279‑11 Determination of claim279‑11 Determination of claim

279‑11 Determination of claim (1) If: (a) the Chief Executive Medicare receives a claim in accordance with section 279‑10; and (b) the criteria specified in the Private Health Insurance (Incentives) Rules for the purposes of this paragraph have been met in relation to the claim; the Chief Executive Medicare must pay the insurer, in accordance with section 279‑15, the amount payable under that section. Note: A decision under this subsection is able to be automated by a computer program: see section 333‑17. (2) If the criteria specified for the purposes of paragraph (1)(b) are not met in relation to the claim, or part of the claim, the Chief Executive Medicare must: (a) if the criteria are not met in relation to part of the claim—refuse the claim in part and only pay the insurer, in accordance with section 279‑15, the amount payable under that section in respect of such part of the claim that meets the specified criteria; or (b) otherwise—refuse the claim. (3) The Chief Executive Medicare must notify the private health insurer if the Chief Executive Medicare makes a decision mentioned in subsection (2). (4) A notice under subsection (3) must include reasons for the decision. (5) The Chief Executive Medicare is taken, for the purposes of this Part, to have accepted a claim in whole if the Chief Executive Medicare does not notify the private health insurer of a decision mentioned in subsection (2) on or before the day under subsection 279‑15(2) by which the claim would have been required to have been paid.