Submit PBS claims for pharmacy

Please check your customer’s concession card before supplying medicine, to confirm if they’re entitled to subsidised medicine.

When you claim PBS medicines online, we’ll also check your customer concessional entitlement with Centrelink.

You can use PBS Online Claims Processing to confirm your customer is eligible for the PBS and Repatriation Pharmaceutical Benefits Scheme (RPBS), including:

• Medicare
• PBS Safety Net
• concession and health care cards, such as Pensioner Concession Card, Commonwealth Seniors Health Care Card and the Health Care Card
• Department of Veterans’ Affairs - Gold, White and Orange cards, Pensioner Concession Card and Commonwealth Seniors Health Care Card.

If a customer isn’t entitled to PBS or RPBS medicine at the subsidised rate, they should pay either:

• an increased contribution
• a private rate.

The rate type will depend on their level of entitlement.

When you claim:

• check your customer’s PBS or RPBS prescription
• enter the prescription information into your pharmacy dispensing software.

For barcoded paper prescriptions and electronic prescriptions, the prescription information is downloaded from the Prescription Delivery Service.

When you enter the prescription information into your dispensing software:

1. The software sends us a transaction. We check the prescription details against PBS or RPBS rules.
2. We check if your patient has a valid entitlement.
3. We’ll send you a message to tell you if the claim is payable.
4. If you get a reason code that needs to be actioned, you’ll need to do this before you supply the medicine to the customer.
5. At the end of your pharmacy’s claim period, close the claim through your dispensing software.

You can check there are no system disruptions using the PBS services status tool. The tool is updated in real time.

You need to keep all prescriptions and claim-related paperwork for 2 years for audits and verifications. You can keep records in electronic or paper form.

You can, in urgent cases, dispense medicine before your patient has supplied a written prescription. A prescriber may tell you the details of the prescription or fax a written and signed prescription.

Prescriptions that need prior authority approval still need approval before you can dispense them. You’ll need to ask the prescriber for the authority approval number.

The prescriber must give you the original PBS or RPBS prescription within 7 days. When you have the prescription, use the owing mark-off function to enter the prescribing date. Mark-off the prescription recorded in your dispensing software. Don’t amend the date of supply.

When you get the prescription, make sure the prescribing date is the date the prescriber requested the prescription. If you get the prescription more than 7 days after the date of supply, it’s still payable if all other requirements including authority approval are met.

If you claim manually, please provide paper prescriptions and claim paperwork to us to process for payment. There’s a processing cost per prescription. Complete and submit these forms:

• Manual prescription processing fee for pharmaceutical benefits form (PB259)
• Approved supplier manual payment reconciliation form (PB242).

To get paid as soon as possible, include the relevant prescription information for each pharmaceutical benefit item you claim.

When you enter information:

• include the patient’s PBS or RPBS eligibility using either their Medicare or repatriation card number and if applicable their concession or safety net card number
• include the prescriber number and date of prescribing
• for owing prescriptions, the date the prescriber contacted you and dispended the medicine is the actual date of dispensing, not the date on the prescription form or the date the prescription was received.

When closing a claim through your dispensing software:

• reconcile prescriptions in the current claim period against the ‘missing script’ report
• delete prescription serial numbers from the dispensing software that aren’t part of the claim, this includes any claim for any uncollected or missing prescriptions
• re-serialise prescriptions that are present but listed as missing
• check both the approval number and claim period number are valid
• ensure an authorised person completed the certification of supply statement
• use the ‘Close a Claim’ transaction to close the current claim period.

To register for online claiming for PBS, you need a pharmacy or hospital approval number. You also need to record your ABN with us.

Once you have your approval number you’ll need to:

1. complete the Notification of Australian Business Number and reference identification for tax treatment purposes and recipient created tax invoice agreement form (HW055).
2. register your organisation in Provider Digital Access (PRODA).

Once you’ve set up PRODA, you can add the PBS Online service provider and register your business to business device. You can only do this after step one has successfully been completed.