Claiming for community nursing services

Last updated:

13 February 2024

Definitions and Descriptions

Definitions and Descriptions
Definition	Description
Add on	An Add on item number cannot be claimed without a Core item number. For each 28 day claim period, CN providers must identify and claim a Core item number (based on the majority of care delivered) and then choose the relevant Add on item number/s if required.
Claim period	Each claim period is 28 days with the date of the first claim period being the date that services to the client commence. A new claim period cannot commence prior to the end of the previous claim period, and must be in sequence with the previous claim period. If a claim with an earlier start date is submitted this will be rejected by Medicare. A new claim will need to be re-submitted with the correct dates. Services are claimed retrospectively and cannot be claimed until the after the end of the 28 day claim period.
CN Schedule of Fees	The CN Schedule of Fees lists the item numbers and associated amount that can be claimed for each 28 day claim period.
Item numbers	CN providers claim for the provision of CN services through the use of item numbers outlined in the CN Schedule of Fees. More than one item number may be claimed in a 28 day claim period.
Ready Reckoners	Ready Reckoners assists in determining the 28 day claim period cycles. They are available in pdf and excel format on the Information for DVA approved CN providers page.
Second provider/two providers	Where two providers are required to provide services to a client in a 28 day claim period, there must be no duplication of services. Where one provider is delivering clinical care and one is delivering personal care, second provider approval is required from DVA to claim opposing core schedule items. This approval needs to be sought from DVA at the end of the claim period, by the second provider to submit a claim to Medicare.

Overview

As a Department of Veterans’ Affairs (DVA) Community Nursing (CN) provider, it is your responsibility to check your client’s eligibility before you provide services or claim for services.

DVA funds CN services on a 28 day claim period basis. The 28 day claim period includes all the services you deliver to the client during that time.

All claims for CN services are processed and paid through Medicare (Services Australia) on behalf of DVA.

CN providers are allocated a provider number that must be used when claiming for CN services. A new provider number may be allocated where there is a change in provider entity or circumstances. The current active provider number must be used when claiming for CN services.

There are two ways to claim for CN services through Medicare – online or manual.

Online claiming

Online claiming is the preferred option and enables the fastest method of payment.

Online claiming is only available using Medicare compliant software, with the list of compliant software and vendors available on the Software developers for Medicare Online Services Australia website.

Further information on online claiming can be found on the DVA education for health professionals Services Australia website.

Manual claiming

Manual claiming requires CN providers to complete the below listed DVA forms and then submit these via post to Medicare. The forms cannot be submitted via email.

In addition to these two forms, CN providers who submit manual claims must also submit the Minimum Data Set (MDS) Collection Tool.

Once completed, the tool must be emailed to mds [at] dva.gov.au (mds[at]dva[dot]gov[dot]au).

Further information on MDS can be found in the Notes for CN Providers. Information on the MDS Collection Tool can be found in the MDS Quick Reference Guide.

Timeframes for claiming

As per the Notes for Community Nursing Providers, claims for payment of community nursing services, regardless of the claiming method used, must be forwarded to Medicare for processing within six months of the first day of the 28 day claim period.

In addition, the Health Insurance Act 1973, section 20B(2)(b), states that a Medicare claim must be lodged with Medicare within two years of the date of service.

Late lodgements due to poor record keeping, inadequate staffing, resources or training, or any issues with record keeping software will not be accepted after the two year timeframe.

Late claims

As advised on the provider claims page, DVA can accept claims up to two years from the date of service.

Claims greater than two years from the date of service can only be considered if the provider can:

show us that if we do not assess your claim, you may suffer financial hardship
provide us with documents that prove you may suffer financial hardship.

If you are seeking to lodge a late claim with DVA, please call 1300 550 017.

Quick reference guide

A Quick reference guide has been developed to provide key information, further definitions and contact numbers. You can use this guide to assist in determining the correct item number/s to claim.

You can download a copy of the Quick reference guide (PDF 1.3 MB).

Enquiries

For all general CN claiming enquiries (not including rejected claims), contact DVA Provider Enquiries on 1800 550 457.

For claims that have been rejected in Medicare, contact Medicare on 1300 550 017 (option 2).

For all other CN claiming enquiries (e.g. second provider, item codes, additional travel) contact the CN Program team at nursing [at] dva.gov.au (nursing[at]dva[dot]gov[dot]au).