Inpatient Billing Cheat Sheet

A quick-reference checklist for Australian specialist inpatient medical billing. Print or save this page for administrative use, then verify the specific claim against current official requirements.

Before billing

• Confirm the patient was admitted, rather than assuming a hospital-based service was inpatient.
• Confirm patient Medicare details and private health insurance information where applicable.
• Confirm date of service, hospital/facility and treating practitioner.
• Use the correct provider number for the relevant location.
• Check referral information where required.
• Confirm billing instructions and MBS item(s) with the treating practitioner.

MBS check

• Use current MBS Online.
• Read the complete item descriptor.
• Read applicable explanatory notes.
• Check restrictions, frequency, duration and co-claiming conditions.
• Do not rely on an old code list or fee schedule.

In-hospital payment basics

For eligible medical services to a private patient in hospital, Medicare generally covers 75% of the MBS fee and private health insurance covers at least the remaining 25% of the MBS fee. The practitioner's actual fee can be higher than the MBS fee, and a gap may apply. No-gap or known-gap arrangements can alter the patient's out-of-pocket amount.

Claim pathway check

• Confirm whether ECLIPSE/In-patient Medical Claim processing is appropriate.
• Check provider/fund registration and relevant identifiers.
• Confirm the applicable gap arrangement rather than assuming one.
• Retain appropriate supporting administrative records.

After lodgement

• Track claim status.
• Reconcile Medicare and insurer payments.
• Review assessment/rejection messages.
• Investigate unpaid or partially paid items.
• Correct and resubmit only where supported.
• Keep an ageing list so outstanding claims do not disappear into a backlog.

Common rejection review

Check patient details → provider/location → service date → MBS item → referral → insurer membership → provider registration → applicable fund arrangement → supporting records.

Do not confuse these terms

• MBS: Medicare Benefits Schedule.
• ECLIPSE: electronic claiming environment; not an MBS code set.
• Schedule fee: the MBS fee for an item; not necessarily the doctor's private fee.
• Gap: difference remaining after applicable benefits compared with the practitioner's fee.
• Inpatient: an admitted patient; not simply anyone treated on hospital premises.

Useful DEVZ guides

Billing codes · Billing guidelines · Bill format · ECLIPSE · Rejected claims