Understanding split billing

We recently received a query from a member regarding a split billing claim and would like to clarify how this works. In this instance, a retired member visited a pharmacy where both chronic and non-chronic medication were dispensed on the same prescription. The pharmacy submitted the claim for chronic medication to AMS. The member paid cash for the non-chronic medication, but the pharmacy omitted to send that portion of the claim to AMS.

The member then submitted the non-chronic claim directly to AMS for tax purposes. However, because the pharmacy had not submitted the full claim electronically, the AMS system was unable to process it. This is because the claim fell into the category of split billing, which is not permitted under the Scheme Rules.

AMS's claims-processing system has built-in controls that prevent split billing. These controls are important safeguards designed to prevent fraud and protect members by ensuring that claims are submitted and processed in a consistent and transparent manner.

What members should do

To avoid this situation, members are encouraged to ask their pharmacy to submit the full claim to AMS, even if part of the benefit limit has already been reached. Where no funds are available for a portion of the claim, the system will automatically reject that amount, and it will then be correctly reflected on the member's tax certificate. This ensures accurate claims processing and avoids delays or confusion for members.

Published January 2026