Little black book of line items

We know swift payment is vital to you.

It’s not compulsory, but when you submit an invoice to a plan manager or the National Disability Insurance Agency (NDIA), including the right line item code can push the claim through much faster. But more importantly, the NDIA has rules and requirements around line items that, if not adhered to, could cause an invoice to be declined.

In this article, we unpack and simplify line items and explore why claims get rejected, to help you pre-empt and avoid common roadblocks. This is a must-read resource for providers who want to get paid quickly.

The anatomy of a line item

The National Disability Insurance Scheme (NDIS) Pricing Arrangements and Price Limits contains a whopping 800 line items for providers to claim from!

And, given a line item lets the NDIA know which budget category in your client’s plan should pay for your services, they’re one of the most valuable tools in a provider’s toolkit.

To simplify line items, let’s break them down.

A line item has two components: a numerical code (‘Item Number’) and a description of the service provided (‘Item Name and Notes’). Below is an example from the NDIS Pricing Arrangements and Price Limits.

Each Item Number contains a support category, sequence number, registration group, outcome domain, and support purpose. When broken up, it looks like this:

When you’re locating a line item in the NDIS Pricing Arrangements and Price Limits, it helps to understand ‘support purposes’ and ‘categories’.

NDIS funding is broken up into three support purposes or ‘budgets’ – Core Supports, Capital Supports and Capacity Building Supports. We explain what’s included in each of these budgets here.

Within each budget, there are several categories – currently there are 15, although this is changing as the NDIA’s new PACE computer system rolls out nationally. You can find out more about PACE here.

Take a look at the budget and category breakdown below:

To find the correct line item, open the NDIS Pricing Arrangements and Price Limits, find the
correct budget (i.e. Core Supports, Capital Supports or Capacity Building Supports) and category,
(i.e. 01 Assistance with Daily Life), then locate the line item that aligns to the service you’ve provided. You can identify this through the ‘Item Name and Notes’ seen in the example below:

What would cause a claim to be declined?

The NDIA has rules and requirements around line item codes that, if not adhered to, could cause a claim to be declined.

At My Plan Manager, we see thousands of invoices every week and can tell you from experience what the NDIA does and doesn’t accept.

To help you pre-empt and avoid roadblocks, we’ve outlined a few common causes of claim rejections.

1. When a support category or support purpose isn’t included in a client’s plan

For example, if you invoice for personal training when your client doesn’t have the Improved Health and Wellbeing category in their NDIS plan, the claim will be rejected.

As a provider, you’re reliant on your client to be transparent about their NDIS funding, so you know it’ll cover the supports you provide. That’s why it’s good to understand whether your supports are funded, and to put a service agreement in place. Both reduce the likelihood of a claim being denied.

Here are our tips for writing an A+ service agreement.

Takeaway: Before commencing supports, check with your client to make sure there’s funding available in their plan for the budgets and categories related to your services – and make sure there’s enough funding left to cover your fees.

2. A practitioner provides therapies that the NDIA doesn’t recognise or a therapist doesn’t have the necessary qualifications

In the NDIS, therapeutic supports are delivered by a broad range of qualified professionals. They also account for one of the largest groups of funded supports in the Scheme.

Many therapeutic supports are delivered by allied health professionals (e.g., an occupational therapist) – university qualified professionals with specialised expertise in developing and implementing strategies to help build a participant’s capacity for independence.

Therapeutic supports can be delivered by a range of professionals, if their qualifications align with the NDIS Pricing Arrangements and Price Limits. For example, a qualified music therapist who’s registered with the Australian Music Therapy Association can deliver therapeutic supports to NDIS participants.

Takeaway: If you’re providing therapeutic supports to an NDIS participant and charging as an allied health professional, you’re required to have the correct credentials to provide the therapies the NDIA recognises. Generally, alternative therapies aren’t funded under an NDIS plan, and established therapies are much more likely to be funded. But, if an alternative support meets the NDIA’s reasonable and necessary criteria, it may qualify and be covered.

3. A provider claims more than is allowed under the NDIS Pricing Arrangements and Price Limits.

The NDIA requires providers to claim within the rates set out in the NDIS Pricing Arrangements and Price Limits. If a claim exceeds those rates, it indicates a provider is either using the wrong line item or charging above the approved rate. Below are two examples:

• A provider charges a client $240 for three hours of support delivered on a Sunday, using code 01_011_0107_1_1. The claim fails because the provider used a weekday code, which has a price limit of $65.47 per hour. Had the provider claimed using the 01_014_0107_1_1 code for support work delivered on a Sunday, the claim would’ve succeeded.
  
• A provider charges a client $240 for three hours of support delivered on a Tuesday, using the 01_011_0107_1_1 code. The claim fails because the price per hour exceeds the NDIA’s limit of $65.47.

Takeaway: Be sure your claim doesn’t exceed the NDIS Pricing Arrangements and Price Limits, and if it does, check it contains the right line item code.

4. The line item code doesn’t exist.

The NDIS Pricing Arrangements and Price Limits is continually changing and sometimes providers submit claims with line item codes that no longer exist.

For example, from 1 January 2024, providers will need to claim for group-based supports under new pricing arrangements from the NDIA. If providers claim under the old method after this time, their claim will be declined, and they’ll need to resubmit it using the new pricing arrangements.

Takeaway: Be sure the line item code you’re claiming against is current.

5. A client has a stated support (e.g., funding to purchase a manual wheelchair) and a provider claims for a different support that’s not been stated (e.g., a shower commode).

Stated supports are prescriptive, meaning funding is allocated for a specific support or service that can’t be deviated from. This is an NDIA requirement that we adhere to and that’s why it’s vital for providers to understand whether the service or support they’re offering is funded in a client’s plan – or whether the client intends to seek a plan reassessment or pay privately. Having a service agreement in place is another important step to help providers reduce the likelihood of a claim being declined.

Takeaway: Ask your client if they have funding included in their plan for the stated support you’re providing. If they don’t, discuss next steps with them – such as a plan reassessment – and what they’d like to do. And make sure you lock in a service agreement.

The NDIA has other claiming rules that providers are expected to adhere to as well. Here’s just a few:

• There are certain supports you can and can’t charge travel for and it’s the same for activity-based transport. You can find these rules in the NDIS Pricing Arrangements and Price Limits, under ‘Provider Travel’ and ‘Claiming under activity based transport’. Providers can only claim for travel costs related to the delivery of a support item if specific conditions are met.
  
• Assistive technology over $1500 must be stated in a participant’s plan and it comes out of Capital Supports funding.
  
• To claim for meal preparation, the support typically needs to be described specifically in the participant’s plan. Not to worry though – if their circumstances change, the participant can access meal preparation temporarily while they seek a plan reassessment. They can also access meal preparation flexibly in extenuating circumstances, for example if they’ve had to isolate and can’t get a support worker to assist them.
  
• Different codes and price limits may apply, depending on the time of day and the day of the week supports are delivered on. Some supports must be delivered face-to-face and invoices require a code to reflect that. Be sure to check the category you’re claiming under before invoicing.

We’re here to help

If you need help or a second opinion about line items or claims, we’re here to help. You can email us at [email protected] or call us on 1800 861 272 from 8am-6pm (SA time), Monday to Friday.