Integrated Private Health Fund Claiming

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Introduction

This document outlines the implementation process for integrating private health fund claiming into Practice Management Software (PMS) using the Tyro HealthPoint system. It is intended for software developers and integration specialists and covers:

1. Overview
2. iClient API
3. Claim Requests
4. Callbacks
5. Claim Response
6. Claim Cancel
7. Testing and Demo

Overview

The PMS is responsible for building and validating claim payloads, including provider details, patient identifiers, and claimable service items. The terminal is used only to capture patient health fund member details via swipe or tap.

Once the claim payload has been drafted, the PMS invokes iClient passing in the list of claim items (in JSON format) along with some other details. The iClient window appears, and the claim is passed through to the terminal for processing. The patient swipes or taps their health fund card in the terminal when prompted, and the claim is sent off to the appropriate health fund for approval. Once approved, the terminal prints the claim receipt and shows the gap amount to the patient. On the PMS, iClient shows the gap amount and asks the operator to Accept or Reject the claim. Pressing the Accept button prompts the terminal to print the patient copy and finalise the claim. Pressing the Reject button prompts the terminal to void the claim and print receipts showing that the claim has been voided. In either case, the result of the original claim is returned to the PMS.

Before beginning development, review the Certification Criteria for iClient Health for minimum requirements.

iClient API

Refer to iClient API for sample HealthPoint claiming code. After downloading and extracting the zip folder, navigate to iclient-api/index.html, then Classes > TYRO.IClientWithUI. At the top left corner underneath the APIs, click on Classes, and then click on TYRO.IClientWithUI, scroll down until you see the index and method tabs, then click on index.

Claim Requests

Claim Payloads

The iClient API for Private Health Fund claims requires specific parameters, including a JSON claim payload. For cancellations, use the same payload as the original claim, and cancellations can only be performed on the same day.

HealthPoint Claiming Implementation

initiateHealthPointClaim(requestParams, transactionCallbacks) - Tell the terminal to start a HealthPoint claim.

Request Parameters

claimItems Table

Item Numbers

The PMS is responsible for maintaining and providing the item numbers for claims. Refer to the HealthPoint reference data for currently approved item numbers. Note that item numbers may change annually, typically on April 1st. Reference HealthPoint reference data for currently approved item numbers by modality.

Service Reference

Each claimable item has an optional 3-character serviceReference. This field is used by various professions to list elements required for claims with particular funds. Refer to the HealthPoint reference data for specific codes. This includes:

• Psychology: Primary condition as 2 numerical characters
• Occupational Therapy: Primary condition as 1 numeric character and Diagnostic Intervention as 1 numeric character
• Physiotherapy and Chiropractic: Body part / Clinical code as 2 alphanumeric characters
• Dentistry: FDI Tooth number as 2 numerical characters
• Other professions: up to 3 alphanumeric characters

Details of these codes can be found in the HealthPoint reference data document.

Modalities

Modalities represent various types of health services. The serviceType field in the claim payload should contain the appropriate modality code. Reference HealthPoint reference data for modalities supported by each Health Fund. Modalities include:

Health funds supported by Tyro HealthPoint

Note this includes funds that support both Private Health Insurance. Some funds also support Overseas Visitors and Overseas Student Cover claims.

Note: The test health fund (ISOFT Fund) is PHF00999 and has identifying card digits of 0099 and only works in non-production environments.

Current list of supported funds by provider modality

Reference the following Excel doc for a list of item codes and responses for each supported fund and modality: <ins><span style="color:red">HealthPoint reference data</span></ins>

Note: A category code is included in the reference data but does not need to be set by the PMS.

Health funds not currently supported by Tyro HealthPoint

• CDH (Hunter Health Insurance)
• GU Health *under migration to nib
• MDHA (Mildura Health Fund)

Example request

iclient.initiateHealthPointClaim({
    providerId: "1455813F", 
    serviceType: "P", 
    claimItemsCount: "2", 
    totalClaimAmount: "20100", 
    claimItems: [
        {
            "claimAmount": "10000",
            "serviceCode": "500",
            "description": "Assessment Consult",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20240921"
        },
        {
            "claimAmount": "10100",
            "serviceCode": "505",
            "description": "Subsequent Consult",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20240921"
        }
    ]}, {
    transactionCompleteCallback: yourPosCode.handleComplete,
    statusMessageCallback: yourPosCode.handleStatusMessage,
    questionCallback: yourPosCode.questionAsked
});

transactionCallbacks

Callback functions that are only required when using TYRO.IClient. When using TYRO.IClientWithUI, status messages and questions are handled by the UI provided.

Steps to follow

The steps to be followed to handle the response are given as follows:

1. You are required to code callback functions to handle the responses returned by iClient via the statusMessageCallback , the questionCallback , and the transactionCompleteCallback. Examples of callback functions are given in the below.
2. You must associate the callback functions that you have created with the callbacks in the function invocation.
3. The PMS must use the response fields returned by the callback, and use them to control any subsequent workflows within the PMS e.g. using the result field to control when the PMS closes the transaction off, displays the result on the screen, and mark the transaction in the correct status e.g. "Approved".
4. The PMS must conduct all follow-up actions/workflows in the callback function.

transactionCompleteCallback Function:

statusMessageCallback Function:

questionCallback Function:

Question Callbacks may not be applicable for all transactions. However, when

Claim Response

Claim responses are typically returned within 5 seconds but may take up to 55 seconds with some funds. If a response is not returned within 55 seconds, the terminal will send an Autovoid and the claim must be reattempted.

Key response fields:

Other elements will echo the request submission.

All responses except "00 - APPROVED" mean the item has been declined by the fund. Items may return a response code other than '00' and still pay a limited benefit. Reference Response codes for details on each type of response.

Loyalty and bonus codes

For select funds like HCF, it's possible to receive back an additional benefit only item code not submitted by the PMS as part of a Health Fund loyalty or bonus program. This benefit only item code will reduce the gap owed by a patient. The code will be displayed on patient and provider receipts with:

• $0 charge amount
• a benefit only amount
• item serviceCode '00992'
• additional detail may be returned in the field healthpointFreeText, such as "Limit Boost"

Example response

{
"result": "APPROVED",
    "transactionId": "6dbdaffd58adac4e89387f2c9d2c0cdd7c1e",
    "healthpointRefTag": "2120599",
    "healthpointTotalBenefitAmount": "6600",
    "healthpointSettlementDateTime": "20240921093316",
    "healthpointTerminalDateTime": "20240921093316",
    "healthpointMemberNumber": "12345678",
    "healthpointProviderId": "2147661H",
    "healthpointServiceType": "P",
    "healthpointClaimItems": [
        {
            "claimAmount": "1000",
            "rebateAmount": "600",
            "serviceCode": "00500",
            "description": "Assessment Consult",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20240921",
            "responseCode": "0000"
        },
        {
            "claimAmount": "10000",
            "rebateAmount": "6000",
            "serviceCode": "00520",
            "description": "Extended Consult",
            "patientId": "02",
            "serviceDate": "20240921",
            "responseCode": "0000"
        }
    ],
    "healthpointGapAmount": "4400",
    "healthpointPhfResponseCode": "00",
    "healthpointPhfResponseCodeDescription": "APPROVED",
    "healthpointHealthFundName": "ISOFT FUND",
    "healthpointHealthFundIdentifyingDigits": "0099"
}

Gap Payments

Once a claim has been approved, there is typically a gap between the benefit amount paid by the health fund and the amount charged by the practitioner. If the patient would like to use a card to pay for the gap amount, the standard purchase method can be used to process the payment. Please be sure to pass in the healthpointTransactionId which is the transactionId returned in the response to the original HealthPoint claim.

Settlement

An aggregated single settlement (aside from HCF who issues a separate settlement) is issued by HealthPoint to the provider the following business day for all approved claims. The settlement claims period is 00:00:00 to 23:59:59 Australian Eastern time, adjusted for daylight savings.

Claim Cancel

An Approved Claim can be cancelled on the same day it was processed prior to settlement (23:59:59 Australian Eastern Time, adjusted for daylight savings).

HealthPoint Claim Cancel Implementation

cancelHealthPointClaim (requestParams, transactionCallbacks) - Tell the terminal to cancel a HealthPoint claim.

Request Parameters

Example Claim Cancel

// to initiate a cancel of a completed healthpoint claim with two claim items totaling $250
iclient.cancelHealthPointClaim({providerId: "2147661H", serviceType: "D", claimItemsCount: "2", totalClaimAmount: "25000", refTag: "0960001", claimItems: [
        {
            "claimAmount": "10000",
            "serviceCode": "00001",
            "description": "SKULL XRAY",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20131010"
        },
        {
            "claimAmount": "15000",
            "serviceCode": "00001",
            "description": "SKULL XRAY",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20140508"
        }
    ]}, {
   transactionCompleteCallback: yourPosCode.handleComplete,
   statusMessageCallback: yourPosCode.handleComplete,
   questionCallback: yourPosCode.questionAsked
 });

Testing and Demo

Use the Tyro non-production integration environment and development terminals to test HealthPoint integrations. A set of test health fund cards can be issued by Tyro - contact your partnerships manager for details.

The following patient and provider details can be used for tests:

Patient IDs on Card:

• 00 John Citizen
• 01 Judy Citizen
• 02 Jack Citizen

Provider details:

HealthPoint Claiming Demo

Demo - JS Fiddle