National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Determination 2002 (Cth)
National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Determination 2002
as amended
made under subsection 99 (8) of the of the National Health Act 1953.
Compilation start date: 1 July 2002
Includes amendments up to: National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Amendment Determination 2002 (No. 1)
Prepared by the Department of Health and Ageing, Canberra.
About this compilation
The compiled instrument
This is a compilation of the National Health (Circumstance for Payment of Supplier of Pharmaceutical Benefits) Determination 2002 amended and in force on 1 July 2002. It includes any amendment affecting the compiled instrument to that date.
This compilation was prepared on 14 August 2013.
The notes at the end of this compilation (the endnotes) include information about amending Acts and instruments and the amendment history of each amended provision.
Uncommenced provisions and amendments
If a provision of the compiled instrument is affected by an uncommenced amendment, the text of the uncommenced amendment is set out in the endnotes.
Application, saving and transitional provisions for amendments
If the operation of an amendment is affected by an application, saving or transitional provision, the provision is identified in the endnotes.
Modifications
If a provision of the compiled instrument is affected by a textual modification that is in force, the text of the modifying provision is set out in the endnotes.
Provisions ceasing to have effect
If a provision of the compiled instrument has expired or otherwise ceased to have effect in accordance with a provision of the instrument, details of the provision are set out in the endnotes.
Contents
Part 1 Preliminary 4
1.Name of Determination 4
2.Commencement 4
3.Definitions 4
4.Purpose of Determination 4
5.Supplier unaware of inapplicability of medicare number 5
6.Inapplicable medicare number warning given less than 90 days
previously 6
7 Supplier aware of inapplicability of medicare number 6
Endnotes 8
Part 1 Preliminary
Name of Determination
This Determination is the National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Determination 2002.
Commencement
(1) This Determination commences on 1 May 2002.
Definitions
In this Determination:
Act means the National Health Act 1953.
individual reference number means the eleventh digit of a medicare number, appearing next to the name of a person listed on a medicare card issued for that medicare number.
issue number means the tenth digit of a medicare number, indicating how many times a medicare card has been issued in relation to that medicare number.
validity test means the algorithm used by the Health Insurance Commission to check that a number tendered as a medicare number is constructed in a valid way.
Note 1 The following terms are defined in subsection 84 (1) of the Act:
·approved supplier
·expiry date (in relation to a medicare number)
·medicare card
·medicare number
·pharmaceutical benefit.
Note 2 See subsection 94 (10) of the Act for the meaning of a medicare number ultimately supplied to the health Insurance Commission in relation to a prescription.
Purpose of Determination
This Determination identifies the circumstances in which, despite subsection 99 (7) of the Act, an approved supplier is to be paid by the Commonwealth in relation to the supply of a pharmaceutical benefit in respect of a person to whom a prescription relates, even though the medicare number ultimately supplied to the Health Insurance Commission in relation to the prescription does not correspond with a mediocre number that is held in the records of the Health Insurance Commission as a number applicable to the person.
Supplier unaware of inapplicability of medicare number
(1) This section identifies the following circumstances:
(a) an approved supplier makes a claim for payment by the Commonwealth for the supply of a pharmaceutical benefit in respect of a person to whom a prescription relates; and
(b) the claim includes a number as a medicare number applicable to the person; and
(c) in processing the claim, the Health Insurance Commission:
(i) finds that the medicare number passes the validity test; and
(ii) finds that:
(A) the medicare number does not correspond with a medicare number held in the records of the Health Insurance Commission; or
(B) at the time of the supply of the pharmaceutical benefit, the issue number was not the current issue number; or
(C) the individual reference number is not correct; or
(D) the medicare card on which the medicare number appears has been cancelled by the Health Insurance Commission and a new medicare card has not been issued in relation to that medicare number; or
(E) the expiry date for the medicare number has passed and a new medicare card has not been issued in relation to that medicare number; or
(F) the name of the person does not correspond with the name of the person held in the records of the Health Insurance Commission as being the person to whom the medicare number applies; or
(G) the medicare number is no longer applicable to the person but the medicare card on which the medicare number appears, or would appear if it were applicable, is valid for another person listed on that medicare card; or
(H) at the time of the supply of the pharmaceutical benefit, the person was not, or was not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973; and
(d) either:
(i) the approved supplier has not previously made a claim including that number as a medicare number applicable to the person; or
(ii) the approved supplier has previously made a claim including that number as a medicare number applicable to the person and, at the time the claim mentioned in paragraph (a) was made, the approved supplier had not been notified of, or warned about, a matter mentioned in paragraph (c).
(2) For subparagraph (1) (c) (ii) no account is taken of the number ‘0’, if that number appears as the issue number or individual reference number, in determining that the issue number or individual reference number is incorrect.
Inapplicable medicare number warning given less than 90 days previously
(1) This section identifies the following circumstances:
(a) an approved supplier makes a claim for payment by the Commonwealth for the supply of a pharmaceutical benefit in respect of a person to whom a prescription relates; and
(b) the claim includes a number as a medicare number applicable to the person; and
(c) in processing the claim, the Health Insurance Commission finds that:
(i) the medicare number passes the validity test; and
(ii) the approved supplier has made a previous claim including the number as a medicare number applicable to the person; and
(iii) in processing the previous claim, the Health Insurance Commission found that:
(A) the medicare number did not correspond with a medicare number held in the records of the Health Insurance Commission; or
(B) at the time of the supply of the pharmaceutical benefit, the issue number was not the current issue number; or
(C) the individual reference number was not correct; or
(D) at the time of the supply of the pharmaceutical benefit, the person was not, or was not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973; and
(d) less than 90 days before the supply of the pharmaceutical benefit to which the claim mentioned in paragraph (a) relates, the Health Insurance Commission gave a warning to the approved supplier about a matter mentioned in paragraph (c) and the effect of including, in a future claim, that number as a medicare number applicable to the person.
(2) For subparagraph (1) (c) (iii) no account is taken of the number ‘0’, if that number appears as the issue number or individual reference number, in determining that the issue number or individual reference number is incorrect.
Supplier aware of inapplicability of medicare number
This section identifies the following circumstances:
(a) an approved supplier makes a claim for payment by the Commonwealth for the supply of a pharmaceutical benefit in respect of a person to whom a prescription relates; and
(b) the claim includes a number as a medicare number applicable to the person; and
(c) in processing the claim, the Health Insurance Commission finds that:
(i) the medicare number passes the validity test; and
(ii) the approved supplier has made a previous claim including the number as a medicare number applicable to the person; and
(iii) in processing the previous claim, the Health Insurance Commission found that:
(A) the medicare card on which the medicare number appears had been cancelled by the Health Insurance Commission and a new medicare card had not been issued in relation to that medicare number; or
(B) the expiry date for the medicare number had passed and a new medicare card had not been issued in relation to that medicare number; or
(C) the name of the person did not correspond with the name of the person held in the records of the Health Insurance Commission as being the person to whom the medicare number applies; or
(D) the medicare number was no longer applicable to the person but the medicare card on which the medicare number appears, or would appear if it were applicable, was valid for another person listed on that medicare card; and
(d) at the time of the supply of the pharmaceutical benefit to which the claim mentioned in paragraph (a) relates, the approved supplier had been notified of a matter mentioned in paragraph (c).
Endnotes
Endnote 1—Legislation history
This endnote sets out details of the legislation history of the National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Determination 2002.
Table of Instruments
| Title | FRLI registration date | Commencement date | Application, saving and transitional provisions | |||
| National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Determination 2002 | 1 May 2007 (see F2007B00630) | 1 May 2002 | ||||
| National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Amendment Determination 2002 (No.1) | 1 May 2007 (see F2007B00631) | 1 July 2002 | ||||
Endnote 2—Amendment history
This endnote sets out the amendment history of the National Health (Circumstances for Payment of Supplier of Pharmaceutical Benefits) Determination 2002.
| ad. = added or inserted am. = amended rep. = repealed rs. = repealed and substituted exp. = expired or ceased to have effect | ||||
| Provision affected | How affected | |||
| Schedule 1 | ||||
| Paragraph 5(1)(c) | am. F2007B00631 | |||
| Subparagraph 5(1)(c)(i) | am. F2007B00631 | |||
| Subparagraph 5(1)(c)(ii) | am. F2007B00631 | |||
| Paragraph 7(c) | am. F2007B00631 | |||
Endnote 3 – Uncommenced amendments [none]
There are no uncommenced amendments.
Endnote 4—Misdescribed amendments [none]
There are no misdescribed amendments.
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