 99AAA(8)(b) of the Act, subsection (2) specifies the information that is to be given to the Secretary by an approved supplier in relation to the supply by the approved supplier of a pharmaceutical benefit.\n (2) The information is the following:\n (a) the approved supplier’s approval number allotted under section 16 of the Regulations;\n (b) if the approval number is to be given using the manual system and the approved supplier is an approved pharmacist:\n (i) the pharmacist’s name; and\n (ii) the address of the premises to which the approval number relates;\n (c) if the approval number is to be given using the manual system and the approved supplier is an approved medical practitioner:\n (i) the medical practitioner’s name; and\n (ii) the address to which the medical practitioner wishes correspondence to be sent;\n (d) if the approval number is to be given using the manual system and the approved supplier is an approved hospital authority:\n (i) the approved hospital authority’s name; and\n (ii) the address of the hospital to which the approval number relates;\n (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.\n\n> Note: The information must be given to the Chief Executive Medicare on behalf of the Secretary (see subsection 8(2)).","sortOrder":8},{"sectionNumber":"10","sectionType":"section","heading":"Procedures for providing information in respect of claims using manual system","content":"#### 10 Procedures for providing information in respect of claims using manual system\n\n For the purposes of paragraph 99AAA(8)(d) of the Act, an approved supplier, in providing information otherwise than by electronic means in relation to the supply by the approved supplier of pharmaceutical benefits, must provide the information to the Chief Executive Medicare, on behalf of the Secretary, in accordance with sections 6 and 7 of this instrument.\n\n> Note: Paragraphs 9(2)(a), (b), (c) and (d) of this instrument also apply.","sortOrder":9},{"sectionNumber":"11","sectionType":"section","heading":"Procedures for giving information using manual system—under co‑payment data not required","content":"#### 11 Procedures for giving information using manual system—under co‑payment data not required\n\n For the purposes of paragraph 98AC(4)(b) of the Act, an approved supplier who is permitted to make a claim using the manual system in accordance with section 99AAB of the Act is not required to give under co‑payment data to the Chief Executive Medicare, on behalf of the Secretary, when using the manual system.\n\n> Note: See subsections 99AAA(4) and (5) and section 99AAB of the Act.","sortOrder":10},{"sectionNumber":"12","sectionType":"section","heading":"Procedures for processing and determining claims","content":"#### 12 Procedures for processing and determining claims\n\n (1) For the purposes of subparagraph 99AAA(8)(e)(i) of the Act, subsections (2) and (3) define 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.\n (2) The Chief Executive Medicare must institute reasonable checks to satisfy the Chief Executive Medicare that:\n (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\n (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.\n\n> Note: Advance payments are permitted in accordance with section 99AB of the Act, on account of amounts that may become payable under section 99 or section 99AAAA of the Act. Advance payments are associated with claims made using the Claims Transmission System.\n\n (3) The Chief Executive Medicare is not required to determine an approved supplier’s entitlement for an ACSS payment in respect of the supply of a pharmaceutical benefit that is the subject of a claim at the same time as the Chief Executive Medicare determines entitlement to a non‑ACSS payment by the Commonwealth in respect of that supply.","sortOrder":11},{"sectionNumber":"13","sectionType":"section","heading":"Procedures for making payments in respect of claims","content":"#### 13 Procedures for making payments in respect of claims\n\n (1) For the purposes of subparagraph 99AAA(8)(e)(ii) of the Act, this section defines 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.\n (2) The Chief Executive Medicare must ensure that:\n (a) payments are made by:\n (i) an electronic funds transfer from the Commonwealth to the account at a financial institution nominated in writing by the approved supplier; or\n (ii) any other form of electronic payment from the Commonwealth to the approved supplier nominated in writing by the approved supplier; and\n (b) a statement of account is given to the approved supplier in respect of each claim for payment.\n\n> Note: Example: For the purposes of subparagraph (a)(ii), other forms of electronic payment include PayID and payments through mobile telephone applications.\n\n (3) Information included in a statement of account about ACSS payments made in respect of ACSS eligible supplies made before 1 July 2025:\n (a) is not required to relate to a particular claim period; and\n (b) may be included in a statement of account that relates to supplies of pharmaceutical benefits made in different claim periods.\n\n> Note: Approved pharmacists are the only approved suppliers who are entitled to ACSS payments – see section 99AAAA of the Act.","sortOrder":12},{"sectionNumber":"2","sectionType":"section","heading":"Additional information to be given using Claims Transmission System—supply on electronic prescriptions","content":"#### 2 Additional information to be given using Claims Transmission System—supply on electronic prescriptions\n\n (1) For the purposes of paragraph 9(2)(e) of this instrument, an approved supplier must give, in relation to the supply of a pharmaceutical benefit on an electronic prescription, the information referred to in an item in the following table in accordance with that item.\n\n> Note 1: The table applies for the purposes of an approved supplier giving information about supplies (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).\n\n> 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.\n\n```html\n

Additional information to be given using Claims Transmission System—supply on 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.

\n```\n\n (2) This clause has effect in addition to clause 1.","sortOrder":14}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"flash_summary":{"complexity_score":8,"scope_assessment":{"changed":false,"description":"This instrument does not expand or narrow who is eligible for PBS/RPBS payments; it implements procedural and data requirements for reporting and claiming under existing Part VII arrangements (authority under ss 98AC(4) and 99AAA(8) of the Act) (s 3). It prescribes how approved suppliers must provide information, certify supplies, and how the Chief Executive Medicare processes and pays claims (ss 6–13, Schedule 1 and Schedule 2), but it does not alter statutory eligibility or payment entitlements defined in the Act and Regulations (see s 5(2) and cross‑references throughout)."},"complexity_factors":["Multiple statutory cross‑references and delegated limits (instrument made under ss 98AC(4) and 99AAA(8) of the Act) (s 3).","Extensive defined terms and reliance on definitions in the Act and Regulations, creating interdependence (clause 5 and s 5(2)).","Parallel manual and electronic (Claims Transmission System) workflows with different documentary and timing rules (ss 6–11).","Detailed, itemised electronic data schema with many conditional fields (Schedule 1 table items 1–41 and Schedule 2 items 1–15), increasing implementation complexity for dispensing software.","Technical IT and interoperability requirements: encryption, conformance identifiers, HPI‑I/HPI‑O, Electronic Transactions Act compliance (s 8(2)–(3); Schedule 2).","Strict timing and grouping rules for claims and submissions, plus exceptions where Chief Executive Medicare may excuse non‑compliance (s 6(3)–(5); s 7(9)).","Certification and criminal liability warnings for false information; certification must identify serial number ranges and counts for payment categories (s 6(6)–(8); s 8(3)(d)).","Operational controls and verification obligations on Chief Executive Medicare, including reasonable checks and selective determination rules for ACSS vs non‑ACSS payments (s 12(2)–(3); s 13).","Sector‑specific exceptions and alternative rules for RPBS, hospitals, continued dispensing, extemporaneous/exceptional prescriptions and medication charts, increasing conditional logic (s 5 definitions; ss 7(8)–(11); Schedule notes).","Potential compliance and software certification burden for suppliers and intermediaries due to conformance identifiers and digital health agency registration (Schedule 2 items 3–4)."],"plain_english_summary":"This instrument sets the procedures suppliers must follow to report PBS/RPBS medicine supplies and to claim Commonwealth payments. It prescribes formats, time limits, certification, serial‑numbering, manual versus electronic (Claims Transmission System) requirements, detailed data fields and payment procedures. \n\nIt applies to approved pharmacists, approved medical practitioners and approved hospital authorities. It matters because it defines what suppliers must record and submit, the timing and IT/security requirements to receive Commonwealth payments, and the administrative burden of compliance."},"kimi_summary":{"content_quality":"ok","complexity_score":7,"scope_assessment":{"changed":false,"description":"The legislation appears to maintain its original scope as an administrative instrument governing data collection and payment claims for pharmaceutical benefits. While highly detailed, the complexity reflects the inherent intricacy of the PBS claiming system rather than scope creep. The instrument consolidates and updates previous rules without expanding into new policy areas beyond its core purpose of regulating how suppliers claim payment and report supply data."},"complexity_factors":["47+ defined terms in section 5, many of which reference other legislation (National Health Act 1953, National Health (Pharmaceutical Benefits) Regulations 2017, Veterans' Entitlements Act 1986, etc.)","Extensive cross-referencing between the Act, Regulations, and multiple other legislative instruments including price determinations and veterans' schemes","Dual-track system with different rules for manual claims (paper-based) versus Claims Transmission System (electronic), with partial exceptions and overlapping requirements","56 separate data items required in Schedule 1, many with conditional applicability depending on prescription type, patient category, or supply circumstances","Nested conditional logic throughout (e.g., 'only required if...', 'not required for...', 'if...then...otherwise')","Multiple prescription formats each with unique requirements: authority prescriptions, repeat authorisations, deferred supply authorisations, prescriber bag supply forms, medication chart prescriptions, electronic prescriptions, continued dispensing","Integration with external systems and identifiers (Healthcare Identifiers Act 2010, Electronic Transactions Act 1999, Australian Digital Health Agency conformance identifiers)","Special arrangements for veterans (RPBS) with modified requirements that parallel but differ from standard PBS rules","Temporal limitations and exceptions (e.g., ACSS payment reporting requirements change after 1 July 2025)"],"plain_english_summary":"This legislation sets the administrative rules for how pharmacies, hospitals and approved medical practitioners claim government payment for supplying medicines under the Pharmaceutical Benefits Scheme and related veterans' schemes. It prescribes required claim information, submission methods and time limits, supplier certification, and special prescription categories.\n\nIt affects approved community pharmacies, hospital authorities, supplying practitioners and the Chief Executive Medicare, and underpins reimbursement, accountability and fraud prevention in Australia’s medicine subsidy system."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-supply-of-pharmaceutical-benefits-under-co-payment-data-and-claims-for-payment-rules","history":"/api/acts/national-health-supply-of-pharmaceutical-benefits-under-co-payment-data-and-claims-for-payment-rules/history","analysis":"/api/acts/national-health-supply-of-pharmaceutical-benefits-under-co-payment-data-and-claims-for-payment-rules/analysis","conflicts":"/api/acts/national-health-supply-of-pharmaceutical-benefits-under-co-payment-data-and-claims-for-payment-rules/conflicts","importantCases":"/api/acts/national-health-supply-of-pharmaceutical-benefits-under-co-payment-data-and-claims-for-payment-rules/important-cases","documents":"/api/acts/national-health-supply-of-pharmaceutical-benefits-under-co-payment-data-and-claims-for-payment-rules/documents"}}