The claim and advance payment cycle
Information for transition care providers
DSS 1630.06.15
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ISBN 978-1-925318-05-0
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The claim and advance payment cycle
Table of contents
Table of contents
Introduction
1Flexible care subsidy for Transition Care
2Claiming a flexible care subsidy
3Processing claims
4Payment period
5Advance payments
6The funding cycle
7Aged care provider statement
8Bank account details
9DHS-Medicare claim form and payment statement
10Entry to Residential Respite from Transition Care
11Transfers between Transition Care services
13Non-payment of Flexible Care Subsidy
13.1Incorrect bank account details
13.2No claim for previous month lodged
13.3Non-payment of flexible care subsidy for one or more transition care ....recipients
13.4Valid ACCR form not submitted
14Enquiries
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Introduction
This documenthas been jointly developed by the Australian Government Department of Human Services (Medicare) and the Department of Social Services. It is a resource for the state and territory governments, as the approved providers of transition care, as well as service providers (including subcontractors), and officers of the Department of Social Services. It provides a general understanding of how monthly payments of Australian Government transition care subsidy are calculated, processed and paid.
State and territory governments administer ‘transition care services’. These services may engage transition care service providers for the delivery of transition care. Where an approved provider operates a transition care service through a subcontractor, the approved provider remains eligible for the subsidy. However, it is possible for an approved provider to have the subsidy paid directly to the subcontractor.
For consistency, this document refers to approved providers rather than transition care services, subcontractors or transition care service providers.
1Flexible care subsidy for Transition Care
Flexible care subsidy for transition care is a payment by the Australian Government to approved providers for providing transition care to people who have been approved to receive that form of care.
An approved provider is eligible for flexible care subsidy for each day the provider provides care to a person who is approved to receive transition care.
Divisions 49 to 52 of the Aged Care Act 1997 and the Aged Care (Transitional Provisions) Act 1997 (the Acts) state the requirements to be satisfied to claim subsidy, the basis on which it will be paid and how the rates will be set.
The conditions under which subsidy may be claimed are established undersection 50-1 of the Acts. The Subsidy Principles 2014 set out the arrangements for payment of flexible care subsidy to approved providers.
The amount of flexible care subsidy for a day for a care recipient is the sum of:
(a) the basic subsidy amount for the day for the care recipient; and
(b) the Dementia and Veterans’ supplement equivalent amount for the day for the care recipient.
The basic subsidy and Dementia and Veterans’ supplement amount payable in respect of a day for a care recipient is found in the Aged Care (Subsidy, Fees and Payments) Determination 2014 on theComLaw website.
2Claiming a flexible care subsidy
Commonwealth Subsidy (Flexible Care) claims for care recipients receiving transition care is in accordance with subsection 50-1(1) of the Aged Care Act 1997 and the Payment Agreement between the Commonwealth and the approved provider.
Approved providers are required to submit a claim for each month containing details of each care recipient for whom they are claiming subsidy in that month. The claim must be signed by a representative of the approved provider.
The amount paid each month is the sum of the all the amounts that are due and are calculated for each eligible day of the month the care recipient is entitled to the subsidy. The signed original claim forms should be forwarded to the Department of Human Services (Medicare) at:
Department of Human Services
Aged Care Payments
GPO Box 9923
Sydney NSW 2001
3Processing claims
The Department of Human Services (Medicare) is responsible for the processing and payment of transition care subsidies.
Where an approved provider has transition care places in more than one service, separate claims must be made for each service. The Department of Human Services (Medicare) will generate a claim form for each service linked to an approved provider.
The claim forms and payment statements are sent to the transition care service’s nominated postal address. If approved providers require all claims to be managed through a central point, all services should have the same postal address.
4Payment period
The payment period for subsidy is one calendar month. In the case where a transition care service commences during a month, the first claim period is from the day of opening to the end of the month, and thereafter monthly. Where a service ceases during the month, the claim period is from the first day of the month to the day of closure.
5Advance payments
An advance payment, (otherwise known as an advance), is the due sum that is paid (or received) in advance for services. The balance is provided following delivery of the service.
An advance is a calculated amount based on the transition care service’s final claim entitlement from the period two months earlier. The advance amount is paid to the approved provider at the beginning of the month for which it is advanced. For example, the April advance payment received is based on the February claim.
The Department of Human Services (Medicare) has undertaken to make advance payments to approved providers by the third working day of each month, provided the claim for the period two months previous has been received and finalised.
For a new transition care service, the approved provider and the Department of Human Services (Medicare) may agree that the first two advances are calculated based on the estimated occupancy levels for that period.
If you have further questions regarding advances please contact the Department of Human Services (Medicare)by phoning the Aged Care enquiries line on
1800 195 206*.
*Note: Call charges apply for mobile phones.
6The funding cycle
The monthly funding cycle operates on the basis of an advance payment and subsequent acquittal, see diagram at Attachment A - Transition Care Payment Cycle.
- For example, the June advance is based on the April actual entitlement. It is calculated in late May and paid in early June based on the pro-rated number of care days in June. The approved provider acquits the June advance in July, advising changes to care recipient details that occurred during the reporting/claimed month.
- The claim for June is calculated and acquitted against the advance. If the actual entitlement calculated exceeds the advance amount, the difference is paid when the claim is finalised. If the actual entitlement calculated is less than the advance amount, the difference is deducted from the next advance payment.
- The final actual entitlement for June is used to calculate the advance for August.
7Aged care provider statement
Approved providers must complete and sign the statement. It is used to ensure that all aged care forms, claims and other relevant documentation to claim payments of subsidy under the Act are appropriately authorised. The statement is submitted every 3 years. The most current statement is valid for the period 1 July 2014 –
30 June 2017.
This form only needs to be completed if the provider is not registered for Aged Care Online Claiming (ACOC).
In May 2014, the provider statement was mailed to approved providers, and was also uploaded on the DHS website. The statement must be signed by the approved provider as defined in Section 9-1(2) of the Act and returned to the DHS.
Note:Those who are registered for online claiming need to complete the statement as the terms and conditions for ACOC have been amended to include the terms and conditions in the provider statement.
For further information, please go to the Department of Human Services website.
8Bank account details
To receive payment, an application to add or change approved care service’s bank details form (AC015) must be completed and submitted to the Department of Human Services (Medicare). This form is available from the Department of Human Services (Medicare) state/ territory offices or online at the Department of Human Services website.
The original of this form should be returned to:
Department of Human Services
Aged Care Payments
GPO Box 9923
SYDNEY NSW 2001
Alternatively the form can be scanned and e-mailed to:
9DHS-Medicare claim form and payment statement
Once a claim form is processed and certified by an approved delegate in the Department of Human Services (Medicare), the approved provider will receive a Payment Statement showing details of the payment. The payment statement should be kept for future reference. The approved provider will also receive a new claim form (forecast claim for the next month).
10Entry to Residential Respite from Transition Care
On the day in which a care recipient enters residential respite care, the transition care service is paid flexible care subsidy and the residential aged care provider is paid residential care subsidy and the respite supplement.
11Transfers between Transition Care services
If a care recipient moves from one transition care service to another without a gap in care, it is considered as one episode of transition care for the purpose of determining flexible care subsidy. For example, if a care recipient is in a transition care service for 62 days and moves immediately to a different transition care service, subsidy will be paid for a maximum of 22 days in the second transition care service (unless an extension is granted).
13Non-payment of Flexible Care Subsidy
There are a number of possible reasons for non-payment of flexible care subsidy for transition care, including the following:
- Incorrect bank account details;
- No claim for previous period lodged;
- Non-payment of flexible care subsidy for one or more transition care recipients; or
- Valid ACCR form not submitted.
13.1Incorrect bank account details
To ensure payments to providers are received in a timely manner, any changes to bank account details must be notified promptly to the Department of Human Services - Medicare using the Application to add or change the Approved Care Service’s bank details form.
The Reserve Bank returns payments with incorrect account details and these payments cannot be re-credited directly. A request for payment must beresubmitted.
13.2No claim for previous month lodged
The monthly advance will not be paid until the claim for the period two months prior has been lodged, and it has been processed. For example, the June advance will not be paid until the April claim has been processed and finalised.
13.3Non-payment of flexible care subsidy for one or more transition care recipients
This can occur for a number of reasons:
- Claiming for more care recipients than the approved allocation of transition care places;
- The care recipient has exceeded their maximum number of days approved for transition care; or
- The care recipient does not have a valid ACAT approval, e.g. the 28-day time period to enter transition care after approval has lapsed, or the ACAT approval date is after the date of admission to transition care, or the Aged Care Application for an Extension of Transition Care form has not been received.
13.4Valid ACCR form not submitted
Where a valid Aged Care Client Record (ACCR) form for a care recipient has not been received in the Department of Human Services (Medicare) office at the time the claim is processed, no subsidy will be paid for that care recipient, for that payment period. A note will be added to the ‘Advice’ section of the Payment Statement indicating that an ACCR form has not been received for the care recipient.
It is the transition care service’s responsibility to follow up with the ACAT to ensure the form is forwarded to the Department of Human Services (Medicare). When the ACCR form is received, subsidy will be paid back to the date of admission when the next claim form is processed.
Note:Where a claim for transition care subsidy is disallowed, the Department of Human Services (Medicare) will notify the Approved Provider in writing, setting out the reasons for this disallowance of subsidy.
14Enquiries
For payment related queries contact the Department of Human Services (Medicare) Program Aged Care enquiries line on 1800 195 206*.
*Note: call charges apply for mobile phones.
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Attachment A – Transition Care Payment Cycle
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