Private health preferred providers

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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 HealthPoint request and response. The HCF 'More for' program is an example of such a claim where an ICD is required, although other funds may be added.

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 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 additional 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

claimItems Table

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
});

Example 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.

Example ICD codes

The following is a list of example ICD codes used by HCF