Private health preferred providers
We highly suggest PMS partners implement the preferred provider functionality to support providers who are enrolled with these Health Fund programs. If an enrolled provider submits a claim without required details, that claim may be declined or may not apply the "No-Gap" assessment. HCF approved providers can be from the following modalities - Chiropractors, Osteopaths Podiatrists, Physiotherapists, Optometrists and Dental.
To certify your PMS product for Preferred providers, please contact partner managers at partner-managers@tyro.com
Preferred providers PMS iClient Implementation
Claims are constructed using the similar patterns as standard claims. However, it requires an additional item code with specific details to trigger preferred provider assessment.
Preferred provider claims will always contain at least two claimItems in a submission. Though additional claimItems can be added, only a single preferred provider claimItem can be submitted per claim.
For the additonal item, the following details need to be set:
- serviceReference: set to 'ZZZ'
- claimAmount: set to $0
- serviceDate: set the same as in other claimItems
- description: ICD-10 code or code description
- serviceCode: set with the appropriate ICD-10 code
- patientId: set the same as in other claimItems
HealthPoint Claiming Implementation
initiateHealthPointClaim(requestParams, transactionCallbacks) - Tell the terminal to start a HealthPoint claim.
Request Parameters
Request Parameters | Type | Description |
---|---|---|
claimItems | String | JSON array of claim items (max 16) |
claimItemsCount | int | Total number of claim items - At least 2 for a 'more for' claim |
mid | Integer | Optional - Required for headless pairing, multi-merchant, or if your browser does not support local storage |
tid | Integer | Optional - Required for headless pairing, multi-merchant, or if your browser does not support local storage |
integrationKey | String | Use if your browser does not support local storage, use developed headless pairing or multi-merchant as a feature |
providerId | String | 8-character provider number (usually Medicare issued) |
serviceType | String | 1-character category of service. See table below |
totalClaimAmount | Int | The total amount of all claim items in cents |
transactionid | String | Optional - Supply a custom transaction ID |
claimItems Table
Claim parameter | Type | Description |
---|---|---|
serviceReference | String | clinical reference or tooth number suffix (max 3 chars). Second claim item must contain 'ZZZ' to indicate that the claim item contains the ICD code. See reference below. |
claimAmount | int | Claim amount in cents (max 10 digits) |
serviceDate | String | Claim date (YYYYMMDD format) |
description | String | Item description for receipt (max 32 chars). ICD code/description will go here in the second claim item |
serviceCode | String | Item number or service code (max 5 chars). Second claim item must contain the ICD code. See reference below. |
patientId | String | Patient identifier (exactly 2 digits) |
Notes: Two Claim items need to be included in a HCF "More for" claim. Field padding is not required however if you do wish to do so you can use a space to the right.
Example Request
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
});
Excample 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 HealthPoint test host simulator that will trigger 'More For' assessment.
The standard service 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.
Modality | Item Code | ICD Code | Test Outcome |
---|---|---|---|
Chiropractic | 1006 | M752 | More For Approved |
Chiropractic | 1001 | None | More For Rejected |
Chiropractic | 1007 | Z999 | More For Not Eligible |
Physio | 560 | G560 | More For Approved |
Physio | 525 | None | More For Rejected |
Physio | 526 | Z999 | More For Not Eligible |
Dental | 949 | K029 | More For Approved |
Dental | 961 | None | More For Rejected |
Dental | 964 | Z999 | More For Not Eligible |
Podiatry | 12 | M235 | More For Approved |
Podiatry | 14 | None | More For Rejected |
Podiatry | 111 | Z999 | More For Not Eligible |
Optical | 890 | H578 | More For Approved |
Optical | 632 | None | More For Rejected |
Optical | 612 | Z999 | More For Not Eligible |
Osteopathy | 1802 | R10 | More For Approved |
Osteopathy | 1803 | None | More For Rejected |
Osteopathy | 1804 | Z999 | More For Not Eligible |
Example ICD codes
The following is a list of example ICD codes used by HCF
Modality | Example ICD |
---|---|
Podiatry | L90, M235, M766, Q665, (Z99, not eligible and will result in 50% rebate). |
Physiotherapy | G560, M069, S74, (Z99, not eligible and will result in 50% rebate). |
Chiropractic | M752, M755, R10, S63, (Z99, not eligible and will result in 50% rebate). |
Osteopathy | M752, M755, R10, S63, (Z99, not eligible and will result in 50% rebate). |
Dental | K029, K01, (Z99, not eligible and will result in 50% rebate) |
Optometry | H578, H258 (Z99, not eligible and will result in 50% rebate) |