Health Fund Claiming Operational Workflow

There are four (4) Health Fund transaction types

Claim

A transaction for a Health Fund member’s (patient) Claim for benefit from their Health Fund for health services provided (initiated at the point of service).

Void (rejection, abort & system)

A transaction to invalidate the last processed Claim transaction. This happens when either the Health Fund member rejects the Claim assessment (at the point of service), or an operator abort (at the point of service) or because of a communications error (initiated by the system).

Cancellation

A Claim transaction that was previously accepted by the Health Fund member is now cancelled within the same day (initiated at the point of service).

Reports

Reports are created directly from the PMS and from the System.

Claim

Health Fund Claims are based on a “Gap” payment method where the Fund member (patient) is able to make a Claim at the point of service in real time and their Health Fund will then direct payment of a benefit (if a benefit is approved) to the health service provider. The member then pays the health service provider the Gap, which is the difference between the service fee and Health Fund benefit.

Each Claim is made up of one or more health service items (max 16 items per Claim). When the Claim is submitted, the Health Fund sends a response for each individual item (in addition to the response for the Claim as a whole). These responses are next to each item on the claim receipt and PMS display. Unless otherwise indicated, all responses except “00 - APPROVED” mean the item has been rejected.

The member also has the option to either “Accept” or “Reject” the Claim following the Health Fund’s “APPROVED” response.

• If Accept, the Claim is finalised and the member then pays the health service provider the Gap and the Heatlh Fund pays the health provider the benefit.
• If Reject, a Void transaction is sent to the Health Fund to invalidate the Claim transaction and the member is required to pay the health service provider the full service fee.

The Health Fund membership card must be present and swiped for a Claim to be submitted. Manual entry or having stored in the PMS is not permitted by the Funds.

Information required to submit a Claim for Health Fund assessment

• Health Fund membership number – swiped from patients Health Fund card.
• Family member number – the no. on the front or rear of the membership card corresponding to this patient.
• Provider number – unique Medicare or Health fund supplied no. associated with the Health provider at this point of service.
• Date of service.
• Service Item(s) number(s) and associated cost of service(s).
• Body part number or Tooth number associated with service item where applicable.

For a Health Fund “Approved” Claim

• Health service details are entered and reviewed in the PMS.
• Patients Health Fund membership card is swiped.
• Patients family member number on their card is entered if not already known by PMS ( 0, 1, 2, 3 etc).
• Claim is processed and the response is sent by the Health Fund in real time.
• A Claim assessment receipt is printed from terminal and displayed in PMS which details the Health Fund response to each service item and to the Claim as Approved.
• Patient reviews the Claim assessment with the rebate(s) and Gap and may choose to either Accept or Reject the Claim.
• Patient advises they Accept the Claim.
  • Patient signs Claim assessment receipt and the practice initials this receipt.
  • Patient signed assessment receipt is filed by the practice and retained for 2 years.
  • Practice activates Accept in PMS.
  • 2nd Claim assessment receipt printed as the Patient copy.
  • Patient is then asked how they wish to pay the Gap – cash, credit, debit or invoice.
  • Payment method is selected in PMS.
  • Gap payment is performed with corresponding receipts printed for patient and practice.
• Patient advises they Reject the Claim.
  • Practice activates Reject in PMS.
  • Health Fund responds with Void accepted message displayed in PMS and on terminal.
  • Void receipt is printed from terminal which also details the Health Fund’s Claim assessment.
  • Patient is then asked options for this Claim?
  • Adjust – return to Claim screen. Option to change details for new Claim assessment.
  • Discard – No further Claim submissions for assessment. Payment of full service fee. Print receipt. Patient to claim directly with their Fund.

For a Health Fund “Rejected” Claim

• Health service details are entered and reviewed in the PMS.
• Patients Health Fund membership card is swiped.
• Patients family member number on their card is entered if not already known by PMS ( 0, 1, 2, 3 etc).
• Claim is processed and the response is sent by the Health Fund in real time.
• A Claim assessment receipt is printed from terminal and displayed in PMS which details the Health Fund response to each service item and to the Claim as a whole.
• Health Fund Rejects Claim showing reason code(s) on assessment receipt.
  • Patient is then asked options for this Claim?
  • Adjust – return to Claim screen. Option to change details for new Claim assessment.
  • Discard – No further Claim submissions for assessment. Payment of full service fee. Print receipt.Patient to claim directly with their Fund.

For patients wanting to understand their Health Fund’s assessment to a Claim prior to proceeding with Health services

The options can be either of:

1. Call the patient’s Health Fund on their member services phone number or
2. Submit a Claim and then Reject (Void) this Claim.
3. Claim is processed and the response is sent by the Health Fund in real time.
4. Practice activates Reject in PMS.
   • Health Fund responds with Void accepted message displayed in PMS and on terminal.
   • Void receipt is printed from terminal and displayed in PMS which details the Health Fund ‘s Claim assessment.
   • Patient is then asked options for this Claim?
   • Adjust – return to Claim screen. Option to change details for new Claim assessment.
   • Discard – No further Claim submissions for assessment.

Void

Void (rejection)

• Claim is processed and the response is sent by the Health Fund in real time.
• A Claim assessment receipt is printed (also displayed in PMS) which details the Health Fund response to each service item and to the Claim as a whole.
• Either of 1. The Health Fund Rejects Claim showing reason code(s) or 2. Patient advises they Reject the Claim.
  • Patient is then asked options for this Claim?
  • Adjust – return to Claim screen. Option to change details for new Claim assessment.
  • Discard – No further Claim submissions for assessment. Payment of full service fee. Print receipt.Patient to claim directly with their Fund.

Void (operator abort)

• Claim is sent to be assessed by the Health Fund in real time.
• Prior to the Claim assessment being received from the Health Fund,
  • Practice activates Cancel in PMS.
  • Health Fund responds with Void accepted message displayed in PMS and on terminal.
  • Void receipt is printed.
  • Patient is then asked options for this Claim?
  • Adjust – return to Claim screen. Option to change details for new Claim assessment.
  • Discard – No further Claim submissions for assessment. Payment of full service fee. Print receipt. Patient to claim directly with their Fund.

Void (system)

• Claim is sent to be assessed by the Health Fund in real time.
• Prior to the Claim assessment being received from the Health Fund.
  • System detects a communications error and displays message in PMS and terminal.
  • Operator options for this Claim from the PMS are:
  • Discard – PMS instructs system to issue a Void for this Claim or
  • Retry – PMS instructs system to resubmit this Claim.

Cancellation

To cancel a Claim using the system, the Claim must have taken place on same day as the Cancellation - prior to Claim settlement (12AM Sydney time – adjusted for day light savings).

To cancel a Claim after the same day, the patient must directly request a cancellation with their Health Fund. The system will not accept a Cancellation post same day.

• A Claim has been Approved by the Health Fund and Accepted by the Patient.
• Patient now wishes to cancel this Claim.
• Cancellation is selected in PMS.
• Patients Health Fund membership card is swiped.
• Patients family member number on their card is entered if not already known by PMS ( 0, 1, 2, 3 etc).
• The system will display in the PMS all submitted Claims for this patient along with their status.
  • SUCCESS – Claim was Approved by the Health Fund and Accepted by patient.
  • REJECTED – Claim was Approved by Fund and Rejected by patient.
  • CANCELLED – Claim is already cancelled.
  • RECONCILED – Claim is already settled (Claimed prior to this day).
  • DECLINED – Claim was declined by the Health Fund.
  • FAILED – an error occur during processing of the Claim, system Void.
• A Claim can only be cancelled with “Success” status.
• Cancellation is selected in the PMS and Cancellation for this Claim is sent to the Health Fund.
• The Health Fund responds and a Cancellation receipt is printed which shows the Health Fund’s responses to the Cancellation of each item and to the Claim as a whole.
• Patient payment of the full service fee is now required. - payment of Health fund benefit.

Reports

Reports are created directly from the PMS and from the System.

PMS Reports

Health Fund claiming is an integrated only function and as such the PMS has knowledge of all these transactions. As a minimum, the PMS should provide the following reports:

• Health Fund summary - list the payment totals only of each Health Fund.
• Health Fund totals by day - list transactions (claim, void, cancellation) by day grouped either by Health Fund or by day.
• Transaction detail - list patient names with the Health Fund transaction including item codes, billing and payment detail.
• Configurable option to show "consolidated" payment view for Health Funds using CSC settlement service and individual payment view for Health Funds who make direct payment ie/ as it would appear in their bank account. The following explains this further:

The Health Fund payment to the health providers bank account is either :

1. Health Fund makes payment directly into health providers bank account (bank account shows individual deposits by each Fund) or
2. Health Fund uses CSC (Computer Sciences Corporation) settlement service to make "consolidated" payment into providers bank account (bank account shows just one consolidated payment for all funds using this service).

The individual Health Funds do not alternate their provider payment method. Over time more funds will use the CSC settlement service.

To assist health providers reconcile their PMS Health Fund reports with their bank account, there should be an option (particularly for the Health Fund summary) to show a "consolidated" payment total by day for those funds using the settlement service alongside showing individual deposits for those Funds who do not use this service. A user configurable "tick box" drop down Health Fund list could be one way to do this as part of setup within the PMS.

Settlement Service (consolidated) Health Funds are - HBF, AHM, Teachers Health Fund (UniHealth), GMHBA (Frank, RACT, Budget Direct), Latrobe, HIF, CUA, Peoplecare, TUH, Navy Health, Police Health, QCH, ACA Health Benefits, onemedifund, health.com.au

Direct payment Health Funds are - Medibank Private, BUPA, HCF, NIB, Australian Unity, Defence Health, CBHS, WestFund, GMF/Healthguard, RT Health.

System Reports

The System offers two types of downloadable Integrated Health Fund reports; a claims reconciliation report and a payments reconciliation report.

• The claims reconciliation report provides a list of all claims processed for a given calendar day including result (approve, cancel, void).
• The payments reconciliation report provides a report of payments made by funds that are settled by CSC. Payments made by funds that are not settled by CSC are not included in this report.

System reports are available for download detailing the Health Fund transactions made during a particular day. These Reports are created by the System at the end of each working day and available to retrieve on the next working day. It will represent the selected period(s) between 12am – 11:59:59pm Sydney time (adjusted for day light savings).