General Medical Services claims

General Medical Services (GMS) are subsidies paid to general practitioners under the Section 88 notice to help reduce patient fees for children and subsidy card holders.

The GP can claim a subsidy if the patient is:

  • 15 years or younger
  • 17 years or younger and not financially independent
  • 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.

I have not been paid for an entire GMS claim, what should I do?

Please call the Sector Operations Contact Centre (0800 458 448) 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 6 months old it will need special approval from your DHB before Sector Operations can process it.

The claim has been processed but it has not been paid at all, why would this be?

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.

The variance report is showing error messages, what do these messages mean?

Error 0513 – Invalid NZMC

The New Zealand Medical Council (NZMC) number given has expired or is not in Sector Operations’s database. Please check your records and call the Sector Operations Contact Centre on 0800 458 448 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 6 months old and will require special approval from your DHB before we can release payment. Please write to your DHB providing details surrounding the reason for submitting late claims. It is at the discretion of your DHB 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. Please check your records and call the Sector Operations Contact Centre on 0800 458 448 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.

I have seen a school student who is 18+ years old, are they still claimed at the ‘J’ rates?

Once a patient has turned 18 they are classed as an adult and claimed at the ‘A’ rates, regardless of their circumstances.

Can I claim an immunisation claim and a GMS claim for 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.

Can I claim more than 1 GMS claim on the same patient, on the same day?

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.

Can I claim 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.

Can I fax amended variance reports?

No, claims need to be re-submitted electronically.

The variance report I have received lists a lot of patients, but nearly all the money has been paid – why is this?

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, frequently a variance report will list the patients who have no NHI’s 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.

How long will it take for my GMS claims to be paid?

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 should I send my discs and manual claims?

Send all completed claim forms and discs to:

GMS claims
Sector Operations
PO Box 1026
Wellington 6140

Please 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 & liabilities applicable to any service provider or funder.

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