Eligibility check response codes
These errors can occur for ECLIPSE claims, and the actions required provide solutions that may allow you to resubmit a claim. The source documentation word file (with Appendix A & B error codes) is available on the Services Australia website.
Response code | Message | Reason | Action required |
1005 | Facility ID not known to fund | The facility ID supplied is not registered at the fund/not current | Check the facility ID; if correct contact the fund, if incorrect re-submits with corrected data |
1100 | Not eligible for selected service | The patient is not eligible for treatment for the presenting illness or item according to the information supplied in the eligibility check | Tell the patient that they are not eligible for the service |
1101 | Eligible for service selected | Patient is eligible for the presenting illness or item according to information supplied in the eligibility check | |
1102 | Eligible subject to conditions | Patient may be eligible for the presenting illness or item according to the information supplied in the eligibility check. However, there may be conditions you will need to note before you proceed such as:
| Refer to OEC guide for assistance on areas to check |
1103 | Resubmit for new assessment if presenting illness is shown | A general presenting illness or item was requested and a general answer displaying all benefit limitation or restriction that apply to the patients cover was returned in the response | Check the eligibility response carefully and re-submit if the actual presenting illness or item is displayed to obtain an accurate assessment |
1104 | Eligible for selected service at previous cover | The patient is eligible for the presenting illness or item on the incoming eligibility request but not at their current cover. This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover | The patient is eligible for the service on their previous level of cover |
1105 | Not eligible for selected service – wait period applied | The patient is not eligible for the presenting illness or item as they have not completed serving their required waiting periods | |
1106 | Eligible for selected service at previous cover – wait period applied | The patient is eligible for the presenting illness or item as input on the incoming eligibility request but not at their current cover. This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover | |
1107 | Not eligible for selected service – pre-existing ailment | The patient is not eligible for the presenting illness or item if it is deemed to be a pre-existing condition | |
1108 | Eligible at previous cover subject to conditions | The patient is eligible for the presenting illness or item as input on the incoming eligibility request but not at their current cover. This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover | |
1109 | Eligible subject to approval of accident certificate | Fund won’t guarantee payment of the service until an accident certificate is supplied and approved | Ask member to contact the fund |
1110 | Eligible subject to conditions and approval of accident certificate | Fund won’t guarantee payment of the service until an accident certificate is supplied and approved and there is another condition that will affect assessment. This could be:
| Ask member to contact the fund regarding the accident certificate and to check the other conditions of the eligibility response |
1111 | Unknown presenting item | The presenting illness or MBS item could be:
| Check the item number. If correct contact the fund, if incorrect amend and re-submit |
1999 | Processing error | Contact fund | |
2001 | Waiting period applies for pre-existing ailments | No benefit payable | |
2002 | Service is within the required waiting period | No benefit payable | |
2006 | Benefit not payable for services claimed or requested | No benefit payable | |
2007 | Incorrect charge – charge exceeds allowable amount for claim type | Charge input is greater than the agreed rate for an agreement or scheme claim | Check the charge amount and claim type, correct the error and re-submit |
2008 | Public hospital table – Nil benefit | No benefit payable | |
2009 | A benefit is not payable for this service under this level of cover | No benefit payable | |
2010 | Membership was not paid to the date when the service was provided | ||
2017 | Default benefit only paid for this procedure | Lesser benefit paid for this service | |
2026 | Member issue as at date of service | Ask the member to contact the fund | |
2888 | Refer to OEC response & assessment text | There is an issue with the overall eligibility response that will affect the service line assessment result | Check and correct the eligibility issue, then re-submit |
2999 | Processing error contact fund | The fund has a processing error that maybe unique to the membership or claim supplied | Contact the fund to find out the reason for the error |
Patient verification error messages
These errors can occur for ECLIPSE claims, and the actions required provide solutions that may allow you to resubmit a claim. The source documentation word file (with Appendix A & B error codes) is available on the Services Australia website.
Response code | Message | Reason | Action required |
7026 | DVA file number does not have a Gold or White card and may not be eligible for services | DVA specific | Verify file number and resubmit claim |
7028 | Name does not match registered name for File Number | DVA specific | |
7035 | Patient gender must be male or DVA specific IHC claims | DVA specific | |
9650 | The patient data supplied failed validation checks against Medicare data | DVA specific | |
9662 | Provider not recognised by fund | Provider not recorded on health fund system | Location or provider to contact fund |
9663 | Member number not recognised by fund | Member number not known by the fund the claim was submitted to. No other patient data checked at this time | Check member number and fund, correct whichever is wrong and try again |
9665 | Patient not recognised on the membership | Member number is valid Cover for membership number is permitted – no patient is identified or multiple patients are identified | Check patient details and re-submit. Make change to the alias name if Medicare has sent back a successful response Provide sufficient patient details to ensure unique match within membership |
9666 | Member to contact fund | Possible fraud, accident claim or membership issues | Member to contact fund |
9667 | Cover is suspended or cancelled | Member Number is valid | Can’t lodge a hospital claim as member is not covered for that service. Check with member |
9668 | Inappropriate cover | Cover is either ancillary or ambulance only | Can’t lodge a hospital claim as member isn’t covered for that service. Check with member |
9669 | Patient is ceased or pending cessation | Member number is valid Appropriate cover for membership number Patient details matched | Member to contact fund Patient may not have current student registration |
9686 | Baby not known at fund | No patient match is found and the DOB of the patient is less than 29 days from the earliest date of service in the Online Patient Verification Request | Member needs to register the baby at the fund |