The claim and advance
payment cycle
Information for transition care providers
DSS 1630.06.15
ISBN 978-1-925318-05-0
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This document the claim and advance payment cycle information for transition care
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The claim and advance
payment cycle
ii
Table of contents
Table of contents .................................................................................................... iii
Introduction ............................................................................................................. 1
1
Flexible care subsidy for Transition Care ........................................................... 1
2
Claiming a flexible care subsidy ......................................................................... 1
3
Processing claims ............................................................................................. 2
4
Payment period ................................................................................................. 2
5
Advance payments ............................................................................................ 2
6
The funding cycle .............................................................................................. 3
7
Aged care provider statement ............................................................................ 3
8
Bank account details ......................................................................................... 4
9
DHS-Medicare claim form and payment statement ............................................. 4
10
Entry to Residential Respite from Transition Care .......................................... 4
11
Transfers between Transition Care services ................................................... 4
13
Non-payment of Flexible Care Subsidy ........................................................... 4
13.1
Incorrect bank account details .................................................................. 5
13.2
No claim for previous month lodged ......................................................... 5
13.3
Non-payment of flexible care subsidy for one or more transition care
recipients ................................................................................................. 5
13.4
Valid ACCR form not submitted ................................................................ 5
14
Enquiries ....................................................................................................... 6
iii
Introduction
This document has 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.
1
Flexible 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 under section
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 the ComLaw website.
2
Claiming 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.
1
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
3
Processing 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.
4
Payment 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.
5
Advance 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.
2
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.
6
The 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.
7

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.
Aged 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.
3
8
Bank 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:
[email protected]
9
DHS-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).
10 Entry 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.
11
Transfers 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).
13
Non-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
4

Valid ACCR form not submitted.
13.1 Incorrect 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 be resubmitted.
13.2 No 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.
13.3 Non-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.
13.4 Valid 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.
5
14 Enquiries
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.
6
Attachment A – Transition Care Payment Cycle
1