Private health preferred providers

Preferred providers programs may reduce or eliminate out of pocket gap payments when ICD codes are provided as part of the health claim. PMS providers will need to make sure their software can handle the ICD code in the Tyro HealthPoint request and response.

The HCF 'More for' program is an example of such a claim where an ICD is required.

Please see below for our implementation guides. To certify your PMS product for Preferred providers, please contact partner managers at partner-managers@tyro.com

Preferred providers PMS iClient Implementation

It is required Tyro HealthPoint be able to receive additional PMS data for initial consult claims to support Provider participation in programs such as but not limited to the HCF More For program.

Submission of this data may facilitate a ‘No-Gap’ assessment by HCF for their members.

Along with the claim Item a second claim item is required to submit the Clinical Code (ICD-10) and enable a possible ‘No Gap’ HCF response for eligible items.

This Clinical Code data is communicated using the second claim item in the serviceCode field. The claimAmount needs to be set to $0.00 and the serviceReference (body part) needs to be populated with “ZZZ”

For the More for program HCF will supply approved providers with a list of the eligible Clinical Code items.

HCF approved providers can be from the following modalities - Chiropractors, Osteopaths Podiatrists, Physiotherapists, Optometrists and Dental.

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

Parameters:

• requestParams Object

An object containing the following properties:

• providerId (String) - The 8 character id of the provider attending the patient.
• serviceType (String) - The 1 alphabetic character representing the category of service.
• claimItemsCount (String) - The total number of claim items. At least 2 for a 'more for' claim.
• totalClaimAmount (Int) - The total amount of all claim items in cents.
• claimItems (Array) - An array containing the following properties:
  • claimAmount (int) - Claim amount in cents - max 10 digits.
  • serviceCode (String) - Item number service code - max 5 characters. ICD code will go here in the second claim item.
  • description (String) - Description of item to appear on receipt - max 32 characters.
  • serviceReference (String) - Body part or tooth number suffix - max 3 characters. Second claim item must contain 'ZZZ' to indicate that the claim item contains the ICD code.
  • patientId (String) - Patient ID on card - exactly 2 digits.
  • serviceDate (String) - Claim date in YYYYMMDD format.

Sample Code

Tyro.iclientWithUI.initiateHealthPointClaim({
    providerId: "2147661H", 
    serviceType: "P", 
    claimItemsCount: "2", 
    totalClaimAmount: "10000", 
    claimItems: [
        {
            "claimAmount": "10000",
            "serviceCode": "560",
            "description": "Assessment Consult",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20190903"
        },
        {
            "claimAmount": "00000",
            "serviceCode": "G560",
            "description": "More For ICD code",
            "serviceReference": "ZZZ",
            "patientId": "02",
            "serviceDate": "20190903"
        }
    ]}, {
    transactionCompleteCallback: yourPosCode.handleComplete,
    statusMessageCallback: yourPosCode.handleStatusMessage,
    questionCallback: yourPosCode.questionAsked
});

Sample Response

{
"result": "APPROVED",
    "transactionId": "6dbdaffd58adac4e89387f2c9d2c0cdd7c1e",
    "healthpointRefTag": "2120599",
    "healthpointTotalBenefitAmount": "10000",
    "healthpointSettlementDateTime": "20190903093316",
    "healthpointTerminalDateTime": "20190903093316",
    "healthpointMemberNumber": "0000000000",
    "healthpointProviderId": "2147661H",
    "healthpointServiceType": "P",
    "healthpointClaimItems": [
        {
            "claimAmount": "10000",
            "rebateAmount": "10000",
            "serviceCode": "00560",
            "description": "Assessment Consult",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20190903",
            "responseCode": "0000"
        },
        {
            "claimAmount": "0",
            "rebateAmount": "0",
            "serviceCode": "0G560",
            "description": "More For ICD code",
            "serviceReference": "ZZZ",
            "patientId": "02",
            "serviceDate": "20190903",
            "responseCode": "0000"
        }
    ],
    "healthpointFreeText": "More For Approved",
    "healthpointGapAmount": "0",
    "healthpointPhfResponseCode": "00",
    "healthpointPhfResponseCodeDescription": "APPROVED",
    "healthpointHealthFundName": "ISOFT FUND",
    "healthpointHealthFundIdentifyingDigits": "0099"
}

Testing

Eligible Item Numbers

The following is the currently supported item numbers within the DXC test host simulator that will trigger ‘More For’ assessment.

The item code should be entered as the first item and the ICD Code as the second item with the ServiceRef field populated with ZZZ.

The Test Outcomes using the below combinations should be as follows:

• More For Approved = 100% Rebate, No Gap is payable.
• More For Rejected = Claim Level Rejection Code 12 – Claim Declined. Item Level Rejection Code 18 – Body Part Required.
• More For Not Eligible = 50% Rebate, Gap is Payable.

Example ICD-AM codes

The following is a list of example ICD codes for use