Evaluation of the National External Breast Prostheses Reimbursement Program

3.5 Appropriate administration to achieve the principles of the program and comply with the business rules

Page last updated: 05 November 2010

It is evident from this evaluation that there are mechanisms in place to ensure appropriate administration of the program with regards to providing service to women as per the principles of the program, and that these are in accordance with the business rules of the program.

For instance, Medicare Australia has established processes to assist in the management of enquiries of varying complexity and a tiered approach is used to separate simple and complex enquiries.

  • Tier 1 or simple enquiries (e.g. the provision of claim form and/or fact sheet) are handled by Medicare Australia staff in person or over the phone
  • Tier 2 or more complex enquiries (payment or rejection determinations) are transferred to the dedicated processing site for resolution
  • Tier 3 or queries of a policy or legislative nature are referred to the department for assessment.