Sch 1
DISKETTE CLAIM FORMAT – VERSION 1
SCHEDULE 1: DISKETTE CLAIM FORMAT – VERSION 1
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Commonwealth legislation
This Act has been repealed and is no longer in force. It is retained for historical reference.
These Rules prescribe how approved suppliers (pharmacists, participating medical/dental practitioners and hospital authorities) must make and support claims for Pharmaceutical Benefits — by paper, diskette or online — and how prescriptions must be marked, bundled and numbered (rules 3, 5–7). They appoint the Health Insurance Commission (via the Managing Director) to check, process and pay claims by EFT, set detailed electronic file layouts and data-validation requirements (Schedules 1–3), and allow limited discretion to accept late or extra monthly claims (rule 3d,f; rules 9–10).
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Direct links to the current provisions in National Health Act 1953 - Rules under subsection 99AAA(8) (No. PB 15 of 2004).
SCHEDULE 1: DISKETTE CLAIM FORMAT – VERSION 1
PART 1 — CLAIM PART HEADER RECORD
| Column 1Field | Column 2Start | Column 3End | Column 4Specifications for field |
|---|---|---|---|
| Record Type | 1 | 1 | One byte alphabetic, value “H”, to identify this record as being a claim part header record; there will be one of these for each claim part |
| Claim Reference | 2 | 5 | Four bytes numeric, consisting of the last two digits of the year followed by the number of the claim submitted by the approved supplier during that calendar year |
| Approval Number | 6 | 11 | Six bytes alphanumeric, being the number allotted to the approved supplier under regulation 8A of the Regulations, and contained within the software in the approved supplier’s computer system |
| Claim Part Number | 12 | 13 | Two bytes numeric, values 01 to 99, representing the number of the claim part within the claim |
| Rest of Claim Part Header | 14 | 128 | One hundred and fifteen bytes of space |
PART 2 — CLAIM PART TRAILER RECORD
| Column 1Field | Column 2Start | Column 3End | Column 4Specifications for field |
|---|---|---|---|
| Record Type | 1 | 1 | One byte alphabetic, value “T”, to identify this record as being a claim part trailer record; there will be one of these for each claim part |
| Claim Reference | 2 | 5 | Four bytes numeric, consisting of the last two digits of the year followed by the number of the claim submitted by the approved supplier during that calendar year |
| Approval Number | 6 | 11 | Six bytes alphanumeric, being the number allotted to the approved supplier under regulation 8A of the Regulations, and contained within the software in the approved supplier’s computer system |
| Number of Prescriptions | 12 | 16 | Five bytes numeric, right justified, zero filled, being the number of prescription records in this claim part |
| Rest of Claim Part Trailer | 17 | 128 | One hundred and twelve bytes of space |
PART 3 — CLAIM TRAILER RECORD
| Column 1Field | Column 2Start | Column 3End | Column 4Specifications for field |
|---|---|---|---|
| Record Type | 1 | 1 | One byte alphabetic, value “Z” to identify this record as being a claim trailer record; there will be one of these for each claim part |
| Claim Reference | 2 | 5 | Four bytes numeric, consisting of the last two digits of the year followed by the number of the claim submitted by the approved supplier during that calendar year |
| Approval Number | 6 | 11 | Six bytes alphanumeric, being the number allotted to the approved supplier under regulation 8A of the Regulations, and contained within the software in the approved supplier’s computer system |
| Number of Parts | 12 | 13 | Two bytes numeric, values 01 to 99, being the total number of parts in the claim |
| Rest of Claim Trailer | 14 | 128 | One hundred and fifteen bytes of space |
PART 4 — PRESCRIPTION RECORD
| Column 1Field | Column 2Start | Column 3End | Column 4Specifications for field |
|---|---|---|---|
| Record Type | 1 | 1 | One byte alphabetic, value “P”, to identify this record as being a prescription record; there will be one of these for each prescription |
| Card Issue Number | 2 | 2 | One byte numeric, being the tenth digit of the medicare number or special number that applies to the person for whose treatment the prescription was written |
| Individual’s Reference Number | 3 | 3 | One byte numeric, being the eleventh digit of the medicare number or special number that applies to the person for whom the prescription was written |
| First Two Digits of Hospital Provider Number | 4 | 5 | Two bytes numeric, being the second and third characters of the hospital provider number where the pharmaceutical benefit was supplied by a public hospital authority; otherwise “00” |
| Form Category | 6 | 6 | One byte numeric, using the following values:original prescription 1repeat authorisation 2original authority prescription 3repeat authorisation relating to authority prescription 4deferred supply authorisation 5prescription written by a participating dental practitioner 6doctor’s bag form 7 |
| Payment Category | 7 | 7 | One byte numeric, using the following values:general benefit 1entitlement card 2concessional benefit and concession card 3doctor’s bag form 5 |
| Serial Number | 8 | 12 | Five bytes numeric, right justified, zero filled, marked upon the prescription in respect of the pharmaceutical benefit supplied by the approved supplier, that uniquely identifies that pharmaceutical benefit within the payment category, pursuant to subsubparagraph 3(g)(iii) of these Rules |
| Prescriber Number | 13 | 19 | Seven bytes numeric, right justified, zero filled, being the prescriber number of the prescribing medical practitioner or participating dental practitioner, issued by the Commission in pursuance of the function granted to it by paragraph 3C(a) of the Health Insurance Commission Regulations 1975, except in respect of a prescription that was written by a medical practitioner where that prescriber number was not available to the approved supplier at the time of the supply of the pharmaceutical benefit, in which case the field shall be zero filled |
| Date Prescribed | 20 | 25 | Six bytes numeric in the format DDMMYY to represent the date on which the prescription was written upon the presentation of which the pharmaceutical benefit was supplied, where DD may have values 01 to 31 (day of month), MM may have values 01 to 12 (month of year) and YY may have values 00 to 99 (last two digits of year) |
| Date Supplied | 26 | 31 | Six bytes numeric in the format DDMMYY to represent the date on which the pharmaceutical benefit was supplied, where DD may have values 01 to 31 (day of month), MM may have values 01 to 12 (month of year) and YY may have values 00 to 99 (last two digits of year) |
| Filler | 32 | 32 | One byte numeric, value “0” |
| Drug Code | 33 | 37 | Five bytes, four bytes numeric followed by one byte alphabetic check character, being the code for the pharmaceutical benefit that appears in the Schedule of Pharmaceutical Benefits published by the Department of Ageing |
| Column 1Field | Column 2Start | Column 3End | Column 4Specifications for field |
|---|---|---|---|
| Brand | 38 | 39 | Two bytes alphabetic, being the manufacturer’s code that represents the brand of the pharmaceutical benefit in the determination made under subsection 85(6) of the Act, in the case of a prescription that identifies the pharmaceutical benefit by reference to a brand; or two spaces, in the case of a prescription that does not identify the pharmaceutical benefit by reference to a brand |
| Quantity | 40 | 44 | Five bytes numeric, right justified, zero filled, to represent the quantity supplied; must be the total quantity supplied where supply of the original prescription and the repeat or repeats is made at the one time pursuant to regulation 24 of the Regulations |
| Price | 45 | 50 | Six bytes numeric, right justified, zero filled, value in cents; for prescriptions priced by the approved supplier in accordance with an election pursuant to paragraph 39 of the determination made under paragraph 98B(1) a) of the Act or priced by the approved supplier as exceptional prescriptions |
| Pricing Election | 51 | 51 | One byte alphabetic; value “Y” where the approved supplier has made an election pursuant to paragraph 39 of the determination made under paragraph 98B(1)(a) of the Act; otherwise “N” |
| Number of Repeats | 52 | 53 | Two bytes numeric, right justified, zero filled; must be the number of repeats prescribed, subject to the maximum allowable, for original prescriptions, original authority prescriptions, repeat authorisations and deferred supply authorisations; must be the number of repeats that are required where supply of the original prescription and the repeat or repeats is made at the one time pursuant to regulation 24 of the Regulations |
| Number of Previous Supplies | 54 | 55 | Two bytes numeric, right justified, zero filled, to represent the number of times that the pharmaceutical benefit has previously been supplied; required for repeat authorisations, repeat authorisations relating to authority prescriptions and deferred supply authorisations; must be “00” for deferred supply authorisation |
| Regulation 24 | 56 | 56 | One byte alphabetic; value “Y” if supply of the original prescription and the repeat or repeats is made at the one time pursuant to regulation 24 of the Regulations; otherwise “N” |
| Check Character of Hospital Provider Number | 57 | 57 | One byte alphabetic, being the eighth character of the hospital provider number where the pharmaceutical benefit was supplied by a public hospital authority; otherwise blank |
| Glass Bottle | 58 | 58 | One byte alphabetic; value “Y” if, in a prescription for extemporaneously-prepared ear drops, eye drops or nasal instillations, a glass bottle is ordered by the prescriber or considered necessary by the approved supplier; otherwise “N” |
| Authority Number | 59 | 66 | Eight bytes numeric, right justified, zero filled; required for original authority prescriptions and repeat authorisations relating to authority prescriptions; being, in the case of an original authority prescription, the number preprinted on that form, or, in the case of a repeat authorisation relating to an authority prescription, the number preprinted on the original authority prescription form to which the repeat authorisation relates |
| Early Re-supply | 67 | 67 | One byte alphabetic; value “Y” if the pharmaceutical benefit was supplied pursuant to paragraph 25(3)(b) or (c) or (4)(b) or (c) of the Regulations; otherwise “N” or blank |
| Column 1Field | Column 2Start | Column 3End | Column 4Specifications for field |
|---|---|---|---|
| Entitlement Identifier | 68 | 78 | Eleven bytes alphanumeric, left justified, space filled; for concessional benefit prescriptions, the number of the Pensioner Concession Card, Health Care Card or Commonwealth Seniors Health Card that applies to the person for whom the prescription was written; for concession card prescriptions, the number of the Safety Net Concession Card that applies to the person for whom the prescription was written; for entitlement card prescriptions, the number of the Pharmaceutical Benefits Entitlement Card that applies to the person for whom the prescription was written; for general benefit prescriptions, blank |
| Medicare Number Stem | 79 | 87 | Nine bytes numeric, being the first nine digits of the medicare number or special number that applies to the person for whose treatment the prescription was written |
| Name Type | 88 | 88 | One byte alphabetic; value “D” |
| Surname | 89 | 112 | Twenty-four bytes alphabetic, left justified, blank filled; being the surname of the person for whom the prescription was written |
| Given Name | 113 | 124 | Twelve bytes alphabetic, left justified, blank filled; being the given name of the person for whom the prescription was written |
| Last Four Digits of Hospital Provider Number | 125 | 128 | Four bytes numeric, being the fourth to seventh characters of the hospital provider number where the pharmaceutical benefit was supplied by a public hospital authority; otherwise four blanks |
SCHEDULE 2: DISKETTE CLAIM FORMAT – VERSION 4.1, 2004
PART 1 — CLAIM PART HEADER RECORD
The Claim Header Record occurs for each claim submitted in the electronic message. It details the sequential number this claim represents for all the claims sent in by the client for the year, the client’s Regulation 8A approval number and the unique sequential number of this claim within the message.
| Column 1 | 2 | 3 | 4 | 5 | Column 6 |
|---|---|---|---|---|---|
| Field | Start | End | CH | Type | Description |
| Record type | 1 | 1 | 1 | A | One byte alphabetic, value 'H', to identify this record as being a claim header record.H = PBS CTS claim file header |
| HIC File Format Specification Version Number | 2 | 3 | 2 | N | Two bytes numeric that identifies the version of the file format specification so that formats can be introduced without impacting existing systems. |
| Approval number | 4 | 9 | 6 | A/N | Six bytes alpha/numeric, right justified, zero filled, being the approval number allotted to the approved pharmacist or approved medical practitioner under regulation 8A of the regulations, and contained within the software in the approved pharmacist's or approved medical practitioner's computer system. |
| Claim Period Number | 10 | 13 | 4 | N | Four bytes numeric, consisting of the last 2 digits of the year followed by the number of the claim submitted by the approved pharmacist or approved medical practitioner during that calendar year. This number is given to the claim to identify the paperwork. |
| Claim reference | 14 | 17 | 4 | N | Four bytes numeric, values 01 to 9999, representing the number of claims within a claim period. |
| Pharmacy Software Name | 18 | 19 | 2 | A | Identifies the pharmacy software system used to build the CTS file. This will allow for more efficient help desk support. Vendors will be advised of their code/s. |
| Pharmacy Software Version Number | 20 | 29 | 10 | A/N | Ten bytes alpha/numeric to help identify the version of pharmacy software used to build the CTS file. This will allow for more efficient help desk support. |
| Carriage return and line feed | N/a | N/a | N/a | N/a | End of record |
PART 2 — PRESCRIPTION RECORD
The Prescription Record contains information on the identification of the patient and details on the claimed services provided by the practitioner or pharmacist to the patient. The prescription record is not a fixed length. As changes are quite prevalent in PBS, the record length is to be variable to allow for any future changes.
The prescription record is as follows:
| Column 1 | 2 | 3 | 4 | 5 | Column 6 |
|---|---|---|---|---|---|
| Field | Start | End | CH | Type | Description |
| Record Type | 1 | 1 | 1 | A | One byte alphabetic, value 'P' upper case, to identify this record as being a prescription record; there will be one of these for each prescription. |
| Form Category | 2 | 2 | 1 | A/N | One byte numeric, using the following values:1 = original2 = repeat3 = original authority4 = repeat authorisation relating to an authority5 = deferred supply authorisation6 = prescription written by a participating dental practitioner7 = doctor's bag order form8 = DVA authority original form9 = DVA authority repeat form |
| Payment Category | 3 | 3 | 1 | N | One byte numeric, batch category:1 = general benefit2 = PBS Safety net (free)3 = concessional benefit4 = repatriation5 = doctor's bag order form |
| Unique Pharmacy Prescription Number | 4 | 23 | 20 | A/N | Twenty bytes alpha/numeric, right justified, space filled. This is a unique number allocated by the PDS and stays with that prescription throughout its lifecycle**. An individual prescription will only ever have one number allocated to it and that number will not be re-allocated to other prescriptions. |
| Serial Number | 24 | 28 | 5 | N | Five bytes numeric, right justified, zero filled. Allocated to the prescription by the approved pharmacists or approved medical practitioner that uniquely identifies that prescription within the payment category. |
| Hospital Provider Number | 29 | 36 | 8 | A/N | Eight bytes, the first seven numeric and the eighth alphabetic, being characters of the hospital provider number where the pharmaceutical benefit was supplied by a public hospital authority; otherwise space filled if not supplied by a public hospital authority. |
| Prescriber Id | 37 | 43 | 7 | A/N | Seven bytes alpha/numeric, right justified, space filled being the prescriber number of the prescribing medical or dental practitioner. |
| Date of Prescribing | 44 | 51 | 8 | N | Eight bytes numeric in the format DDMMCCYY to represent the date on which the prescription was prescribed, where DD may have values 01 to 31 (day of month), MM may have values 01 to 12 (month of year) and CCYY may have values 0000 to 9999. This field should not default to the current date however should default for DBOF. This field is mandatory. |
| Column 1 | 2 | 3 | 4 | 5 | Column 6 |
|---|---|---|---|---|---|
| Field | Start | End | CH | Type | Description |
| Date of Dispensing | 52 | 59 | 8 | N | Eight bytes numeric in the format DDMMCCYY to represent the date on which the prescription was dispensed, where DD may have values 01 to 31 (day of month), MM may have values 01 to 12 (month of year) and CCYY may have values 0000 to 9999. This field is mandatory. |
| Date of Supply | 60 | 67 | 8 | N | Eight bytes numeric in the format DDMMCCYY to represent the date on which the Pharmaceutical benefit was supplied, where DD may have values 01 to 31 (day of month), MM may have values 01 to 12 (month of year) and CCYY may have values 0000 to 9999. In the case of owing prescriptions, this field should be protected. This field is mandatory. |
| Patient Category | 68 | 68 | 1 | A/N | One byte alpha/numeric, identifies the patient category type:Valid values are:‘H’ = paperless private hospital patient.‘B’ = public hospital patient.‘N’ = nursing home patient.‘C’ = paperless public hospital patient.‘0’ (zero) = community patient.Blank/space is an invalid value. |
| PBS/RPBS Item Code | 69 | 74 | 6 | A/N | Six bytes, right justified, zero filled, five bytes numeric followed by one byte alphabetic check character, being the code for the pharmaceutical benefit which appears in the Schedule of Pharmaceutical Benefits for Approved Pharmacists published by the Department of Health and Ageing. A zero code is to be used in the case of Repatriation items which are not included in the Schedule but have been prior approved by the Department of Veterans’ Affairs. |
| Brand | 75 | 76 | 2 | A | Two bytes alphabetic, being the manufacturer's code which represents the brand of the pharmaceutical benefit in the Determination made under sub-section 85(6) of the Act, in the case of a prescription which identifies the pharmaceutical benefit by reference to a brand; or two spaces, in the case of a prescription which does not identify the pharmaceutical benefit by reference to a brand. |
| Quantity | 77 | 81 | 5 | N | Five bytes numeric, right justified, zero filled, to represent the quantity supplied. The value must be the total quantity supplied where supply of the original prescription and the repeat(s) is made at the one time pursuant to Regulation 24 of the Regulations. A value must be present for all items. |
| Price | 82 | 88 | 7 | N | Seven bytes numeric, right justified, zero filled, value in cents; for prescriptions priced by the approved pharmacist or approved medical practitioner in accordance with an election pursuant to paragraph 37 of the Determination made under sub-section 98B(1) of the Act or priced by the approved pharmacist or approved medical practitioner as exceptional prescriptions or items that do not appear in the Schedules of PBS or RPBS Pharmaceutical Benefits and have been prior approved by the Department of Veterans’ Affairs must be priced. |
| Number of repeats | 89 | 90 | 2 | N | Two bytes numeric, right justified, zero filled; must be the number of repeats prescribed, subject to the maximum allowable, for original prescriptions, repeat authorisations, original authorities, authority repeats and deferred supply authorisations; must be the number of repeats which are required where supply of the original prescription and the repeat(s) is made at the one time pursuant to regulation 24 of the Regulations. |
| Column 1 | 2 | 3 | 4 | 5 | Column 6 |
|---|---|---|---|---|---|
| Field | Start | End | CH | Type | Description |
| *Original PBS Approval Number | 91 | 96 | 6 | A/N | Six bytes alpha/numeric, right justified, zero filled; this being the field printed on a repeat authorisation in the box “Original Prescription Details” that is the approval number allotted to the approved pharmacist or approved medical practitioner under regulation 8A of the regulations, that supplied the original prescription. If not present in PDS, value is null. |
| * Original Unique Pharmacy Prescription Number | 97 | 116 | 20 | A/N | Twenty bytes alpha/numeric, right justified, space filled. This is the field printed on a repeat authorisation in the box “Original Prescription Details” that is the unique pharmacy prescription number allocated by the approval that supplied the original prescription. If not present in PDS, value is null. |
| *Date of previous supply | 117 | 124 | 8 | N | Eight bytes, numeric, in the format DDMMCCYY; that is the date printed on a repeat authorisation in the box “Name and PBS Approval number of the pharmacist issuing this authorisation” (where it is called “Date this Authorisation Prepared”). If not present in PDS, value is null. |
| Previous Supplies | 125 | 126 | 2 | N | Two byte numeric field, right justified, zero filled. This field is required on all repeats, authority repeats and deferred supply forms. It is the number of times (including the original supply) that the item has been supplied prior to this supply. Should be '00' for all deferred supply forms. |
| Regulation 24 | 127 | 127 | 1 | A | One byte alphabetic, value 'Y' if supply of the original prescription and the repeat(s) is made at the one time pursuant to regulation 24 of the Regulations; otherwise 'N'. |
| Glass Bottle | 128 | 128 | 1 | A | One byte alphabetic, value 'Y' if, in a prescription for extemporaneously-prepared ear drops, eye drops or nasal instillations, a glass bottle is ordered by the prescriber or considered necessary by the approved pharmacist or approved medical practitioner; otherwise 'N'. |
| Authority Prescription Number | 129 | 136 | 8 | N | Numeric field, right justified, zero filled. This field is required for all authority and all authority repeat forms. It is the number that appears at the top right of the authority form and is transferred to the authority repeat form. |
| Authority Approval Number | 137 | 144 | 8 | A/N | For Future Use. To be sent to HIC space filled until required. Associated check digit routines/formats will be provided in the future. |
| Immediate Supply Necessary | 145 | 145 | 1 | A | One byte alphabetic field. Acceptable values for this field are; 'Y' 'N'. Where immediate supply was necessary the value will be 'Y' otherwise 'N' or blank. 'Y' indication does not remove the need for physical endorsement of the prescription. This field is required to identify prescriptions endorsed and supplied within the 4 and 20 day period (Reg 25).NB Blank/space is an invalid value. |
| Medicare Number | 146 | 156 | 11 | N | Eleven bytes numeric, being made up of the first nine digits of the Medicare card number (Medicare number stem). The tenth digit being the card issue number and the eleventh digit being the individuals reference number. The Medicare number can also be a special Medicare number which applies to the person for whose treatment the prescription was written. For RPBS prescriptions where an entitlement number is supplied or doctors’ bag order forms, this field is zero filled. |
| Entitlement id | 157 | 167 | 11 | A/N | For concessional benefit prescriptions, the entitlement number from the Health Care Card, Pensioner Concession Card, Repatriation Health Card (Specific Conditions), Repatriation Health Card (All Conditions), Commonwealth Seniors Health Card, Repatriation Pharmaceutical Benefits Card or PBS Safety Net Entitlement Card or PBS Safety Net Concessional Card which applies to the patient. For general benefit prescriptions or doctors’ bag order forms, this field is space filled. |
| Family name | 168 | 207 | 40 | A | Alphabetic field, left justified, blank filled; being the surname of the person for whom the prescription was written. This being the name on the Medicare card or equivalent DVA card. For doctors’ bag order forms this field is space filled. |
| Given name | 208 | 247 | 40 | A | Alphabetic field, left justified, blank filled; being the given name, or the first letter of that name, of the person for whom the prescription was written. This being the name on the Medicare card or equivalent DVA card. For doctors’ bag order forms this field is space filled. |
| Resubmission Flag | 248 | 248 | 1 | A | Alphabetic field, right justified; being a field which indicates that this prescription was rejected in a former claim and is being resubmitted for payment. Acceptable values for this field are; 'Y' or 'N', with ‘N’ being the default. |
| Pharmacy Processing Code | 249 | 250 | 2 | A/N | Alphanumeric field, right justified; being a field which indicates that the Pharmacy has reason to contest the response from HIC. These will be in the form of a processing code (supplied to pharmacy by HIC). The following are acceptable values:00 – Processing code not required (default)01 – Entitlement Validation Indicator02 – ISP not available03 - Safety Net** The pharmacy has sighted information showing that the consumer is a new customer to Centrelink, that day and is actually entitled to PBS at the concessional rate. |
| PBS Reference Number | 251 | 262 | 12 | A/N | Alpha/numeric field, right justified; being a number created by HIC when a pre-assessment was requested by pharmacy. This number will be used to honour pharmacy payment where entitlement details may have changed since the pre-assessment was completed only if the pre-assessment was supplied on the same day. |
| Carriage return and line feed | N/a | N/a | N/a | N/a | End of record |
* New or enhanced fields.
**Each script is treated as an individual i.e. for example an original and five repeats, each repeat is regarded as a new script for this purpose.
PART 3 – CLAIM TRAILER RECORD
This details the end of the claim reiterating the claim number for the year and listing the number of prescription records in the claim.
| Column 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|
| Field | Start | End | CH | Type | Description |
| Record type | 1 | 1 | 1 | A | One byte alphabetic, value 'Z', to identify this record as being a claim trailer record. |
| Number of scripts | 2 | 6 | 5 | N | Five bytes numeric, values 00001 to 99999, being the total number of scripts in the claim. |
| Carriage return and line feed | N/a | N/a | N/a | N/a | End of record |
Sourced from the Federal Register of Legislation (legislation.gov.au), CC BY 4.0.
COMMONWEALTH OF AUSTRALIA
National Health Act 1953
PHARMACEUTICAL BENEFITS
RULES UNDER SUBSECTION 99AAA(8)
No. PB 15 of 2004
I, ALLAN RENNIE, Assistant Secretary, Pharmaceutical Access and Quality Branch, Department of Health and Ageing and Delegate of the Minister for Health and Ageing, pursuant to subsection 99AAA(8) of the National Health Act 1953, hereby make the following Rules:
Preliminary
(b) Rules No. PB 8 of 2002 under subsection 99AAA(8) of the National Health Act 1953 made on 22 April 2002 with effect from 1 May 2002, as amended, are repealed.
Definitions
(a) a word or expression shall be taken to have the same meaning as in Part VII of the Act;
(b) “Act” means the National Health Act 1953;
“A section” means:
(i) in respect of an authority prescription, a repeat authorisation, a deferred supply authorisation or a doctor’s bag 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
(ii) in respect of a prescription other than a prescription specified in paragraph (a) - the section of the stamp format marked “A” appearing on the prescription;
“authority prescription” means a prescription written on an authority pursuant to regulation 13 of the Regulations, subparagraph 14(d) of the declaration under subsection 85(2) of the Act or subparagraph 11(d) of the determinations under sections 85, 85A and 88 of the Act;
“Commission” means the Health Insurance Commission established by the Health Insurance Commission Act 1973;
“deferred supply authorisation” means a deferred supply authorisation prepared under regulation 26A of the Regulations upon which a pharmaceutical benefit has been supplied;
“diskette” means a computer diskette used to record data and programs for use on a computer system where the diskette is compatible with the MS-DOS operating system and where, unless otherwise agreed with the Commission, the format of the diskette is one of the formats listed in the following table:
Capacity Physical Disk Size Compatibility
720 kilobytes 3.5 inches IBM
1.44 megabytes 3.5 inches IBM
“diskette claim” means a claim by means of a computer file named PBPCTS.DSK recorded on a diskette forwarded to the office of the Commission to which the claim, pursuant to rule 3, is furnished;
“doctor’s bag form” means an order form for the purpose of regulation 16 of the Regulations or a notification form for the purpose of regulation 18A of the Regulations;
“exceptional prescription” means a prescription for an extemporaneously-prepared pharmaceutical benefit that is not a standard formulae preparation and for which the price of the ingredients calculated in accordance with paragraphs 21 to 24 of the determination made under paragraph 98B(1)(a) of the Act is not less than twice the amount calculated in accordance with paragraph 38 of that determination, excluding container price, dispensing fee and administration 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;
“Managing Director” means the Managing Director of the Commission;
“online claim” means a claim by means of:
(a) a modem transmission to the Central Office of the Commission using a computer program supplied by the Commission; and
(b) a computer file transmitted to the Central Office of the Commission by means of a telecommunications provider or electronic mail, using a computer encryption program supplied by the Commission.
“prescriber” means the medical practitioner or participating dental practitioner who wrote or prepared the prescription;
“prescription” includes an authority prescription, a repeat authorisation, a deferred supply authorisation and a doctor’s bag form;
“prescription record” means:
(a) each item of information listed in Column 1 of Part 4 of Schedule 1 as described in Column 4 of Part 4 of that Schedule; or
(b) each item of information listed in Column 1 of Part 2 of Schedule 2 as described in Column 6 of Part 2 of that Schedule;
“Regulations” means the National Health (Pharmaceutical Benefits) Regulations 1960 made under the Act;
“repeat authorisation” means a repeat authorisation prepared under regulation 26 of the Regulations upon which a pharmaceutical benefit has been supplied;
“S section” means:
(i) in respect of an authority prescription, a repeat authorisation, a deferred supply authorisation or a doctor’s bag 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
(ii) 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.
Claims procedures
(a) the claim shall be made on and in accordance with the form approved by the Managing Director; and
(b) except as provided in subparagraph (d), the claim shall be made in respect of pharmaceutical benefits supplied during a period not exceeding 35 days; and
(c) except as provided in subparagraph (d), the claim shall be furnished to an office of the Commission not more than 30 days after the last day of the period in respect of which the claim is made; and
(d) where the Managing Director is satisfied that an approved supplier was unable, through circumstances outside the approved supplier’s control, to comply with subparagraph (b) or (c), a claim may be made or furnished outside the requirements of those subparagraphs; and
(e) except as provided in subparagraph (f), a claim shall not be furnished to the Commission during the same calendar month as any previous claim; and
(f) notwithstanding subparagraph (e), a claim may be furnished to the Commission in the same calendar month as a previous claim in accordance with an arrangement between the approved supplier and the Managing Director in which the approved supplier has proposed that one or more additional claims be accepted in a calendar month and which the Managing Director, provided that he or she is satisfied that the arrangement will not impose additional administrative expenses on the Commission, has accepted; and
(g) the claim shall be furnished accompanied by the original prescriptions:
(i) upon the presentation of which the pharmaceutical benefits that are the subject of the claim were supplied; and
(ii) on each of which that is not an authority prescription, a repeat authorisation, a deferred supply authorisation or a doctor’s bag 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
(iii) 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:
(A) in respect of general benefit prescriptions — commencing at “1” in each claim and continuing consecutively in respect of that claim; and
(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; and
(C) in respect of entitlement card prescriptions — commencing at “E1” in each claim and continuing consecutively in respect of that claim; and
(D) in respect of doctor’s bag forms — commencing at “1” in each claim and continuing consecutively in respect of that claim; and
(iv) 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 subparagraph (iii) the letter “A”; and
(v) on each of which that is a deferred supply authorisation shall be marked as a prefix to the serial number allocated under subparagraph (iii) the letter “D”; and
(vi) on each of which shall be marked in the A section or A sections:
(A) where the approved supplier has made an election pursuant to paragraph 39 of the determination made under paragraph 98B(1)(a) of the Act and the prescription is in respect of an extemporaneously‑prepared pharmaceutical benefit not included in the Standard Formulae List, the price calculated by the approved supplier in accordance with paragraph 20 of that Determination; or
(B) where the approved supplier has not made an election pursuant to paragraph 39 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 paragraph 20 of that Determination; or
(C) 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 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 Managing Director, outside the supplier’s reasonable control; and
(h) the claim shall be divided into four bundles in accordance with the categories set out in subsubparagraph (g) (iii), with the prescriptions in each bundle sorted into the order of the serial numbers allocated under that subparagraph with the least serial number at the top of each bundle.
Information requirements
(a) the name of the approved supplier; and
(b) the number allotted to the approved supplier under regulation 8A of the Regulations; and
(c) the address:
(i) where the approved supplier is an approved pharmacist — of the premises in respect of which the pharmacist is approved under section 90 of the Act; or
(ii) where the approved supplier is an approved medical practitioner — to which the medical practitioner would seek correspondence to be directed; or
(iii) where the approved supplier is an approved hospital authority — of the hospital; and
(d) in the case of a diskette claim – the prescription record.
Electronic claims procedures
(a) the information provided in one provision of information shall not relate to more than one claim (in this rule referred to as the “relevant claim”) made in accordance with rule 3; and
(b) the information shall be provided in not more than 99 parts (in this rule referred to as “claim parts”); and
(c) the information shall be provided by means of either a diskette claim or an online claim; and
(d) the information in each claim part shall be provided in the form of a standard ASCII computer file that:
(i) complies with the applicable format requirements for diskette claims or online claims, as the case may be; and
(ii) is produced by a computer program that:
(A) does not allow the approved supplier to alter the description of the pharmaceutical benefit or its drug code (within the meaning of the Schedule to these Rules) within the program; and
(B) ensures that the prescription information entered into it is accurately transposed to the file; and
(C) ensures that the information recorded in the file in respect of each pharmaceutical benefit is in accordance with the Act and Regulations and all Determinations, Declarations and Rules made under the Act and Regulations as they applied at the time that the pharmaceutical benefit was supplied; and
(D) takes all reasonable precautions to ensure that information relating to the supply of a substance that was not, in the circumstances, a pharmaceutical benefit, or that was a pharmaceutical benefit but was supplied contrary to section 89 of the Act, is not included in the file.
Format requirements – diskette claims
(a) is divided into the following sections, in the following order:
(i) a single claim part header record consisting of the fields listed in column 1 of Part 1 of Schedule 1 to these Rules; and
(ii) a prescription record for each prescription being claimed, each consisting of the fields listed in column 1 of Part 4 of Schedule 1 to these Rules; and
(iii) a single claim part trailer record consisting of the fields listed in column 1 of Part 2 of Schedule 1 to these Rules; and
(iv) where the information in relation to the relevant claim is provided in one claim part, or in more than one claim part and the claim part is the final part in which the information will be provided, a single claim trailer record consisting of the fields listed in column 1 of Part 3 of Schedule 1 to these Rules;
where each field contains the information described opposite to the field in column 4 of that Part of that Schedule in the form so described, commencing at the position specified in column 2 of that Part of that Schedule opposite to the field and ending at the position specified in column 3 of that Part of that Schedule opposite to the field; or
(b) is divided into the following sections, in the following order:
(i) a single claim part header record consisting of the fields listed in column 1 of Part 1 of Schedule 2 to these Rules; and
(ii) a prescription record for each prescription being claimed, each consisting of the fields listed in column 1 of Part 2 of Schedule 2 to these Rules; and
(iii) a single claim part trailer record consisting of the fields listed in column 1 of Part 3 of Schedule 2 to these Rules; and
where each field contains the information described opposite to the field in column 6 of that Part of that Schedule in the form so described, commencing at the position specified in column 2 of that Part of that Schedule opposite to the field and ending at the position specified in column 3 of that Part of that Schedule opposite to the field.
Format requirements – online claims
Manual claims procedures
Claim processing procedures
This is an opening excerpt, not the complete document.