Medicare, HICAPS, Tyro & private health claims, in plain English

Bulk billing is a Medicare concept: the practitioner accepts the Medicare rebate as full payment for a Medicare-funded service. No-gap is a private health fund concept: the practitioner accepts the fund's scheduled benefit as full payment for an extras-funded service. Both result in zero out-of-pocket, but they sit on different claim rails. A practice can be bulk-billing for Medicare items and known-gap for private items at the same time.

A Chronic Disease Management (CDM) referral is issued by a GP under a GP Management Plan or Team Care Arrangement. It gives the patient access to up to 5 Medicare-rebatable allied-health visits per calendar year (combined across physio, OT, podiatry, speech, exercise physiology, etc., not 5 per discipline). The referral nominates eligible providers; the allied-health professional bills MBS item 10960 (or discipline-equivalent) per visit and writes back to the referring GP after the initial and final consult.

No, not for the same service. Section 19(2) of the Health Insurance Act prevents claiming a Medicare benefit and a private-fund benefit on the same item. A patient with a CDM referral can claim either the Medicare rebate OR their fund's physio extras, not both. Some practices structure longer visits to bill Medicare for the first portion (under the CDM item) and a private extras item for an extended modality afterwards, but each item must be separately documented and clinically distinct.

HICAPS typically charges a monthly terminal-rental fee plus a per-transaction processing fee. Tyro's pricing is structured similarly. The exact figures vary by terminal model, expected transaction volume and bank relationship, always request a current quote rather than relying on third-party guides. The terminal cost is usually offset many times over by the reduction in patient-side claim friction (and the lift in book-rate from no-gap arrangements).

For Easyclaim bulk-bill submissions, payment to the practice bank account is typically next-business-day. For paper or batch claims, allow 5 to 10 business days. Private health no-gap settlements via HICAPS are usually next-business-day as well. WorkCover and CTP remittance is far slower, 14 to 60 days depending on the scheme and whether the invoice attached the required treatment notes.

Services Australia returns a rejection code (the most common categories are: wrong item number, invalid Medicare card, item-restriction breach, duplicate claim, missing referral). The practice can correct and re-lodge within 2 years of the date of service. Don't write off rejects without investigating, about 80% of rejections are fixable with a corrected re-lodge. Keep a rejection log and review monthly to identify recurring patterns (e.g., a particular item being mis-keyed).