Offline solution claiming procedures

The administration of payments for claims by Medicare Australia to state and territory health departments for HSD and PBS trastuzumab (Herceptin®) began on 1 July 2009.

From this time, under the offline solution, payment will occur monthly in arrears after Medicare Australia has received HSD and PBS trastuzumab (Herceptin®) claiming information from state and territory health departments.

Updated HSD and PBS trastuzumab (Herceptin®) claim forms will be emailed by Medicare Australia to state and territory health departments before the start of each month. Claims must be submitted on the Medicare Australia approved claim form.

Claim form information

Claims for Highly Specialised Drugs

When claiming HSD through the offline solution, the claim form must include the following information:

• PBS item name
• PBS code
• form
• pack size
• total cost
• total number of patients
• month of dispensing

Claims for CAR medicines and PBS trastuzumab (Herceptin®)

When claiming CAR medicines and PBS trastuzumab (Herceptin®) through the offline solution, the claim form must include the following information:

• PBS item name
• PBS code
• form
• pack size
• total cost
• total number of patients
• month of dispensing
• hospital approval number
• Medicare Australia Authority prescription number
• original supply or repeat number
• supply date
• number of packs dispensed

All HSD and PBS trastuzumab (Herceptin®) are to be claimed on the spreadsheet that relates to the month in which they are dispensed. For example, if a medicine is dispensed in July 2009, then it must be claimed in the July 2009 spreadsheet.

State and territory health departments must complete the columns stating the number of packs dispensed and the total number of patients for each item claimed.

Failure to provide complete information will delay payment for that item.

The format of the claim spreadsheet is not to be altered.

The spreadsheet has been formatted to show the amount claimed based on the packs dispensed multiplied by the price. The state or territory is entitled to claim that amount less 0.8 per cent. This is shown in the ‘Claimable amount (cost less 0.8%)’ column.

Claiming information for CAR HSD and PBS trastuzumab (Herceptin®) must also be included. Failure to provide complete information will delay payment.

Information that identifies the patient is not required under the offline solution.

For more information on the spreadsheet please see Payment for approved CAR HSD dispensed by public hospital pharmacies

Certification

By submitting the claim form, you agree and certify that the HSD and PBS trastuzumab (Herceptin®) were supplied after 1 July 2009and that the items have not been included in any separate claim made directly by the approved HSD public hospital or by any agent of the hospital to Medicare Australia.

Submission of claim form

Under the offline solution, state and territory health departments are to forward their claim form (as an Excel spreadsheet in electronic form (email or CD)) each month to claim for eligible HSD and PBS trastuzumab (Herceptin®) medicines that have been dispensed.

State and territory health departments are responsible for collating their respective state/territory claims and submitting one collated claim form per month.

More than one claim form per month is allowed where the other claim forms are for HSD and PBS trastuzumab (Herceptin®) dispensed in different months.

Claims forms must be received by Medicare Australia no later than three months from the end of the claim period. For example, all claims for items dispensed in the month of July 2009 will need to be received by 31 October 2009.

Claim forms should be submitted a minimum of two weeks before the payment date to guarantee inclusion in the following payment run. Completed forms are to be emailed to public.hospital.hsd@medicareaustralia.gov.au

Participating public hospitals—CAR HSD and PBS trastuzumab (Herceptin®)

Participating public hospitals are able to claim CAR HSD and PBS trastuzumab (Herceptin®) in their normal PBS claims to Medicare Australia.

State and territory health departments must make sure that if a participating public hospital claims these items directly from Medicare Australia, the items are not included in the state or territory health department monthly claim form.

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Last updated: 30 June, 2010