The result

What an eligibility check looks like.

One call, before the claim goes in. Below is a real result, in full.

Eligibility check

Edmond FLETCHER

Card4951525561/2Born18 Dec 1986SettingOut of hospitalServicing2447781LReferrer2447791K

Verified

The patient information matches Medicare's records.

1 not eligible1 to confirm1 eligible
Benefit payable $88.36
  • MBS item37201 Not eligible
    Benefit — Schedule fee $992.10

    The rebate for this Medicare item is only available for in-hospital patients, while the patient is marked as out-of-hospital.

    7 checks 1 flagged
    • Patient age This Medicare item does not have patient age restrictions.Eligible
    • Referrer eligibility Having a referral for this Medicare item is optional, therefore, referral check was skipped.Eligible
    • In-hospital status The rebate for this Medicare item is only available for in-hospital patients, while the patient is marked as out-of-hospital.Not eligible
    • Patient sex This item is not restricted based on patient sex.Eligible
    • Frequency of service This item's frequency-of-service and prior-claim limits were not exceeded.Eligible
    • Multiple item restrictions No conflicting or mutually exclusive item restrictions applied to this claim.Eligible
    • Other Medicare checks Medicare's remaining checks (servicing provider, referral requirements, and similar) raised no restrictions.Eligible
  • MBS item10960 Cannot determine
    Benefit — Schedule fee $74.55

    This item has a frequency-of-service limit, and Medicare doesn't verify it online for out-of-hospital claims. Without the patient's claim history, eligibility can't be determined.

    5 checks 1 flagged
    • Patient age This Medicare item does not have patient age restrictions.Eligible
    • Referrer eligibility Having a referral for this Medicare item is optional, therefore, referral check was skipped.Eligible
    • In-hospital status The rebate for this Medicare item is available for out-of-hospital patients, and the patient is marked as out-of-hospital.Eligible
    • Patient sex This item is not restricted based on patient sex.Eligible
    • Frequency of service This item has a frequency-of-service limit, and Medicare doesn't verify it online for out-of-hospital claims. Without the patient's claim history, eligibility can't be determined.Cannot determine
  • MBS item104 Eligible
    Benefit $88.36 Schedule fee $103.95

    The patient is eligible to claim this item.

    All 7 checks cleared
    • Patient age This Medicare item does not have patient age restrictions.Eligible
    • Referrer eligibility A 'Physiotherapist' is considered a 'Practitioner' therefore eligible to refer this Medicare item.Eligible
    • In-hospital status The rebate for this Medicare item is available to both in-hospital and out-of-hospital patients.Eligible
    • Patient sex This item is not restricted based on patient sex.Eligible
    • Frequency of service This item's frequency-of-service and prior-claim limits were not exceeded.Eligible
    • Multiple item restrictions No conflicting or mutually exclusive item restrictions applied to this claim.Eligible
    • Other Medicare checks Medicare's remaining checks (servicing provider, referral requirements, and similar) raised no restrictions.Eligible

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.

Verified

Everything lines up. Nothing to do.

Verified

The patient information matches Medicare's records.

Mismatch, corrected

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

Didn’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: CLINT.

Given namePETERCLINT

Mismatch, no correction

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

Didn’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.

Couldn’t be verified

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

Couldn’t be verified

'PatientDateOfBirth' is provided as '1986-13-99' which is not in correct format. Acceptable date format: 'yyyy-MM-dd'.

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 information matches Medicare's records.",shown verbatim
    "CorrectGivenName": null,correction chips, when set
    … five more Correct* fields, all null here
  },
  "Rebates": [
    {
      "ItemNumber": "104",match on this, not array order
      "IsEligible": true,the pill
      "Reason": "The patient is eligible to claim this item.",shown verbatim
      "Benefit": "88.36",dollars, as a string
      "ItemScheduleFee": "103.95",
      "Checks": [the expandable list
        {
          "Title": "Patient age",
          "IsEligible": true,
          "Reason": "This Medicare item does not have patient age restrictions."
        },
        … six more checks
      ]
    },
    … items 37201 and 10960
  ]
}
The verification, then one entry per item. Trimmed to the fields the screen uses; the full payload is in the CalculateRebate reference.

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, first in the list.
Cannot determine IsEligible: null Not a no. Say what is missing and how to resolve it.

Five 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.
  5. Match rebates by ItemNumber. Rules that weigh items against each other can reorder the array, so never zip it against your request by index.

Read the CalculateRebate 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 verdicts, the reasons, the benefit, and the checks, ready to render however suits your product.

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