What is the term for the statement from the insurer that details the amount billed to a patient?

Information to help you understand your legal obligations if you choose to privately bill a patient.

Table of Contents Show

on this page
Itemised accounts
Health professional details required on account or receipt
Referral details required on account or receipt
Multiple attendances on the same day
Services to in-patients
Benefits for professional services
Paid accounts
Unpaid and partially paid accounts
Related subjects

Itemised accounts

A Medicare benefit isn’t payable unless it’s on an account that includes the fee and service details, including:

the name of the patient
the date of the service
the amount charged
the total amount paid
any amount still owing
an item number and/or a description to identify the service.

Under the Health Insurance Act 1973, you’re legally responsible for services billed to Medicare under either:

your Medicare provider number
your name.

You're also responsible for incorrect claims. This includes when someone else records the information on your behalf, for example, the practice manager.

Health professional details required on account or receipt

Under section 51 of the Health Insurance Regulations 2018, you must include certain information on an account or receipt.

You can provide either or both:

the name of the health professional that’s providing the service and address of the place of practice for the service
the provider number of the health professional.

We can record more than one practice location for you. Always use the provider number for the practice location where you provide the services.

When a locum provides a service on behalf of another health professional, the account documents must use either:

the word Locum
the letters LT.(Locum Tenens).

Referral details required on account or receipt

You need to provide referral details on the account or receipt for patients referred to you. You need to include the following:

the name of the referring health professional
the address or provider number of the referring health professional
the patient’s referral date
the period the referral is valid for.

If a referral is valid for anything other than 12 months, you should reflect it in months. For example, write 3 months. You can also write indefinitely.

Multiple attendances on the same day

We can pay Medicare benefits if you attend to a patient several times on the same day. As long as they’re not continued from the initial or earlier visit.

If you attend to a patient more than once in the same day, include each time on the account. This will help us assess the claims.

Read more about billing multiple MBS items.

Services to in-patients

Mark the account with an asterisk * or the letter “H” if you provide or request services for an in-patient:

of a hospital
at an approved day hospital facility.

You can provide services as part of a privately insured episode of hospital-substitute treatment. The patient may choose to receive a benefit from a private health insurer, if so the claim should include either:

hospital-substitute treatment directly after an item number and brief description of the professional service
hospital-substitute treatment and a description of the professional service identifying the item related to the service.

Ask us to include the account reference details in your Medicare statement of benefit.

This will help you work out which account we’ve paid the Medicare benefit for. The account can hold up to 11 alphabetical and numeric characters.

If we can’t clearly identify the service as qualifying for Medicare benefits, we may delay or not pay the claim.

Benefits for professional services

The claimant is the person who incurred or is liable for the expense for the medical services. We pay Medicare benefits to the claimant.

The claimant and patient aren’t always the same. For example, a parent may pay for the service but they may not be the patient.

Paid accounts

The claimant may pay your account and then claim the Medicare benefit with us.

Unpaid and partially paid accounts

If the claimant hasn’t paid your account, they can present the unpaid or partially paid account to us.

In this case, we’ll forward a Medicare benefit cheque to the claimant made payable to you, the service provider. This is a Pay Doctor via Claimant Cheque (PDVC).

The claimant is responsible for providing the cheque to you and for paying any outstanding balance of the account.

The 90-day pay doctor cheque scheme lets us cancel a PDVC cheque for eligible health professionals. We’ll then pay you the Medicare benefit by EFT instead.

Read more about the 90 day pay doctor cheque scheme.

After your doctor’s appointment, your doctor’s office submits a bill (also called a claim) to your insurance company. A claim lists the services your doctor provided to you. The insurance company uses the information in the claim to pay the doctor for those services.

When the insurance company pays your doctor, it might send you a report called an Explanation of Benefits, or EOB, that shows you what it did. You need to be able to read and understand the EOB to know what your insurance company is paying for, what it’s not paying for, and why. An EOB is not a bill.

Your doctor’s office might send you a statement. A statement shows how much your doctor’s office billed your insurance company for the services you received. If you receive a statement before your insurance company pays your doctor, you do not need to pay the amounts listed at that time. After your insurance company pays your doctor, you may need to pay the doctor any balance due.

Keep in mind that not all insurance companies send EOBs, and not all doctors’ offices send statements. You may receive one or the other or both.

The images below show an EOB and a billing statement with instructions to help you understand them. You should use what you learn to review your EOBs and billing statements carefully. Here are some things to look for:

If the dates of service and description of services on your EOB and billing statement aren’t the same, or if they don’t match other records you may have of the visit, contact your doctor’s office first.
If you have questions about why your insurance company did not cover something or about the amount you have to pay, contact your insurance company.
If more than 60 days have passed and your insurance company still hasn’t paid your doctor, contact your insurance company.

Finally, you should keep your EOBs and statements organized (e.g., filed by date) so that you can access them easily should questions arise.

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

On Jan. 13, 2004, Mary Jones took her daughter Ann to see James Ellis, MD, at his office. In addition to the office visit, Dr. Ellis’s practice provided Ann with an immunization and a blood draw. The sample EOB shows how the Jones’ insurance company, Healthway, handled the claim submitted by Dr. Ellis’s office.

Mrs. Jones has obtained her insurance through her employer, Bayview Industries, so she is the Member, and her employer is the Plan Sponsor. Ann is the Patient, since it is she, not Mrs. Jones, who received the services from Dr. Ellis. The Plan, 02BNAPPO, indicates Mrs. Jones is in the Preferred Provider plan. This is Claim 01.

Dr. Ellis is listed as the Provider, and Jan. 13 is listed as the date of service, since this is the date that he saw Ann. Dr. Ellis charged the insurance company $60 for the office visit, $10 for administering the immunization, $90 for the vaccine itself and $25 for the blood draw.

The Negotiated Savings shows that Dr. Ellis has agreed to accept $50 for the office visit (i.e., $60 charge minus $10 negotiated savings) and $20 for the blood draw (i.e., $25 charge minus $5 negotiated savings).

The insurance company does not cover immunizations, so those related charges ($10 and $90) are listed under Charges Not Covered with a Remark Code to this effect. Both the office visit and blood draw are covered, so the amount listed under Charges Not Covered is $0 for both of those.

Mrs. Jones’s plan requires a $15 co-payment for all office visits, so the EOB shows that she owes $15 for the office visit.

The Total Payable column shows that the insurance company owes Dr. Ellis $55: $35 for the office visit ($50 -$15) and $20 for the blood draw. A check in this amount was issued to Dr. Ellis on Feb. 20. Mrs. Jones owes $115 (the $15 co-pay for the office visit plus $10 for the noncovered immunization administration plus $90 for the vaccine).

The statement from Dr. Ellis’s office to Mrs. Jones dated Jan. 31 shows the same dates of service, a slightly different description of services, and corresponding charges of $185. It shows that Mrs. Jones paid the co-payment ($15) at the time of service. It shows that the account balance is $170, but the insurance company payment hasn’t been posted yet, so there is no amount due from Mrs. Jones at this time.

Mrs. Jones will receive another statement from Dr. Ellis’s office after the insurance company makes a payment. This second statement will show the $55 payment received from Healthway on Feb. 25, and it will show the Negotiated Savings amount of $15 (from the EOB) in the Adjustment column. It also will show the balance of $100, which will then be due from Mrs. Jones.

Dr. Ellis sent Ann’s blood to a lab to be tested. The lab will send a claim for the test to Mrs. Jones’s insurance company. The lab will also send a bill to Mrs. Jones. After the insurance company pays the lab, Mrs. Jones may need to pay the lab any remaining balance.

You probably receive a Medicare Summary Notice. The Medicare Summary Notice is like an EOB, but it has its own terms and explanations. You can learn more about how to understand Medicare Summary Notices by visiting the Medicare Web site at http://www.medicare.gov/Basics/SummaryNotice_HowToRead.asp.