Australian Government - Department of Health - Office of Hearing Services
Hearing Services Program

e-Claim File Format Guide

The e-Claim File Format Guide is designed to assist Service Providers understand and use the e-Claim facility. This is version 6 updated on 30 June 2014.

Table of Contents 

Introduction

This e-Claim File Format Guide (file format guide) was written by the Department of Health (the Department) with input from the Department of Human Services (DHS) (on 1 July 2011) Centrelink, Medicare, Child Support Agency and CRS Australia were integrated into the Department of Human Services. Learn more at http://www.humanservices.gov.au.

The file format guide is designed to assist

  • Service providers to understand and use the e-Claim facility
  • The Department and DHS staff to understand and administer the e-Claim facility

The e-Claim file format guide will be revised periodically. Comments on the content and format are always welcome.

The e-Claim facility is a web based electronic claim for payment lodgement application that enables the Australian Government Hearing Services Program (the program’s) contracted service providers to lodge electronically generated hearing service claims for payments via the Internet. The e-Claim facility allows authorised service providers to lodge a claim for payment file electronically with DHS and retrieve the accepted claim file, rejected claim file and summary details file electronically for the specific batch.

The Department and DHS endeavour to ensure that the e-Claim facility operates smoothly and that adequate support and monitoring is provided, with opportunities for the participating service providers to contribute feedback.

The e-Claim facility will be enhanced over time to incorporate feedback from service providers and other initiatives by the Department.

You can visit the program's website at www.hearingservices.gov.au 

Top of Page

Overview of Claim File

The record formats are based on the Electronic Data Interchange (EDI) (“Health Level 7”) (HL7) format. This format specifies that each field in a record is to be delimited by a termination character. The HL7 standard specifies | (vertical bar) as the delimiter character.

The delimiter character in the claim file indicates the end of the field value and is ignored once the field value has been stripped from the claim file for processing. The delimiter character is not used in the accepted, rejected or summary file record definitions.

The vertical bar cannot be used in any field except in the first record of a claim file that defines that the vertical bar is the delimiter character. The characters ^ ~ \ & are separation characters also and should not be used in any field other than the first record of the file.

An example of the HL7 coding format for each record is shown for each record type. For some record types, the page is not sufficiently wide to allow all of the example record to be shown on a single line.

The service provider specifies a file name of their choice for each claim file during the
e-Claim facility upload.

To minimise the amount of explanation of fields required, and to reduce any duplication of existing information, the e-Claim file format guide relies on the definition of fields and requirements for completing fields already provided by the Department.

To link the paper stream claim for payment form with the electronic stream claim fields:

  • Completion of the electronic stream claim field is to be decided as for the paper stream claim for payment form, except where a variation is required to suit electronic input and is noted in the format table.
  • For each pair of tick boxes for ‘Yes’ and ‘No’ that appear on the paper stream claim for payment form, there is a single electronic stream claim field which may have the values of either ‘Y’ or ‘N’.

Some fields that appear on the paper stream claim for payment forms do not appear in the electronic stream file. An example is the family name of the client that is used for visual verification on the paper stream claim for payment forms.

The structure of the claim file is summarised below

Record Type Count Sequence EDI segment type
Message Header 1 First MSH
Batch Header 1 Second Z12
Claim At least 1   Z13
Item One to three per claim   Z14
Batch Trailer 1 Last Z15

The field types in the record layouts are explained below

Type Description Examples
A Field may contain both alphabetic and numeric characters of the specified length. All alphabetic fields are variable lengths up to the maximum length listed. A5:
Ant
Ba8ts
Fr3W
N Field may contain only numeric characters of the specified length. N3:
387
51
9
9.9 Field may contain only numeric characters with decimal point (in the exact position indicated) of the specified length. Field may be zero filled. 9999.99:
72.45
6925.00
0003.04
D Field may contain only a valid date of the specified format and length. All non-blank date fields are in fixed DDMMCCYY format of 'day/month/century/year'. D:
01062004
23111999
15042000

 

Top of Page

Format of Claim File

Note: GST means Goods and Service Tax and WHT means Withholding Tax

Message Header Record

Name Paper Field Id Type Comments
Segment Id N/a A3 'MSH'. Message Header Record.
As shown in example.
Field Separator N/a A1 '|' Repeated three times as in example.
Encoding Characters N/a A '^~\&' As shown in example.
Sending Application N/a A Null
Sending Facility N/a A Null
Receiving Application N/a A Null
Receiving Facility N/a A Null
Date Time Of Message N/a A Null
Security N/a A Null
Message Type N/a A7 'Z10^Z11' As shown in example.
Message Control Id N/a N4 Identifies a batch. Value is incremented by 1 each time a batch is successfully sent. Copied to the result files to allow matching to the input claim file.
Processing Id N/a A1 'P' . Short for production environment.
As shown in example.
Version Id N/a A3 '2.3'. The HL7 release standard being used. Not likely to change. As shown in example.
Sequence Number N/a A Null
Continuation Pointer N/a A Null
Accept Acknowledgement Type N/a A Null
Application Acknowledgement Type N/a A Null
Country Code N/a A Null
Character Set N/a A Null
Principal Language Of Message N/a A Null

Example

MSH|||^~\&|||||||Z10^Z11|2|P|2.3||||||||

Note - MSH record is one continuous line.

Encoding Characters field is followed by seven field separators.

Version Id field is followed by eight field separators.

Batch Header Record

Name Paper Field Id Type Comments
Segment Id N/a A3 'Z12' As shown in example.
Minor Customer Id N/a A8

Allocated by Medicare at the time of granting access to facility and is linked to User id.

May be allocated to a whole service provider or to an individual service provider site depending on how the service provider operates. The Department suggests central processing if possible.

Record Type N/a A3 'HDR' Batch Header Record.
As shown in example.
From N/a A3 'CON' short for Contracted Service Provider.
As shown in example.
File Description N/a A30

‘Claim Records For Processing’

Field value is not validated and may be formatted as desired. As shown in example.

.

Tax Invoice N/a A11

Identifies document as a Tax Invoice. On file as the words

"Tax Invoice".

Date Of Issue Of Tax Invoice N/a D Date Tax Invoice issued
To N/a A3 'HIC' Short for Health Insurance Commission (now Medicare)
As shown in example.
Contracted Service Provider Id 40 A7 Identifier of the service provider.
Name of Contracted Service Provider 3 A50 Identifies contractor name of service provider
Name Of Recipient 1 A50

Will always be the Department of Health and Aged Care

It’s substitute.

Address or ABN of Recipient 2 N11 Department's ABN number is 83 605 426 759.
ABN Branch Extension N/a N3 Department's additional ABN identifier. Currently Null.
Environment N/a A5 'PROD' Short for production environment.
As shown in example.
Batch Format Version N/a N2

'03' As shown in example.

Will be incremented each time there is a change in file format or record layout to allow for future changes. Not likely to change often. Version 01 will reject after 1 July 2000. Version 2 rejects after 1 December 2000

Example

Z12|CSP00087|HDR|CON|CLAIM RECORDS FOR PROCESSING|TAX INVOICEl15042000lHIC|031576W|lDEPARTMENT OF HEALTH AND AGED CAREl83605426759llPRODl03l

Note - Z12 record is one continuous line.

Top of Page

Claim Record

Name Paper Field Id Type Comments
Segment Id N/a A3 'Z13' As shown in example.
Record Type N/a A3 'CLM' claim Record. As shown in example.
Contractor Claim Id N/a A15 Allows a Service Provider to assign a unique id of their choice to a claim to aid in reconciling claims. Copied to the response files.
Number Of Items N/a N3 Count of item records for this claim
Number Of Devices N/a N3 Null
Voucher Number 4 A19  
Client Tier/ Category Left 15 A2  
Client Tier/ Category Right 22 A2  
3fahl Left 29 N3 May be 0.00 but not null
3fahl Right 30 N3 May be 0.00 but not null
Total Cost To Client 38 99999.99 May be 0.00 but not null
Name Of Authorised Person 44 A50  
Signed By Authorised Person 45 A1 'Y' or 'N'
This is an indicator field but appears as a signature on the claim form
 
Date Signed By Authorised Person 46 D  
Australian Business Number (ABN) 43 N11 Australian Business Number issued by the ATO.
ABN Branch Extension 41 N3 Additional ABN identifier completed at the discretion of the Service Provider. May be null.
GST Registered 42 A1 Contractor confirmation business is GST registered (Y or N only).
Income Tax Exempt 39 A1 Contractor confirmation business is Income Tax Exempt. (Y or N only).
Maintenance Payment To Provider 32 A1 ‘Y’ or ‘N’
Maintenance Payment To Provider Amount 33 99999.99 'Y' or 'N'
Eligible For Hearing Services 34 A1 ‘Y’ or ‘N’
Client Signature Name 35 A50  
Signed By Client 36 A1 'Y' or 'N'
This is an indicator field but appears as a signature on the claim form
Date Client Signed 37 D  

Example

Z13|CLM|99043|1||WWM000447X-12011999|||40|30|0.00|J SMITH|Y|15041999|12345678915l234lYlNlY|25.00|Y|ROY BROWN|Y|15041999|

Note - Z13 record is one continuous line.

Voucher Number field format is the concatenation of the client number and voucher issue date separated by a minus sign as shown in example.

The maximum size of the claim file is one megabyte and may contain up to five thousand Z13 claims records with associated Z14 claim item records.

Z13 claim records and associated Z14 item records will be processed in the sequence in which they appear in the claims file.

Top of Page

Item Record

Name Field Id Type Comments
Segment Id N/a A3 'Z14' As shown in example
 
Record Type N/a A3 'ITM' Item Record. As shown in example.
 
Contractor Item Record Id N/a A15 Allows a service provider to assign a unique id of their choice to a claim item to aid in reconciling claims. Copied to the response files.
Item Number 5 N3  
Tax Exclusive Amount Of Item 9 99999.99 May be 0.00 but not null. Refer to table (TBA).
GST Payable For Item 10 99999.99 May be 0.00 but not null. Refer to table (TBA) Must be 0.00 if invoicing WHT.
WHT Deducted For Item N/a 99999.99 May be 0.00 but not null. Refer to table (TBA). This will always be calculated as a negative amount. Must be 0.00 if invoicing GST.
Total Amount Payable For Item 11 99999.99 May be 0.00 but not null.
Date Of Service 6 D  
Date Of Rehab Item Follow Up 31 D Compulsory if Item 670 is claimed. Must be Null in all other cases.
Site Id 7 A6 If claiming for a HOME visit ensure HOME is in upper case.
Practitioner Number 8 A8  
Left Device Code 12 A7  
Left Date Of Fitting 13 D  
Left Cost To Client 14 99999.99 May be 0.00 but not null.
Tax Exclusive Amount Of Left Device Category/Tier 16 99999.99 May be 0.00 but not null. Refer to Table (TBA).
GST Payable For Left Device Category/Tier 17 99999.99 May be 0.00 but not null. Refer to Table (TBA). Must be 0.00 if WHT is being invoiced.
WHT Deducted For Left Device Category/Tier N/a 99999.99 May be 0.00 but not null. Refer to Table (TBA). This will always be calculated as a negative amount. Must be 0.00 if GST is being invoiced.
Total Amount Payable For Left Device Category/Tier 18 99999.99 May be 0.00 but not null.
Right Device Code 19 A7  
Right Date Of Fitting 20 D  
Right Cost To Client 21 99999.99 May be 0.00 but not null.
Tax Exclusive Amount Of Right Device Category/Tier 23 99999.99 May be 0.00 but not null. Refer to Table (TBA).
GST Payable For Right Device Category/Tier 24 99999.99 May be 0.00 but not null. Refer to Table (TBA). Must be 0.00 if WHT is being invoiced.
WHT Deducted For Right Device Category/Tier N/a 99999.99 May be 0.00 but not null. Refer to Table (TBA). This will always be calculated as a negative amount. Must be 0.00 if GST is being invoiced
Total Amount Payable For Right Device Category/Tier 25 99999.99 May be 0.00 but not null.
Total Benefit Of Items And Devices Tax Exclusive. 26 99999.99 May be 0.00 but not null.
Total GST Payable On Items And Devices 27 99999.99 May be 0.00 but not null.
Total WHT Deducted On Items And Devices N/a 99999.99 May be 0.00 but not null. This will always be a negative amount in calculating Total Benefit of Items and Devices payable.
Total Benefit Of Items And Devices Payable. 28 99999.99 May be 0.00 but not null. Total benefit due for service and supply of device(s).

Example

Z14|ITM|1246|800|0.00l0.00l0.00l0.00l13122000|24122000|245831|2225454H|||0.00|0.00l0.00 l0.00l0.00||l0.00l0.00l0.00l0.00l0.00l0.00l0.00l0.00l0.00l

Note - Z14 record is one continuous line.

Z14 claim item record is logically linked to the immediately preceding Z13 claim record.

A claim file may contain a maximum of three Z14 claim item records for each Z13 claim record. The Z14 claim item record does not contain the identifier of the Z12 batch header record to which they are related. The linkage to the Z12 batch header record is provided by the sequence of the records in the file.

If there are dependencies amongst the Z14 claim item records, then the claim file should be constructed to should present the Z13 claim records and Z14 claim item records in the appropriate sequence in the claim file.

The usual sequence of Z14 claim item records will be the Date of Service with the earliest date first.

Top of Page

Batch Trailer Record

Name Field Id Type Comments
Segment Id N/a A3 As shown in example.
Record Type N/a A3 'TRL' Batch Trailer Record.
As shown in example
Number Of Claims In Batch N/a N4 Count of claim records in this batch.
Number Of Items In Batch N/a N4 Count of item records in this batch.
Date Time Batch Finalised N/a A17 DDMMCCYY HH:MM:SS (24 hour clock)
Date and time that the Service Provider finished creating this

Example

Z15|TRL|27|63|01071999 17:45:33|

Note - Z15 record is one continuous line.

Date Time Batch Finalised field has a one-character space between the year and hour numerics and has the format 'day''month''century''year' 'hour':'minute':'second'.

Overview of Accepted, Rejected and Batch Summary Files

Processing of an input Claims file produces the following output files:

  • Accepted Claims file
  • Rejected Claims file
  • Batch Summary file

The accepted and rejected files will contain only records of claims that were submitted electronically for a specific batch. If a claim is submitted through both the paper and electronic streams, or twice electronically, then the second instance of the claim will be rejected as a duplicate.

If an electronic claim batch has zero accepted records, then all three electronic files will still be produced. The accepted claim file in this case will contain

  • A header record
  • No claim records or associated claim item records in the accepted claims file
  • A trailer record and a value of zero in the count field

If an electronic claim batch has zero rejected records, then all three electronic files will still be produced. The rejected claim file in this case will contain

  • A header record
  • No claim records or associated claim item records in the rejected claims file
  • A trailer record and a value of zero in the count field

The accepted, rejected and batch summary output files will be aggregated and compressed into a single file for e-Claim facility download. The decompressed files will be named accept.txt, reject.txt and summary.txt. The service provider will be able to change the names of the accepted, rejected and summary files during decompression.

The record fields are fixed length format rather than character delimited. There is no field separator character between fields in the accepted, rejected and summary files as there is for the input claim files. All fields from the input claim files are present in the accepted, rejected or summary files unless stated otherwise.

The relationship between Claim and Claim Item records is

  • Explicit; that is, all Claim Item records contain the identifier of the Claim record that they relate to; and
  • Positional; that is, each Claim Item record immediately follows the related Claim record.

All date fields (D) are in fixed ddmmccyy format (e.g. 01052003, 27031997)

For each rejected item in the reject claims file, a reason code for the rejection will be provided. A separate file of reason codes and textual description is in the e-Claim Handbook. The codes are the same set as appear on the rejection reports for claims lodged through the paper stream.

Top of Page

The structure of the accepted file is summarised below.

Record Type Count Sequence
Header record Exactly 1 First
Claim Record Zero or more  
Item record Zero up to three per claim  
Trailer record Exactly 1 Last

The structure of the rejected file is summarised below.

Record Type Count Sequence
Header record Exactly 1 First
Claim Record Zero or more  
Item record Zero up to three per claim  
Trailer record Exactly 1 Last

The structure of the batch summary file is summarised below.

Record Type Count Sequence
Header record Exactly 1 First
Summary record Exactly 1 Second
Trailer record Exactly 1 Last

Format of Accepted File

Accepted Header Record

Name Type Contents and Comments
Record Type A3 'HDR'
File Type A1 'A'
From A3 'HIC'
File Description A30 'ACCEPTED HEARING CLAIMS'
To A3 'CON'
Contracted Service Provider ID A7 Copied from input claim file
Batch Sequence Number N4 Copied from input claim file
Claim File Name A12 Name of input claim file
Date Batch Received at Medicare D Date the batch was received at Medicare
Expected Date Of Payment D Date that HIC expects the payment to be credited to the contractor's bank account
Environment A5 'PROD'
Format Version N2 '02'. Will be incremented each time there is a change in file format or record format (allows for future changes)

Example

HDRAHICACCEPTED HEARING
CLAIMS^^^^^^^CON124376A0213FILENAMEFILE2205199905061999PROD^02

(^ indicates space)

Note - HDR record is one continuous line

Top of Page

Accepted Claim Record

Name Type Contents and Comments
Record Type A3 'CLM'
Contractor Claim Id A15 Copied from input claim file
Medicare Claim Number N3 Allocated by Medicare during processing
Voucher Number A19 Copied from input claim file

Example

CLMACLAIM14532^^^^037123456789X-22011999

(^ indicates space)

Note - CLM record is one continuous line

Accepted Item Record

Name Type Contents and Comments
Record Type A3 'ITM'
Contractor Claim Id A15 Copied from input claim file
Contractor Item Record Id A15 Copied from input claim file
Medicare Claim Number N3 Allocated by Medicare during processing
Medicare  Item Record Number N2 Allocated by Medicare. Sequence of item within claim
GST 9999999.99 Amount of GST to be paid on this claim item
WHT 9999999.99 Amount of WHT to be withheld on this claim item
Amount To Be Paid 9999999.99 Amount expected to be paid for this item inclusive of GST
Item Number N3 Copied from input claim file
Date Of Service D Copied from input claim file

Example

ITMCLAIM03451^^^^^ITEM34267Q23^^^034030000105.000000000.000000605.008
0022051999

(^ indicates space)

Note - CLM record is one continuous line

Accepted Batch Trailer Record

Name Type Contents and Comments
Record Type A3 'TRL'
Number Of Accepted Items N5 Count of accepted item records in this file. May be zero if no accepted claims in a batch
GST 9999999.99 Amount of GST that is payable on this claim
WHT 9999999.99 Amount of WHT to be withheld on this claim
Total Payment Amount 9999999.99 Amount that Medicare expects to be paid, including GST or WHT to the CSP's bank account for the accepted items in this batch. May be zero if no accepted claims in a batch

Example

TRL000570000105.000000000.000000210.00

Note - TRL record is one continuous line

Top of Page

Format of Reject File

Rejected Header Record

Name Type Contents and Comments
Record Type A3 'HDR'
File Type A1 'R'
From A3 'HIC'
File Description A30 'REJECTED HEARING CLAIMS'
To A3 'CON'
Contracted Service Provider ID A7 Copied from input claim file
Batch Sequence Number N4 Copied from input claim file
Claim File Name A12 Name of input claim file
Date Batch Received At Medicare D Date the batch was received at Medicare
Environment A5 'PROD'
Format Version N2 '02'. Will be incremented each time there is a change in file format or record format (allows for future changes)

Example

HDRRHICREJECTED HEARING
CLAIMS^^^^^^^CONSDF12340023MINOR.123^^^01061999PROD^02

(^ indicates space)

Note - HDR record is one continuous line

Rejected Record

Name Type Contents and Comments
Record Type A3 'CLM'
Contractor Claim Id A15 Copied from input claim file
Medicare Claim Number N3 Allocated by Medicare during processing
Voucher Number A19 Copied from input claim file

Example

CLM4CLAIM32764^^^^123123456789X-22011999

(^ indicates space)

Note - CLM record is one continuous line

Top of Page

Rejected Item Record

Name Type Contents and Comments
Record Type A3 'ITM'
Contractor Claim Id A15 Copied from input claim file
Contractor Item Record Id A15 Copied from input claim file
Medicare Claim Number N3 Allocated by Medicare during processing
Medicare Item Record Number N2 Allocated by Medicare. Sequence of item within item
Rejection Code N3 Code of reason for rejection
Item Number N3 Copied from input claim file
Date Of Service D Copied from input claim file

Example

ITMCLAIMITEM142^^^090010479^^^^^^0900104780001061999
(^ indicates space)

Note - ITM record is one continuous line

Rejected Batch Trailer Record

Name Type Contents and Comments
Record Type A3 'TRL'
Number Of Rejected Items N5 Count of rejected item records in this file. May be zero

Example

TRL00002

Note - TRL record is one continuous line

Top of Page

Batch Summary File

Batch Summary Header Record

Name Type Contents and Comments
Record Type A3 'HDR'
File Type A1 'S'
From A3 'HIC'
File Description A30 'BATCH SUMMARY INFORMATION'
To A3 'CON'
Contracted Service Provider ID A7 Identifier of CSP
Batch Sequence Number N4 Copied from input claim file
Claim File Name A12 Name of input claim file
Date Batch Received At Medicare D Date the batch was received at Medicare
Environment A5 'PROD'
Format Version N2 '02'. Will be incremented each time there is a change in file format or record format (allows for future changes)

Example

HDRSHICBATCH SUMMARY
INFORMATION^^^^^CONSDF00030043BATCH.043^^^22051999PROD^02

(^ indicates space)

Note - HDR record is one continuous line

Top of Page

Batch Summary Counts Record

Name Type Contents and Comments
Record Type A3 'CNT'
Date Time Batch Processed A17 DDMMCCYY HH:MM:SS (24 hr clock). Date and time HIC started processing this batch
Number Of Claims Expected N5 Copied from the trailer record in the input claim file
Number Of Claims Received N5 Count of claim records received and processed in this batch
Number Of Items Expected N5 Copied from the trailer record in the input claims file
Number Of Items Received N5 Count of items received and processed in this batch
Number Of Items Rejected N5 Count of rejected items in this batch
Number Of Accepted Items N5 Count of accepted items in this batch
GST 9999999.99 The total GST payable for this claim
WHT 9999999.99 The total WHT withheld for this claim
Total Payment Amount 9999999.99 Amount that Medicare expects to pay, inclusive of GST accepted items in this batch and WHT, to the CSP's bank account for the accepted items in this batch
Expected Date Of Payment D Date that Medicare expects the payment to be received in the CSP's bank account

Example

CNT21041999^10:06:330016700167001930019300014001790000250.000000000.0
00040132.0004051999

(^ indicates space)

Note - CNT record is one continuous line

Batch Summary Trailer Record

Name Type Contents and Comments
Record Type A3 'TRL'

Example - TRL

Top of Page

e-Claim File Format Guide (PDF 218 KB)

e-Claim Handbook

Complementary Content