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 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 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

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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

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{
"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)
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