The terms behind Medicare billing in Australia, defined plainly and kept current. For the booking desk and the billing team, not just the developers.
The list of medical services the Australian Government subsidises, and the rules for each. Every service has an item number, a description, and a schedule fee. The Department of Health, Disability and Ageing sets it; Services Australia pays the claims. It runs to about 6,000 items.
The number that identifies one service in the MBS. You quote it to claim the benefit for that service. Each item has its own descriptor and requirements, so the wrong item, or the right item without meeting its rules, is a common reason a claim is rejected.
The fee the Government sets for an MBS item. The Medicare benefit is worked out as a percentage of this fee. It is not a maximum or a required charge: a provider can charge above it, and the patient pays the difference as a gap.
The amount Medicare pays toward a service, set as a percentage of the schedule fee: 100% for GP services to non-admitted patients, 85% for most other out-of-hospital services, and 75% for a private patient in hospital. On higher-fee services a set gap can apply instead of a flat 85%, and the benefit is never more than the fee actually charged.
The yearly adjustment to schedule fees, applied on 1 July (2.6% in 2026). It covers most general medical, diagnostic imaging, and specified pathology items, but not all items, and fees were frozen for several years before 2017. Worth checking the current figure rather than assuming a rise. We track each change in the MBS updates.
A way of billing where the provider accepts the Medicare benefit as full payment, so the patient pays nothing for that service. The benefit is paid straight to the provider, and no extra fee can be charged to the patient for it. It relies on the patient assigning their benefit.
A claim where the patient is billed and the Medicare benefit is paid to the patient, not the provider. It can be lodged before or after the account is paid. Unlike bulk billing, the patient can be left with a gap to cover.
The patient's agreement to have their Medicare benefit paid to the provider. It is what makes bulk billing possible. From 1 July 2026 it can be given on paper or electronically, before or after the service, with no approved form required, and ongoing agreements are allowed for regular bulk-billed GP care.
When Medicare cannot pay a claim as lodged, it returns a code explaining why. Reason codes (3 digits) describe how a claim was assessed and appear on the statement of benefits. Return codes (4 digits) come back when an online or ECLIPSE transaction errors. A rejection is usually not the end: the claim can often be corrected and resubmitted.
The Medicare card shows a person's access to Medicare. The IRN (Individual Reference Number) is the single digit next to each name on the card; with the card number, it identifies each person listed. Up to nine people can share one card, and an IRN can change when a new card is issued, so the card number, IRN, and valid-to date all need to match for a claim to be assessed.
Two separate gates, and both must hold for a benefit to be paid. Medicare eligibility is whether the person is enrolled with a valid card, and whether their claim history leaves the item claimable. Clinical eligibility is whether the service is one the MBS lists and is clinically warranted; that judgment sits with the provider. A valid card does not, on its own, mean a benefit is payable.
A check of whether a patient holds a current Commonwealth concession card, as at the date of service. It affects PBS co-payments and some bulk-billing incentives. The result reflects what Services Australia held at the time of the check, so it is a point-in-time answer, not a guarantee for other dates.
Funding for veterans' treatment, claimed to DVA rather than Medicare. Cover depends on the card: Gold covers all clinically needed conditions, White covers accepted conditions plus some mental health care, Orange covers pharmaceuticals. DVA is separate from Medicare, with its own fee schedule, and it will not pay for a service already met by Medicare or insurance.
A number issued to a health professional for a specific practice location, needed to claim under the MBS. Because it is tied to a location, a provider has a different number at each place they work, and using the wrong one can cause a rejection. It is not the same as an AHPRA registration or a prescriber number.
The login and identity system, run by Services Australia, that lets providers and organisations reach government online services such as HPOS, the AIR, and the claiming channels. PRODA verifies who you are; it does not lodge claims itself. Individual and organisation accounts are registered separately.
The current technology behind digital Medicare claiming, secured through PRODA. It replaced the older adaptor and PKI channel, which was switched off in 2022. The same web-services approach also carries ECLIPSE, DVA, AIR, and PBS claiming.
A Services Australia channel that connects providers, Medicare, private health funds, and DVA over one secure link, used mainly for in-hospital and private patient claims and for checking a patient's cover. It routes claims and eligibility checks between the parties in a single transaction.
The national record of vaccinations given to people in Australia, across all ages, not just children. It covers National Immunisation Program, most school-program, and most privately funded vaccines. Only a recognised vaccination provider can add to it, and some vaccines must be reported by law.
A location identifier, also called a Location or Software ID, used to link a practice to Services Australia's claiming channels during PRODA setup. Your software provider allocates it, one per location, and a practice can hold more than one.
One call verifies the patient and checks each item against the rules, so a ‘no’ comes back with the reason.