12Procedures for processing and determining claims

12 Procedures for processing and determining claims

(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. (2) The Chief Executive Medicare must institute reasonable checks to satisfy the Chief Executive Medicare 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 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.

(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.