Health Fund Claiming Operational Workflow

This document outlines the operational workflow for Health Fund claiming integration. This is a set of flows applicable for Private Health Insurance, Overseas Student Cover and Overseas Visitor Cover insurer transactions. It covers the supported transaction types and the processing flow for various scenarios.

Transaction Types

The system supports five Health Fund transaction types:

1. Claim : Process a Health Fund member's claim for benefit at the point of service.
2. Rebate Estimate : Retrieve an estimate of patient eligibility, benefit, and gap amount without financial settlement.
3. Void : Invalidate the last processed Claim transaction due to rejection, abort, or system error.
4. Cancellation : Cancel a previously accepted Claim within the same day.
5. Reports : Generate reports from the PMS over transactions and settlements.

Claim

Claims use a "Gap" payment method where the Fund member can claim at the point of service in real-time. The Health Fund pays the benefit directly to the provider, and the member pays the Gap (difference between service fee and benefit).

Claim Submission Requirements

• Health Fund membership number (swiped or tapped from card).
• Patient number - on the front or rear of the membership card corresponding to the patient.
• Provider number - Medicare or Health fund supplied no. associated with the Health provider at this point of service.
• Date of service - usually only the current date can be run for claims.
• Service item(s) number(s) and associated cost(s) - a max of 16 items can be claimed at a time.
• Body part or tooth number (if applicable).
• ICD-10 code / preferred provider details (for specific funds like HCF and enrolled providers) ref: Private health preferred providers page for details.

The Health Fund membership card must be swiped or tapped for a Claim to be submitted. Health fund details stored by a PMS for presentment to the terminal is not permitted.

Claim Approval Process

1. Enter and review health service details in the PMS.
2. Swipe or tap patient's Health Fund membership card.
3. Enter patient number if not already sent by PMS.
4. Process claim and receive real-time response from Health Fund.
5. Print claim assessment receipt and display result in PMS.
6. Patient reviews and chooses to Accept or Reject the claim.

Health Fund Approved Claims

On approval, the Health Fund will return an overall approval status, along with a benefit amount per service item. Approved claim can include individual service items that are both approved and declined. Unless otherwise indicated, all responses except "00 - APPROVED" mean the item has been declined by the fund.

Patient Accepted Claims

On Accept, the Claim is finalised and the member then pays the health service provider the Gap and the Health Fund pays the health provider the benefit.

• Patient signs assessment receipt; practice files it for five years.
• Print second receipt for patient.
• Process Gap payment as selected by patient.

Patient Rejected Claims

On 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.

• Activate Reject in PMS.
• Print Void receipt.
• Offer options to adjust claim details or discard for full service fee payment.

Health Fund Declined Claims

On Decline, the Health Fund reason code(s) will be displayed on the assessment receipt. The fund can return both a claim level response code and a item level response code per service item. There are also network level exceptions and errors which will return a Tyro or HealthPoint four digit response code

Patient is then asked options for this Claim:
A. Adjust: return to Claim screen. Option to change details for new Claim assessment. B. Discard: No further Claim submissions for assessment. Print receipt. Patient may seek to claim directly with their fund.

Rebate Estimate

Rebate Estimates allow patients to understand their Health Fund's benefit prior to service. The request and response payload is similar to a claim but without financial settlement and without a need for the patient to Accept or Reject the tranasction.

Void

Void transactions can occur due to:

1. Claim rejection
2. Operator abort
3. System communication error

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. Print receipt. Patient may seek 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. Print receipt. Patient may seek 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, the Claim must have taken place on same day as the Cancellation - prior to Claim settlement (23:59:59 Australian Eastern time adjusted for day light savings).

• 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 or tapped.
• Patients 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.

Note on HealthPoint claim refunds

A HealthPoint claim cannot be refunded. You can only Cancel a HealthPoint claim the same day it was processed prior to settlement. A refunded HealthPoint claim would mean that the doctor/provider who received the benefit would need to return that amount to the health fund. Automated refunds cannot be processed via HealthPoint and require the provider to contact the patient Health Fund for return of the original benefit amount.

Reports

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.
• Settlements : show "consolidated" payment view for Health Funds using HealthPoint settlement service and individual payment view for Health Funds who make direct payment ie/ as it would appear in their bank account.

The Health Fund payment to a provider is either:

1. Health Fund uses HealthPoint consolidated settlement service to make a single, aggregated, payment to the provider, or
2. Health Fund issues a direct payment to the provider.

At present, all HealthPoint supported Health Funds use consolidated settlement except for HCF. HCF is slated for later migration to consolidated settlement. Under consolidated settlement, a single payment for all approved claims is issued to the provider's nominated practice bank account, by HealthPoint the following business day.

HealthPoint Reports

HealthPoint offers two types of downloadable Integrated Health Fund reports:

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

HealthPoint 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 00:00:00am and 23:59:59pm Australian Eastern time (adjusted for day light savings).