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Proforma
General PHIAC Circulars
Collection of Date - Sample Proforma
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No out-of-pocket cost to consumer due to gap agreement/scheme in place that caps doctors charges to 100% of MBS |
Gaps Agreement/ Scheme |
Known Gap Agreement/ Scheme |
No Agreement/ Scheme |
Totals |
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Invoiced amount is: |
Less than or equal to 100% of MBS Fee |
Greater than MBS Fee |
Greater than MBS Fee |
Less than or equal to 100% of MBS Fee |
Greater than MBS Fee |
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1. Invoiced Amount |
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Total Charges |
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2. Benefits Paid |
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Total Benefits Paid |
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3. Number of Services |
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Total Number of Services |
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4. Gap |
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Total Gap |
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5. % of Services |
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6. Average above MBS fee |
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Definitions'No gap' - is where the difference between the invoiced amount and the benefit paid = 0 and an MPPA, HPPA/PA or gap cover scheme is in place 'Known gap' - is where there is a difference between the invoiced amount and the benefit paid, an MPPA, HPPA/PA or gap cover scheme is in place, and the patient has provided informed financial consent No agreement - is where there is no MPPA, HPPA/ Practitioner's Agreement, Gap Cover Scheme in place 'Gap' - the difference between the combined fund benefit and Medicare benefit and the amount charged by the doctor Benefits paid is the sum of the Medicare benefit and the fund benefit NotesItems 1 to 3 need to be provided by the registered organisations Items 4, 5 and 6 are derived, as are the totals. Totals are then cross-checked against other data items in the PHIAC 1 return. |
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