Health Fund Claiming Operational Workflow

Introduction

This document outlines the operational workflow for Health Fund claiming integration. It describes the set of workflows applicable to Private Health Insurance, Overseas Student Cover, and Overseas Visitor Cover insurer transactions. The document details the supported transaction types and the corresponding processing flows for various scenarios.

Transaction Types

The system supports five Health Fund transaction types:

Claim : Processes a Health Fund member’s claim for benefits at the point of service.
Rebate Estimate : Retrieves an estimate of patient eligibility, benefit, and gap amounts without financial settlement.
Void : Invalidates the most recently processed Claim transaction due to rejection, abort, or system error.
Cancellation : Cancels a previously accepted Claim within the same calendar day.
Reports : Generates reports from the PMS covering transactions and settlements.

Claim

Claims use a Gap payment method, allowing Health Fund members to submit claims at the point of service in real time. The Health Fund pays the benefit directly to the provider, while the member pays the gap (the difference between the service fee and the benefit amount).

Claim Submission Requirements

Health Fund membership number (captured by swiping or tapping the membership card).
Patient number - displayed on the front or rear of the membership card and corresponding to the patient.
Provider number - a Medicare- or Health Fund–issued number associated with the healthcare provider at the point of service.
Date of service - typically limited to the current date for claim submission.
Service item(s) number(s) and associated cost(s) - up to a maximum of 16 items may be claimed in a single transaction.
Body part or tooth number (if applicable).
ICD-10 code / preferred provider details (required for specific funds, such as HCF, and for enrolled providers). For more information, refer to the ref: Private health preferred providers page for details.

The Health Fund membership card must be swiped or tapped in order for a claim to be submitted. Health Fund details stored within a Practice Management System (PMS) must not be presented to the terminal.

Claim Approval Process

Enter and review health service details in the PMS.
Swipe or tap the patient’s Health Fund membership card.
Enter the patient number if it has not already been provided by the PMS.
Process the claim and receive a real-time response from the Health Fund.
Print the claim assessment receipt and display the result in the PMS.
The patient reviews and chooses to accept or reject the claim.

Health Fund Approved Claims

Upon approval, the Health Fund returns an overall approval status along with a benefit amount for each service item. An approved claim may include individual service items that are both approved and declined. Unless otherwise indicated, any response code other than “00 – APPROVED” indicates that the service item has been declined by the Health Fund.

Patient Accepted Claims

Upon acceptance, the claim is finalised. The member pays the healthcare provider the gap amount, and the Health Fund pays the provider the benefit amount.

The patient signs the assessment receipt, which the practice retains for five years.
Print a second receipt for the patient.
Process the gap payment using the method selected by the patient.

Patient Rejected Claims

Upon rejection, a Void transaction is sent to the Health Fund to invalidate the claim, and the member is required to pay the healthcare 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 an 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 transaction.

Void

Void transactions can occur due to:

Claim rejection
Operator abort
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 daylight 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.
Patient's Health Fund membership card is swiped or tapped.
Patient's 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 occurred 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:

Health Fund uses HealthPoint consolidated settlement service to make a single, aggregated, payment to the provider, or
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 daylight savings).