The result

What an eligibility check looks like.

One call: you send the patient and the items, and you get back one answer per item. Below is a real result. Open any item for Medicare’s working.

You send

Eligibility check

Rose RIVIERA

Card2987654351/2Born12 Oct 1985SettingOut of hospitalProvider1234561Y
4 MBS items
  • 44
  • 12315
  • 104
  • 11506

You get back

Eligibility result

2 of 4 items are eligible.

2 eligible1 not eligible1 cannot determine
Benefit payable $143.10

Patient verified The patient's details match Medicare's records.

  • Item 44Eligible Benefit$122.15

    The patient is eligible to claim this item.

    All 7 checks passed

    • Patient age This check found no age limit for this item.. Eligible.
    • Referrer eligibility Medicare pays this item with any referrer or with none, because a referral is optional for this item.. Eligible.
    • In-hospital status Medicare pays this item only for out-of-hospital patients. This submission does not mark the patient as in hospital.. Eligible.
    • Bulk billing Medicare pays this item whether or not the service is bulk-billed.. Eligible.
    • Frequency of service Medicare found this item within its limits on how often it is paid, including limits based on the patient's earlier claims.. Eligible.
    • Multiple item restrictions Medicare found no restriction on claiming this item with other items.. Eligible.
    • Other Medicare checks Medicare's other checks, including the servicing provider and referral requirements, found no restriction.. Eligible.
    Schedule fee$122.15

    MBS item description

    Professional attendance by a general practitioner at consulting rooms (other than a service to which another item in the table applies), lasting at least 40 minutes and including any of the following that are clinically relevant: (a) taking an extensive patient history; (b) performing a clinical examination; (c) arranging any necessary investigation; (d) implementing a management plan; (e) providing appropriate preventive health care; for one or more health-related issues, with appropriate documentation-each attendance

  • Item 11506Eligible Benefit$20.95

    The patient is eligible to claim this item.

    All 7 checks passed

    • Patient age This check found no age limit for this item.. Eligible.
    • Referrer eligibility Medicare pays this item with any referrer or with none, because a referral is optional for this item.. Eligible.
    • In-hospital status Medicare pays this item for patients in hospital and out of hospital.. Eligible.
    • Bulk billing Medicare pays this item whether or not the service is bulk-billed.. Eligible.
    • Frequency of service Medicare found this item within its limits on how often it is paid, including limits based on the patient's earlier claims.. Eligible.
    • Multiple item restrictions Medicare found no restriction on claiming this item with other items.. Eligible.
    • Other Medicare checks Medicare's other checks, including the servicing provider and referral requirements, found no restriction.. Eligible.
    Schedule fee$24.60

    MBS item description

    Measurement of spirometry, that: (a) involves a permanently recorded tracing, performed before and after inhalation of a bronchodilator; and (b) is performed to: (i) confirm diagnosis of chronic obstructive pulmonary disease (COPD); or (ii) assess acute exacerbations of asthma; or (iii) monitor asthma and COPD; or (iv) assess other causes of obstructive lung disease or the presence of restrictive lung disease; each occasion at which recordings are made

  • Item 12315Not eligible Benefit—

    7 checks · 1 flagged

    • Frequency of service Maximum number of services for this item already paid. Not eligible.
    • Patient age This check found no age limit for this item.. Eligible.
    • Referrer eligibility Medicare pays this item with any referrer or with none, because a referral is optional for this item.. Eligible.
    • In-hospital status Medicare pays this item for patients in hospital and out of hospital.. Eligible.
    • Bulk billing Medicare pays this item whether or not the service is bulk-billed.. Eligible.
    • Multiple item restrictions Medicare found no restriction on claiming this item with other items.. Eligible.
    • Other Medicare checks Medicare's other checks, including the servicing provider and referral requirements, found no restriction.. Eligible.
    Schedule fee$122.55

    MBS item description

    Bone densitometry, using dual energy X‑ray absorptiometry, involving the measurement of 2 or more sites (including interpretation and reporting) for diagnosis and monitoring of bone loss associated with one or more of the following conditions: (a) primary hyperparathyroidism; (b) chronic liver disease; (c) chronic renal disease; (d) any proven malabsorptive disorder; (e) rheumatoid arthritis; (f) any condition associated with thyroxine excess; other than a service associated with a service to which item 12306, 12312 or 12321 applies For any particular patient, once only in a 24 month period

  • Item 104Cannot determine Benefit—

    7 checks · 1 flagged

    • Referrer eligibility This item needs a referral from a provider recognised as 'Practitioner'. Enter the referrer provider number, then check again.. Cannot determine.
    • Patient age This check found no age limit for this item.. Eligible.
    • In-hospital status Medicare pays this item for patients in hospital and out of hospital.. Eligible.
    • Bulk billing Medicare pays this item whether or not the service is bulk-billed.. Eligible.
    • Frequency of service Medicare found this item within its limits on how often it is paid, including limits based on the patient's earlier claims.. Eligible.
    • Multiple item restrictions Medicare found no restriction on claiming this item with other items.. Eligible.
    • Other Medicare checks Medicare's other checks, including the servicing provider and referral requirements, found no restriction.. Eligible.
    Schedule fee$103.95

    MBS item description

    Professional attendance at consulting rooms or hospital by a specialist in the practice of the specialist’s specialty after referral of the patient to the specialist—initial attendance in a single course of treatment, other than a service to which item 106, 109, 125 or 16401 applies

Checked against Medicare's records in real time.

Before any item is assessed

Patient verification outcomes.

Every check begins by matching the patient's details against Medicare's records. Each outcome below leaves the front desk something different to do.

Patient verified

Everything lines up. Nothing to do.

Patient verified The patient's details match Medicare's records.

Details don’t match, corrected

Medicare returns the right value, so it is offered ready to apply.

Details don’t match Patient Verification has been accepted however patient details were not an exact match. Please check patient Given Name before claiming. Correct Given Name: ROSE.

  • Given nameROSAROSE

Details don’t match, no correction

Medicare does not name the field that is wrong. Check the card with the patient.

Details don’t match The card number and/or patient details submitted did not match Medicare checks. Please verify the details and resubmit with additional information if available.

Cannot determine

Several causes are possible; here, a date in the wrong format. The reason always names the cause.

Cannot determine The patient’s date of birth '1986-13-99' is not a valid date. Enter it as year-month-day, for example 1975-03-14.

For developers

Building this in your product.

Everything above is one CalculateRebate response, rendered in our brand. Here is the response itself, and what to carry across into yours.

The response, annotated

{
  "PatientVerification": {
    "Verified": true,the banner under the patient
    "Reason": "The patient's details match Medicare's records.",shown verbatim
    "CorrectGivenName": null,the correction, when set
    … five more Correct* fields, all null here
  },
  "Rebates": [
    {
      "ItemNumber": "44",
      "IsEligible": true,the pill
      "Reason": "The patient is eligible to claim this item.",shown verbatim
      "Benefit": "122.15",dollars, as a string
      "ItemScheduleFee": "122.15",
      "Checks": [the ledger, and the bar strip
        {
          "Title": "Patient age",
          "IsEligible": true,
          "Reason": "This check found no age limit for this item."
        },
        … six more checks
      ]
    },
    … items 12315, 104 and 11506
  ]
}
The verification, then one entry per item. Trimmed to the fields the screen uses; the full payload is in the Eligibility Check reference. The MBS item description on each card is the one thing above that is not in this response. Join it from the schedule yourself, as our own app does.

Three states, three jobs

StateResponseWhat the screen must get across
Eligible IsEligible: true Claim it. Benefit is what Medicare pays, in dollars.
Not eligible IsEligible: false The claim would be rejected, and why. Give this your strongest treatment, wherever your ordering puts it.
Cannot determine IsEligible: null Never a quiet no. Show Reason: it says what could not be checked and why.

Four rules

  1. Colour is never alone. Every state carries a colour, an icon and a word. Roughly one in twelve men cannot separate red from green.
  2. Show Reason exactly as returned. Services Australia requires its messages reach the end user unchanged: not truncated, not reworded. Never parse it either, at item or check level.
  3. Branch on IsEligible, never on ReasonCode. The code set grows as rule coverage expands. It is for your analytics, not your logic, and not for the screen.
  4. Render Checks as returned. Each check carries the same IsEligible and Reason pair as the item, so one component renders both. Titles are an open set that grows with rule coverage; render unfamiliar ones rather than filtering to a known list. The bar strip in each item’s header is that same array at a glance and is decorative only, which is why the ledger below still says it in words.

Read the Eligibility Check reference How the eligibility check works

This result, in your software.

Every result on this page came from one API call. The response carries the answers, the reasons, the benefit, and the checks, ready to render however suits your product.

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