Note: You should not rely solely on the answers provided here. The contracts applicable to each provider and all relevant legislation must be consulted to determine the full rights and liabilities applicable to any service provider or funder.
When a GP can claim
The GP can claim a subsidy if the patient is:
- 15 years or younger
- 17 years or younger and not financially independent
- a casual patient
- a Community Services Card holder, or
- a High Use Health Card holder.
If the GP’s fee is more than the subsidy then the patient may need to pay the difference.
If you have not been paid for an entire GMS claim
Call the Sector Operations Contact Centre (0800 855 066) to find out whether the claim has been received and, if so, the reason for non-payment.
If the claim has not been received it will need to be resubmitted to Sector Operations. If the claim is now over 2 months old it will need special approval from Te Whatu Ora before Sector Operations can process it.
If your claim has been processed but it has not been paid at all
If the contract number is not valid, or if the payee number is not correct, a payment may be stopped or may be directed to the wrong account. In most cases these claims can be amended by Sector Operations, once the correct information is provided.
A claim can also be rejected if it is not formatted correctly, in these cases the claim will need to be resubmitted once your claiming software is updated.
Error messages on the variance report
Error 0513 – Invalid NZMC
The New Zealand Medical Council (NZMC) number given has expired or is not in Sector Operations’s database.
Check your records and call the Sector Operations Contact Centre on 0800 855 066 with the correct details so that adjustments can be made. If the NZMC is correct then Sector Operations will need to check that the Doctor's Annual Practising Certificate (APC) is still valid and covers the dates of service of the claim.
Error 0517 – Claim is stale
The dates of service on the claim are more than 2 months old and will require special approval from Te Whatu Ora before we can release payment.
Write to Te Whatu Ora providing details surrounding the reason for submitting late claims. It is at the discretion of Te Whatu Ora to approve these claims for payment.
Error 0520 – Invalid service for contract
The contract number given has expired or is not in Sector Operations's database.
Check your records and call the Sector Operations Contact Centre on 0800 855 066 with the correct details so that adjustments can be made. If the contract number is correct then Sector Operations will need to check that the Doctor's Annual Practising Certificate is still valid and covers the dates of service of the claim.
Error 9999 – Place holding error code
This indicates that the patient has another error under their transaction number, if an incorrect immunisation claim has also been made ,for example using the wrong vaccine codes, then the GMS will also be rejected with the error 9999.
If a school student is over 18
School students over 18 years old are not claimed at ‘J’ rates.
Once a patient has turned 18 they are classed as an adult and claimed at the ‘A’ rates, regardless of their circumstances.
Claiming an immunisation and GMS claim on the same day
As long as a full consultation unrelated to the immunisation was undertaken with the patient, then both services can be claimed. You may not claim GMS if you have only assessed and immunised the patient and did not provide any other unrelated services.
Making multiple GMS claims
As long as full and separate consultations were given then multiple claims can be made. Multiple claims cannot be made for 1 lengthy consultation or a consultation that covered a number of different issues. The patient must be treated at different times during the day.
Claiming GMS and ACC for the same patient from a single consultation
If a patient is seen by a doctor and the patient has 2 completely separate complaints, 1 accident related, 1 medical problem, then the doctor can make 2 claims. The 2 problems must be quite separate and each must be worthy of a full consultation, with distinctly separate supporting clinical notes.
How to submit amended variance reports
Amended variance repots cannot be faxed. Claims need to be re-submitted electronically.
Understanding variance reports
You might receive a variance report that lists a lot of patients, but nearly all the money has been paid.
When a claim is paid at a different rate from the amount claimed, a variance report is automatically generated. This report will list any patients who have missing or amended information.
A variance report will often list the patients who have no NHIs supplied, but these patients will have been paid if the claim reached the 70% target of supplied NHI’s. Check the ‘amount claimed’ and ‘fee payable’ columns to see if the patient’s subsidy has been paid.
GMS payment timeline
Payment turnaround time is based on the way Sector Operations receives your claims.
- If you send your claims electronically, they will be processed within 10 working days of receipt of a valid claim.
- If you send your claims on discs they will be processed within 15 working days of receipt of a valid claim.
- If you send your claims on paper they will be processed within 20 working days of receipt of a valid claim.
Where to send discs and manual claims
Send all completed claim forms and discs to:
PO Box 1026