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How do I process a Medicare Safety Net (OMSN or EMSN) claim?
How do I process a Medicare Safety Net (OMSN or EMSN) claim?

How can I tell if the EMSN benefit is applicable?

Pete Williams avatar
Written by Pete Williams
Updated over a week ago

Both Original Medicare Safety Net (OMSN) and Extended Medicare Safety Net (EMSN) claims can be processed and submitted on Tyro Health systems via:

  • Tyro Medicare EasyClaim enabled terminals,

  • Tyro Health Online Medicare Online services, and

  • Tyro Health Online ECLIPSE services

Claims can be submitted as Patient Claims, either fully, partially or as unpaid claims. No special codes or action is required - Medicare automatically invokes the OMSN or EMSN status, if applicable, and returns an adjusted benefit amount. OMSN and EMSN claims are not applicable for Medicare Bulk Billing.

Medicare Safety Net claims can pay a benefit amount greater than the scheduled benefit amount when:
1) the patient is eligible for Medicare claims,
2) the patient has exceeded thresholds for annual out-of-pocket expenses, and
3) the claimed item and service category EMSN benefit has not exceeded annual caps.

Typically, the EMSN will pay the scheduled benefit amount + 80% of the out-of-pocket expense. As an example, if the scheduled item benefit is $50 and the provider charges $100, under the EMSN rules, the patient will receive a $90 benefit.

Medicare uses the terms:

  • gap expenses: referring to the difference between the Medicare benefit you get and the scheduled fee (70% for in-hospital services, 85% for allied/specialist services and 100% for select GP services)

  • out-of-pocket expenses: referring to the difference between the Medicare benefit amount and the health practitioner charge amount.

Both can contribute to annual thresholds for Medicare Safety Nets.

Details on Medicare rules for Extended Medicare Safety Net and Original Medicare Safety Net claims is posted at: https://www.health.gov.au/topics/medicare/about/safety-nets

Further explanation with examples are published at:

How will I know if the benefit is applicable?
When you process a Medicare Patient Claim, the response from Medicare will note approval for the claim and additional item level response codes indicate if the Safety Net threshold applies. Medicare Safety Net item level response codes can include but are not limited to:

  • 511 Emsn threshold reached - cap applied to benefit

  • 517 Mpsn threshold reached - 80% out of pocket paid

  • 518 Benefit paid at 100% schedule fee + emsn

  • 519 Mpsn threshold reached - partial 80% out of pocket paid

  • 520 Benefit paid at 100% schedule fee + part 80% out of pocket

  • 521 Paid part 80% out of pocket + between 85% and 100% increase

  • 522 Benefit paid - emsn + between 85% and 100% schedule fee

  • 524 Safety net benefit adjusted

The adjusted benefit amount will be returned and the Statement of Claim and Benefit will note the Safety Net status.

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