Rejection Code Reference

Medicare has already paid a benefit for the same (or an equivalent) item number for this patient on the same day.

• The item was already claimed earlier that day, e.g. by another provider at the practice.
• A same-day rule applies — some items can only be claimed once per day per patient regardless of provider.

• Confirm whether this item has a same-day claiming restriction in its MBS descriptor.
• Check whether another provider at the practice already billed the same or an equivalent item today.

The item you billed cannot be claimed together with another item already claimed for the same patient and date of service.

• Two items in the same MBS group are structured as alternatives, not additions (e.g. different consult levels for the same encounter).
• An item's descriptor explicitly excludes billing with another named item on the same day.

• Use the Safe & Maximal Claim Checker to test the specific combination before resubmitting.
• Read both items' MBS descriptors for 'not in conjunction with' or 'except in conjunction with' wording.

The item requires a valid referral, and Medicare's records show no referral, an expired referral, or a referral that doesn't cover this service.

• The referral's validity period has lapsed (standard referrals are typically valid 12 months; indefinite referrals need specific wording).
• The referral was never submitted or was submitted after the service date.
• The referral is for a different specialty or a different patient issue than the service billed.

• Confirm the referral date, validity period, and that it names the correct referring practitioner and provider type.
• For a new problem outside the original referral's scope, a new referral is generally required.

Medicare has no active enrolment for this patient, or their eligibility doesn't cover this service category.

• Medicare card details entered don't match Services Australia's records (name, DOB, card/IRN mismatch).
• Visa/residency status doesn't currently confer Medicare eligibility.
• Reciprocal Health Care Agreement coverage has specific service restrictions.

• Verify the Medicare card number, individual reference number (IRN) and patient details exactly as they appear on the card.
• Confirm current eligibility status if the patient's visa or residency situation has recently changed.

The item has a capped number of services payable per patient per year (or lifetime), and that cap has already been reached.

• Items like some allied health, mental health, or specific screening items have an annual services cap.
• The patient has already used their capped services with a different provider.

• Check the item's descriptor for a stated annual/lifetime limit.
• Ask the patient whether they've already used related services elsewhere this year (this is patient-reported, not something to look up in patient records here).

The item claimed requires a minimum consultation duration, and the claim as submitted doesn't reflect that minimum.

• A higher-level attendance item (e.g. a longer consult tier) was billed but the documented time doesn't support it.
• Time-tiered items (e.g. some mental health or case conference items) have specific minimum-duration thresholds per tier.

• Confirm actual consultation time against the item's stated minimum, and consider whether a lower time-tier item applies instead.

The item's benefit depends on the billing provider's type/registration (e.g. GP vs specialist, or a derived-fee arrangement), and the claim doesn't match.

• The provider number used isn't registered for the specialty the item requires.
• A derived-fee item (fee depends on another service billed the same day, e.g. anaesthesia items) was billed without the associated service present.

• Confirm the provider number's registered specialty matches what the item requires.
• For derived-fee items, confirm the associated primary service was also billed correctly.

Another provider has already been paid a benefit for an equivalent service for this patient in the relevant period.

• The patient saw another provider (possibly at a different practice) for a similar service recently.
• A locum or covering practitioner billed under a different provider number for the same encounter.

• This is patient-reported information only — the tool has no access to any provider's claim history. Ask the patient if they've seen another provider recently for the same issue.

The telehealth item requires an established clinical relationship (a recent face-to-face service) or a specific exemption, and neither is met.

• No face-to-face service with this practitioner/practice in the required window, and no applicable exemption.

• Use the Telehealth Eligibility Quick Check tool to review the relationship requirement and common exemptions.

The claimed fee or benefit doesn't match the schedule fee currently in effect for that item.

• Billing software hasn't updated to the latest MBS release, so an old schedule fee was submitted.
• The item's fee changed in a recent indexation or targeted review.

• Confirm the item's current schedule fee on this site's MBS page, and check your billing software's schedule data is up to date.