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ECLIPSE user guide

1. SEE 23 athl 23 Claim Processing REport seccsessssssssssssssessssssssesssnsessnccsssecsncesssecsnssesnsssnsessuceessessusesssecsnsessusssncessnssessessusesssessusessuesssnsessnceessessncessesssneesaeessneersess 24 Eligibility Processing REP OR eerte tete reete O O 26 sire 28 Processing Messages and Response Codes esee ttti thoi ttt ttt sanan 30 Medicare Explanation Codes i er a 30 Processing Messages sacco duet A ii 31 Medicafte services CU O 38 Private health insurer conta ias 39 General Miri tei ence hans eee attis 40 Field Notes Patiernt Iori iii na 40 Field Notes Hospital INFOrmation oc cecceecssssssssssssessssssessessssssssseceseccsnccesecsnscssuecssseessscssssessuscessccsnscesnesssscessscssssessucesseecsuscessessnseesuesssneesnneesess 41 Field Notes Medical Information eee seee ace 42 Glaim Type Codes o concedendo emddanemtiece mtem dead 42 Claim processing mWiformablOfian educar a Up ctn HP oe Rena ei uam RE Ox Rc Rune 45 informed Financial Constan 43 Obtaining Informed Financial Cons iia 43 Financial Interest DISClOSULE marcaci n mece ette tette ertet caia 43 TimesDependent Restrictiom Dd 43 A OIN I I EA A AA A AE A A AAAA N AAAA AAE AA A AAN 44 Assisting AnaesthetiS hiena e N a 44 A ICS TAE E
2. Add the account reference id and then re submit ECLIPSE Response Code 1008 1009 1100 1101 1102 1103 1104 Medical and Eligibility User Guide V2 2 for Medical Practitioners Message EFT details not registered with fund Billing agent claims can t be accepted by the health fund Not eligible for service selected Eligible for service selected Eligible subject to conditions Re submit for new assessment if presenting illness is shown Eligible for service selected at previous cover EFT details are not recorded for the 1 fund payee id 2 principal provider or 3 billing agent The patient is not eligible for treatment for the presenting illness or item according to the information supplied in the eligibility check Patient is eligible for the presenting illness or item according to information supplied in the eligibility check Patient may be eligible for the presenting illness or item according to the information supplied in the eligibility check However there may be conditions you will need to note before you proceed such as financial status reduced benefit is payable possible pre existing condition A general presenting illness or item was requested and a general answer displaying all benefit limitation or restriction that apply to the patients cover was returned in the response The patient is eligible for the presenting illness or item on the incoming e
3. Availability Benefits Deletes Timeframes Payments AG Agreements written or verbal MPPAs HPPAs PAs SC Approved gap cover schemes IMC AG SC claims can be submitted to ECLIPSE at any time In most cases a patient verification will be performed in real time as part of the claim acceptance acknowledgment process If the Medicare system is unavailable the claim will be provisionally accepted and a message will be returned advising that the patient verification has not yet been performed As soon as the Medicare system becomes available the claim will continue normal processing If the ECLIPSE system is unavailable you ll receive a message advising you to try again at a later time ECLIPSE claiming has the following benefits for a practice paperless claiming Medicare and the private health insurer use the same data as that generated by the practice There is no need for either entity to re key data resulting in a faster turn around of the claim and the integrity of claim data is maintained most data validation is performed at the client s end of the system resulting in fewer rejected claims additional assessment data can be submitted with claims privacy is maintained throughout the patient verification process Same day deletes are not available for this claim type For the majority of claims an assessed result will be known within 24 hours Some claims may take longer to process because of th
4. 9662 9665 9665 Medical and Eligibility User Guide V2 2 for Medical Practitioners Message Compensation claim not allowed for this service Member Issue as at date of service Fund payee id MUST be specified Fee charged invalid Unknown prosthesis item Refer to OEC response and assessment text Processing error contact fund RHBO system unavailable or service problems Provider not recognised by fund Member number not recognised by fund Patient not recognised on the membership Reason No benefits are payable Fund payee id has not be specified and it is required by the fund to process the payment correct The prosthesis item number as input in the eligibility request is either 1 not recorded on the health fund system 2 incorrectly input There is an issue with the overall eligibility response that will affect the service line assessment result The fund has a processing error that maybe unique to the membership or claim supplied RHBO system may be undergoing scheduled maintenance or experiencing service difficulties may be set by hub or health fund system Provider not recorded on health fund system Member number not known by the fund the claim was submitted to No other patient data checked at this time Member number is valid Cover for membership number is okay no patient is identified or multiple patients are identified Action required Ask the member
5. reflecting the degree of difficulty of the procedure Initiation of Management of Anaesthesia atime unit reflecting the total time of the anaesthetic and modifying unit s recognising certain added complexities The Department of Health and Ageing has incorporated the Relative Value Guide RVG for Anaesthesia into the Medicare Benefits Schedule book The Relative Value Guide for Anaesthesia has an outline of the RVG system some recommended billing guidelines example accounts example Medicare benefit statement information reason code explanations and contact details This information is available at humanservices gov au then For health professionals gt Information by program gt Medicare Assisting anaesthetist The RVG provides for a separate benefit to be paid for the services of an assistant anaesthetist for an operation or series of operations in specified circumstances The assistant anaesthetist can t be the surgeon assistant surgeon or principal anaesthetist A doctor can only act in one capacity in an operation The principal anaesthetist s items must also be contained in same check to allow the benefit to be determined for the assistant anaesthetist services Claim processing information Informed financial consent Where there is an out of pocket expense a practice must confirm that written informed financial consent IFC has been obtained from the patient before a medical claim can be submitted u
6. Details applicable to admission Co pay Amount Co pay Description 50 00 per day to a maximum of 250 00 per admission Co pay Days Excess Amount 200 00 Excess Description 200 00 excess payable per hospital admission including same day up to 1000 00 per family Excess Bonus Used 0 00 Exclusion Description Benefit Limitations Hip replacement Financial Status N Potential PEA Y ECLIPSE Medical Benefits payable Item Charge Medicare Fund Benefit Benefit 49527 1540 00 1155 10 339 50 591524 45 40 0 00 0 00 Level of cover Private health insurers describe their level of cover differently and you should check the table description carefully Some private health insurers have room restrictions such as shared in the product information while others may show it in the benefit limitations The following example shows how they may appear Level of Cover Hospital Saver with General Extras Table Name Product information used for assessment Table Description Full cover for hospital accommodation and theatre fees at participating private hospitals and public hospitals in a shared room Basic benefits are payable for benefit limitations if any No excess or co payment applies if basic benefits are payable No benefits are payable on exclusions Table Scale Family Medical and Eligibility User Guide V2 2 for Medical Practitioners Medicare Service Assessment Ex
7. not assistants evident in claim Facility id not known to fund Maximum voucher Service count reached Account reference id required Reason Patient details supplied are correct at the day processed Patient details can be used to 1 process a medical claim 2 obtain an eligibility check The fund payee id supplied is 1 incorrect 2 not specified in claim 5 not current or 4 principal or servicing provider is not known on fund payee id specified The principal or servicing provider is 1 not registered at the fund 2 not current on the fund system The billing agent number supplied is 1 not registered on the fund system 2 not current The facility id supplied is 1 not registered at the fund 2 not current The fund cant handle the total number of service lines submitted The account reference id is missing Action required Check Fund Payee Id if correct contact the fund if incorrect amend and re submit the transaction Check provider Id if correct contact the fund if incorrect amend and re submit the transaction Check billing agent number if correct contact the fund if incorrect amend and re submit the transaction You can t have multiple providers in one claim other than assistants split the claim and re submit Check the facility id if correct contact the fund if incorrect re submits with corrected data Claims must be split and then re submitted
8. 1800 550 457 non metropolitan areas Medical and Eligibility User Guide V2 2 for Medical Practitioners o Eligibility checking Eligibility checking assists the provider or hospital to determine the patient s out of pocket expenses for in hospital care Before a patient eligibility check check can be undertaken consent must be obtained from the patient or a legally authorised representative A check can be submitted for an anticipated admission date up to 12 months in the future or up to seven days in the past for an emergency admission The information returned in the check will be the product and benefit information for the admission date available on the day the check is submitted The benefit amounts are the amounts that apply on the day you submit the check based on the patient s history and level of cover It doesn t take into account future Medicare Benefit Schedule or private health insurer changes Note It is recommended that you submit one eligibility check to get an informed financial consent IFC and for an admission date well into the future perform another check before the patient s admission This will identify any changes in benefits that may impact on the patient s out of pocket expenses For example the patient has a maximum benefit they can receive in a financial calendar or membership year from their private health insurance the patient has had another service performed since the in
9. Service Code Type Code The type of item being charged Service Id A unique identifier for the service in the claim This is the Object Id assigned to the service when created Service Fund Explanation Code The Fund s explanation reason code for the service assessment status Provides additional information on the assessment of a service Service Fund Explanation Text The Fund s explanation text for the service explanation code ECLIPSE Remittance Advice report ERAs are only available for the following claim types Claim Type Description AG An unpaid in patient episode where the service was provided under an Agreement MPPA HPPA PA SC An unpaid in patient episode where the practitioner has opted to participate in an Approved Gap Cover Scheme MB A claim submitted by a billing agent for an unpaid in patient episode where the service wasn t provided under Gap Cover Arrangements MPPA HPPA PA or Approved Gap Cover Scheme MO A claim submitted by a billing agent for an unpaid in patient episode where the service wasn t provided under Gap Cover Arrangements MPPA HPPA PA or Approved Gap Cover Scheme A remittance advice is only available to a site that is on Release 4 or above where they have submitted a claim to a private health insurer that is also on Release 4 or above ERA reports can be retrieved at any time and may be requested more than once in a six month period after the original request Medical and Elig
10. The functions available to the practice depend on the functions for which the software vendor has attained a Notice of Integration NOI Functionality may vary greatly between different software packages and it s suggested that all health sector entities thoroughly research the capability of each software product before engaging a vendor For more information on software vendors go to humanservices gov au then For health professionals gt Doing business with Medicare gt Online business Software vendor lists ECLIPSE Release functions are detailed in Appendix A Getting ECLIPSE ready You must do the following before you can complete your first ECLIPSE transaction 1 Ensure you have an internet connection 2 Obtain and install an ECLIPSE enabled Practice Management Software PMS package For a list of ECLIPSE enabled practice management systems go to humanservices gov au healthprofessionals or talk to your software vendor 5 Complete the Human Services registration process to get a Public Key Infrastructure PKI Site Certificate A PKI Site Certificate allows a number of authorised people at the same location to sign and encrypt messages on behalf of the site This certificate provides confidentiality authentication and integrity of the transmitted information To register for a PKI Site Certificate you must review and meet the certificate pre application checklist complete and submit the releva
11. This indicates the eligibility check could result in a Fotential FEA i different response if the condition is deemed PEA ECLIPSE Co payment Amount Description and Days Remaining To determine the co payment payable for the admission you must use the information supplied in any or all of the co payment fields This will help you calculate the co payment amount The estimated length of stay submitted in the request is not used to perform any co payment calculations Excess Amount Description and Excess Bonus The excess amount if displayed should be the total excess payable for the admission If the excess amount is blank and there is an excess description use this information to determine if an excess is payable If the excess amount is 0 00 no excess is payable When a dollar amount appears in the excess bonus used field an excess bonus has been applied and the excess amount has been reduced by the bonus Exclusions No benefits are payable for any presenting illness condition shown in the exclusions field Care must be taken to ensure the patient is not being treated for one of these illnesses conditions or the patient will be liable for payment Benefit Limitations Read this section carefully It details any applicable restricted benefits at the admission date which may affect the benefit payable Note If the check submitted was for presenting illnesses 320 medical admission or 399 unknown or other
12. agent IMC Medicare Only IMC MO the benefit from Medicare is paid to the specified billing agent There is no private health insurer involvement ERAs ECLIPSE Remittance Advices are now available for billing agents and providers offering Medicare and or private health insurer payment information in relation to ECLIPSE IMCs and MPVs Multiple Patient Verifications allows providers and billing agents to submit up to 200 patient verifications in a single request Some system information can now be retrieved through ECLIPSE such as the number of days until a Location Certificate expires and Logic Pack version details IMPORTANT To access ECLIPSE Release 4 functionality IMC MB MO IMGPC amp ERA the practice software and the private health insurer must have implemented ECLIPSE Release 4 Medical and Eligibility User Guide V2 2 for Medical Practitioners ECLIPSE Release 5 Functions available in this release OEC Online Eligibility Check enables institutional or individual health care providers or billing agents to lodge electronic eligibility checks to Medicare and or private health insurers on behalf of a patient An OEC lets providers facilitate the patient receiving informed financial consent IFC Consent to submit the OEC through ECLIPSE must be obtained from the patient or other lawfully authorised person before submitting the OEC An OEC consists of information about the patient Medica
13. and response codes Codes documented in the manual apply to private health insurers processing only As new private health insurer processing requirements emerge processing codes can be added and deleted The descriptions used in the messages are standardised and apply to all private health insurers Processing messages can be displayed in transactions for one of the following reasons message advising a rejection and possible cause information only or awarning that you will need to note The latest list of private health insurer processing codes and messages can be located at privatehealthcareaustralia org au The Australian Health Insurance Association has changed its name to Private Health Care Australia Medical and Eligibility User Guide V2 2 for Medical Practitioners Medicare explanation codes Medicare explanation codes or reason codes assist you by providing information on the assessment of the claim For a viewable and downloadable table of codes and explanations go to humanservices gov au then For health professionals For new software vendors Reason codes 30 31 Processing messages For ease of locating messages are listed in numerical order Response Code 1001 1002 1003 1004 1005 1006 1007 Message Patient known to fund Fund payee id not recognised by fund or other issues Provider not recognised by fund Billing agent not known to fund Multiple providers
14. illness condition on the admission date It provides the out of pocket expenses for excess exclusions and co payments associated with the patient s hospital product Medicare only checks ECM used by hospitals day surgeries and medical providers to determine whether Medicare covers the patient and what Medicare benefits are payable for in patient medical services Hospital and medical checks at both Medicare and the private health insurers OEC used by hospitals day surgeries and medical providers to determine whether the patient is eligible for a selected presenting illness condition on the admission date It provides the out of pocket expenses for excess exclusions and co payments associated with the patient s hospital product and the Medicare and the private health insurer benefits payable for the medical services ECLIPSE Information on eligibility checks Patient information validation 1 The first step in the check is a validation check against Medicare and the private health insurer to ensure the patient can be identified If the patient details are correct the ECLIPSE system will accept the check for processing 2 If Medicare or the private health insurer can t identify the patient the check won t be processed and you ll receive a response with the reason the patient can t be matched Possible reasons why the patient can t be identified the patient is unable to be uniquely identified the patient s
15. paid e g Assistant 1234567X 51 Constraints The assistant anaesthetist can t be the surgeon assistant surgeon principal anaesthetist The assistant surgeon can t be the Surgeon anaesthetist assistant anaesthetist The surgeon anaesthetist can t be the assistant ECLIPSE Appendix A ECLIPSE Release 3 Functions available in this release IMC Agreements AG the provider has signed an agreement with a private health insurer of which the patient is a member specified in the claim The Medicare benefit is paid by the private health insurer to the provider IMC Schemes SC the provider is operating under a scheme arrangement with a private health insurer of which the patient is a member specified in the claim The Medicare benefit is paid by the private health insurer to the provider The benefit is paid by paper statement year release ECLIPSE Release 4 Release 4 of ECLIPSE incorporates several significant enhancements that expand its usability and makes it easier for clients to interact with Medicare and each other Functions available in this release IMC Patient Claim IMC PC patient claims are submitted to Medicare and the private health insurer for an in patient service where the service was not provided under a Gap Cover Arrangement IMC Medicare Benefit IMC MB benefits from both Medicare and the specified private health insurer are paid to the specified billing
16. request The indicator is E Self determined A specialist may deem services to be necessary In this case the services are self determined and are not subject to the written request requirements Medicare benefits will be paid if the claim is endorsed self determined or SD 46 47 Same day deletes There is no facility to delete a claim once it has been accepted by the ECLIPSE hub If you want to delete a claim after this time contact the eBusiness Service Centre They will advise the most appropriate course of action depending on the outcome of the claim assessment Adjustments There is no mechanism to submit a claim variation through ECLIPSE All latter day adjustments must be sent manually to both Medicare and the private health insurer Refer to Appendix C for more information Free format text Any claim that contains free format text requires manual intervention at Medicare This will cause a processing delay in the assessment of that claim The amount of free format text has been reduced by additional input fields on the processing of some services Fee charged Notional charges aren t accepted through ECLIPSE All service lines must contain a fee charged ECLIPSE The overall OEC response The response code will advise you if a check has been successful The overall response Response Code A Indicates the overall eligibility result Assessment 1101 Code Assessment Tex
17. service text field Medical and Eligibility User Guide V2 2 for Medical Practitioners Emergency situations If the referral relates to an emergency Medicare benefits will be paid at the referral rate if the appropriate indicator is used or the claim is notated with emergency referral in the service text field These two provisions only apply to the initial attendance and a letter of referral should be obtained for subsequent services Requests for specialist services A medical practitioner approved dental practitioner oral and maxillofacial surgeon prosthodontist chiropractor physiotherapist and podiatrist may request a variety of services for a patient A request is valid only for the specific service requested A written request from a practitioner for diagnostic imaging or pathology services must contain the following details patient s full name requesting provider s name and provider number and or address Sufficient information to identify the item of service requested signature of requesting provider and date of request Special circumstances Lost stolen or destroyed requests If a written request for services has been lost stolen or destroyed Medicare benefits will be paid if the claim is endorsed lost request The indicator is L Emergency request Where services are requested in an emergency situation Medicare benefits will be paid if the claim is endorsed emergency
18. surgery and information is displayed in the benefit limitations field the check should be repeated with the specific illness condition to ensure an accurate patient entitlement is obtained Medical and Eligibility User Guide V2 2 for Medical Practitioners Financial The response shown in the financial field indicates whether the patient is financial at the admission date A response of N non financial means that the patient must be financial at the date of admission for the claim to be paid Note It is recommended that you advise patients the payment of a claim will always be subject to their financial status Potential PEA Indicator If the private health insurer s response is that the presenting illness condition could be deemed as possible pre existing a Y PEA indicator will be returned with a warning on the assessment When a warning response is received with a Y PEA indicator the check should be repeated with the PEA indicator set to Y The private health insurer will use this indicator to respond as if the presenting illness condition was deemed pre existing Note This will allow a best case worst case scenario 14 Medical benefits When a hospital and medical check or a Medicare only check has been requested the Medicare and or private health insurer benefits for each MBS item will be displayed The amounts displayed in the Medicare Benefit and Fund Benefit fields will be t
19. t be the surgeon the anaesthetist or the assistant anaesthetist Assistant surgeon item numbers are found in Category 3 Group T9 of the Medicare Benefits Schedule 44 Assistants An assistant s claim can come as part of the principal provider s claim or as a separate claim Where the assistant is lodging a separate claim the assistant must use his her provider number in the principal provider field for payment of the claim One claim can have multiple assisting providers but only one principal provider Where the assisting provider is paid separately to the principal provider the principal provider s claim must be submitted and assessed before the assistant s claim Assistant provider where the assistant items are included on the surgeons account Medicare benefits are payable to the doctor who assists the surgeon during a surgical procedure Assistance can be provided during operations a caesarean section or during specified interventional obstetric procedures The assistant surgeon can t be the surgeon the anaesthetist or the assistant anaesthetist Assistant surgeon item numbers can be found in Category 3 of the Medicare Benefits Schedule You must enter in the service text field the name and or number of the assistant surgeon If an assisting provider lodges a claim separate the assisting provider must be listed as the health care service provider and the following details should be provided in the text field of
20. that can be submitted to e Medicare only e DVA only e Private health insurer only or Medicare and private health insurer check in one go Patient verification provides the following e confirmation that a patient is known to Medicare on the date of enquiry e confirmation that the patient is known to a private health insurer on the date of enquiry and e consistency of patient details held by a practice against the details held by Medicare and the private health insurer records An immediate real time response will be provided If Medicare or the private health insurer is unable to perform the patient verification part or the entire request will be rejected and you will need to re try at a later time Enterprise Patient Verification EPV Note The enterprise patient verification can only be performed if supported by the private health insurer check Get Participants This functionality is available for ECLIPSE Release 5 and higher Description Availability Benefits Timeframes 55 Enterprise patient verification allows you to submit multiple patients verifications in one transmission up to 1 000 patients per transmission in batch mode For the convenience of practices batches can contain multiple private health insurers Enterprise patient verification is not an immediate real time functionality Responses for enterprise patient verification requests may not be available for up to 72 hours after you submit
21. the assistant service s principal provider name and or numbers principal provider MBS surgical item numbers Locums Locum accounts can be processed by noting the locum provider as the servicing provider and inputting the payee provider number in the principal provider field Payment will go to the principal provider Aftercare After an operation the surgeon or another doctor routinely attends the patient to check the patient s progress general condition healing of the wound removal of sutures etc These routine attendances are referred to as aftercare The aftercare period is the duration of the normal healing process Reamputation In the case of reamputation of a previously amputated stump to provide adequate skin and muscle cover the Medicare Benefit for Item 44376 is calculated using a Schedule Fee that is 75 per cent of the original amputation fee for the item number listed in the MBS In addition to mandatory information required by all claims the claim must contain the original amputation item number with the reamputation date of service provider number and a charge of 1 00 The 1 00 charge allows the claims to be sent from the practice system and the reamputation Item 44376 date of service provider number and charge The benefit for the reamputation item will be paid shown against the original amputation item The reamputation item will be rejected with reason code 128 benefit paid o
22. the operation Medical and Eligibility User Guide V2 2 for Medical Practitioners Benefits For anaesthesia assistance the time taken is the period that the assistant anaesthetist is in active attendance The following information must be entered for an assistant anaesthetist date of service item numbers relating to the assistant services performed assistant anaesthetist s provider number and fees charged The RVG provides for a separate benefit to be paid an assistant anaesthetist for an operation or series of operations in specified circumstances The assistant anaesthetist can t be the surgeon assistant surgeon or principal anaesthetist that is the doctor can act in one capacity only at the operation You must enter in the service text field the name and or number of the principal anaesthetist anaesthetic item number s and surgical item number s Principal providers For unpaid claims the principal provider is entitled to the benefits even if they are not one of the servicing providers This ensures that the principal provider can claim on behalf of locum providers and assistants Assisting provider If you are submitting an in patient medical claim that includes assistant surgeon services it must also include the services for the principal surgeon Assistance can be provided during operations a caesarean section or specified interventional obstetric procedures The assistant surgeon can
23. to or less than MBS fee As Medicare do not pay a benefit we are unable to pay a gap benefit Letter of explanation is being sent separately Benefit for this service has been previously paid Default benefit only paid for this procedure Benefits assessed in line with the doctor agreement Incorrect charge benefit paid per schedule of fees Fee invalid no provider registration Limit reached nil benefit Hospital claim has not been processed Medicare have overpaid this service refer back to Medicare Provider not recognised by fund Reason Fund can t process the service until a pre existing certificate is obtained from the member Information message only No Fund benefit is payable for this service Duplicate service no benefit payable Lesser benefit paid for this service Information only message Servicing provider is not registered for an agreement or scheme claim with the Fund No benefits are payable for this service No benefit is payable until the hospital claim has been processed Provider number supplied is 1 not registered at the fund 2 not current at the fund Action required Manually send the claim to the fund for processing outside the ECLIPSE system Hold the claim until you receive the letter Contact the fund to register or change the claim type ECLIPSE Response Code 2025 2026 2027 2028 2029 2888 2999 5040
24. 5 cent tolerance on the fee charged per service line has been allowed to cater for variable rounding rules Claim assessment Where a private health insurer provides a rejected claim assessment no benefits Medicare or private health insurer will be paid to the provider whether or not service lines show accepted or rejected The claim must be re submitted for processing with the rejected service lines corrected or removed or additional information provided if required Where a private health insurer accepts a claim assessment benefits Medicare and or private health insurer will be paid to the provider whether or not service lines show accepted or rejected Where Medicare rejects the whole claim the claim won t be forwarded to the private health insurer Benefits are paid by EFT IMC In patient medical claim Patient Claims PC Patient claims are only available in Release 4 or above ECLIPSE IMC PC functionality allows you to submit an electronic claim to Medicare and the private health insurer for an in patient service where the service was not provided under a Gap Cover Arrangement MPPA HPPA PA or Approved Gap Cover Scheme subject to the patient s written or verbal consent Patient claims can be either fully paid or fully unpaid Claim Type Availability Benefits Deletes Timeframes Assessment Report Payments PC patient claims The ability to submit claims a
25. ANNA 44 Principal Provide kS sess cesses 2 sccosesesseesascewsssaca eguevedsnsesssegusssass USEB ENTRY esta REEE AE AEE EE E ENEE Eni IR HUE EENE 44 Assisting aa 44 ASSIS AM Sae P ERE 45 Assistant provider where the assistant items are included on the surgeons account see 45 LO GUNNS E 45 clc 45 AS A 45 cnc e HQ 45 peterrals inshospital ssec a e LU EM 46 Lost stolen or destroyed referrals oe eeeceecssessssssssssscssesssssssessssssssnccsseecsnscssecsnsessusssssssusccsssessnseessecsnsessuesssseesusecsasessusesasecsneesessnseesueesseeessecesess 46 Emergency Situations Sese itt teta dati quiam E EN EUN EEUU E REE 46 Requests for Specialist Services us steterit tissu be euer teretes toten oeste eter eee 46 Special Ci GUMS CAGES e n T ECC I 46 DVA Claiming Informal OU oae aan nae e pinta bur eR te bud inn epi 49 Veteran Verification nct inre e eee ee e Peri tits iii 49 Fees and Rounding Rules scena tte i rn He ER nete ta ete td t reiten tttm dec tant orb erecta reir 49 Anaesthetist Clallns oce onim rd Dente died ER 50 Pathology Clais uideret ti treten rode tie eret tei eei tiui eerte ei eite dH 50 Assistant SEP VICES nereta 5 Appendix Pi cts idiesicciio naa nta a dM ainia 52 ECLIPSE Raras 52 ECLIPSE Release 4 tes
26. Medical and Eligibility User Guide V2 2 for Medical Practitioners A CUNGSTRALIA J zA Australian Government Department of Human Services E C L I P S E humanservices gov au Table of contents TDG site uro NN 1 About ECLIPSE o pope ted E O dece TENi 2 sctgEdsel i E 2 Where does ECLIPSE fit in with Medicare Online Claiming eee ttt nn tente tn te ntc tentis 2 Berlefits OF using ECLIPSE tadas 2 DVA In Patient Medical Claiming oe cecsecsssssssssssssessssssnesssseesssccsssecsuscessecsnscssnesssseesuscesssessncesssecsnsessuesssseesuecesssessuceessessnsesseessnseesueeseusesnneesaeeess 2 Medicare Online to ECLIPSE T 2 Getting ECLIPSE TO usuarias ERE 3 Transmitting ECLIPSE CMS iaa 3 Important things totes 4 Understanding Patient Verificatior Responses stu e ar E eed 5 Understanding DVA Patient Verification Responses teen tte tnn ttt tetti tetti tt tno nenas tnnt titt 6 A a CEDE Od OE 7 Patient A 7 Multiple Eligibility Checks for the Same Patient ecsessssssssecssssecssssscsessecsessecsessecsuseecsuscecsuseecsuscecseseecsnseecsnsescsnseecsneecsnseecueseecuneeceeseesee 7 Iormeidsl iuwaescteecce ties 7 Information om Eligibility Gliecks eem tete donet ett oett eee smettere oett ene edet 8 Disclaimers asian iaa eraut n detta a eau iE Gentes 8 Patient Caint Int
27. S schedule fee payable by Medicare will be forwarded to the claimant by a cheque made payable to the payee provider The private health insurer will determine payment of 25 per cent of the MBS schedule fee in accordance with the terms and conditions of the membership 90 Day Pay Doctor Cheque Scheme Under the 90 Day Pay Doctor Cheque Scheme Medicare will automatically cancel Medicare cheques made payable to eligible health professionals through their patient when the cheque hasn t been banked after 90 days The amount is then paid directly into the health professional s nominated bank account Eligible health professionals include registered GPs specialists and consultant physicians including pathologists More information on this scheme can be obtained by contacting Human Services on 132 150 or at humanservices gov au then For health professionals gt Medicare gt Schemes and initiatives gt 90 Day Pay Doctor Cheque Scheme Medical and Eligibility User Guide V2 2 for Medical Practitioners Paid accounts When an account has been paid 75 per cent of the MBS schedule fee is paid to the claimant either by EFT or cheque made payable to the patient or claimant The private health insurer will determine payment of 25 per cent of the MBS schedule fee in accordance with the terms and conditions of the membership Claimant The person claiming the Medicare benefit might not be the patient when a person other than the patien
28. SE Claim processing report A claim processing report provides information on the medical services provided in a claim Claim processing reports can be retrieved at any time and may be requested more than once within the six month period after the claim is complete The presentation and structure of the report will depend on the type of software your practice uses but should provide the following details PETI Description Account Reference Id This is set by the location when the claim was transmitted Claim Fund Assessment Code A You will be paid for a service line with a benefit greater than zero R Rejected No payment made W Warning C Completed These codes with your service assessment will determine what you will or won t be paid Claim Id Claim identifier Used in conjunction with the receipt date to identify claims sent to a health fund Current Patient First Name Patient s first name recognised by Medicare Returned when this information differs to that sent by the client system Current Patient Medicare Card Medicare Card number recognised by Medicare Number Returned when this information differs to that sent by the client system Current Patient Reference The patients individual Reference Number as known by Medicare Number Returned when this information differs to that sent by the client system Fund StatusCode 2 digit identifier that identifies the version of the statement format The version number will incr
29. action Depending on your software the report may be requested or it can be provided automatically in response to a submitted transaction The response will depend on the state of the transmission Processing applies to patient verifications in claiming claiming and eligibility checks Ready applies to claiming eligibility checks and remittances or Reported applies to claiming eligibility checks and remittances Responses depend on the originating transaction For example private health insurer responses won t be seen in the in patient medical claim Medicare only patient verification 25 Processing Response Description Received Claim or eligibility check is received and accepted for processing Medicare The PVM process failed Unverified Medicare Verified The PVM is successful PVF is being performed Health Fund The PVF failed Unverified Health Fund The PVF is successful Verified Medicare The claim or eligibility check is Assessing being assessed by Medicare Health Fund The claim or eligibility check is Assessing being assessed by a health fund Ready Response Description Medicare Claim rejected by Medicare Rejected report available Health Fund Claim rejected by health Rejected fund report available Complete Claim or eligibility assessment is complete report available Requested For IMC PC Delete Reported Response Description Complete The report has been retrieved ECLIP
30. ainst the private health insurer membership are incorrect card Refer to page 31 for private health insurer error codes for appropriate action 5 Medicare and Private health No action is required Insurer details are correct ECLIPSE Understanding DVA patient verification responses There are two types of DVA patient verification 1 DVA patient verification with personal details only or 2 DVA patient verification with DVA file number and personal details DVA Patient Verification with personal details only Response Action required 1 Personal details match a DVA patient file number and eligibility type is returned to the client valid DVA patient record 2 Personal Details do not Contact DVA to confirm patient details and DVA file number match a valid DVA patient record 1300 550 457 metropolitan areas 1800 550 457 non metropolitan areas 3 Potential match identified Patient details have a potential match with DVA data Updated details have been supplied Please check the information returned with the patient and if correct update your records DVA patient verification with DVA file number and personal details Response Action required 1 Details match a valid DVA DVA patient file number is confirmed and eligibility type is returned to patient record the client 2 Details do not match a valid Contact DVA to confirm patient details and DVA file number DVA patient record 1300 550 457 metropolitan areas
31. al service in cents Medicare Explanation Code Medicare Service Explanation Reason Code Provides additional information on the assessment of a service Schedule Fee The fee determined in the Medical Benefits Schedule for this individual service Service Fund Assessment Code The assessment status of a service determined by the Fund Service Id A unique identifier for the service within the claim This is the Object Id assigned to the service when created Service Fund Explanation Code The Fund s explanation reason code for the service assessment status Provides additional information on the assessment of a service Service Fund Explanation Text The Fund s explanation text for the service explanation code Billing agents can only retrieve the claim processing report after the private health insurer has paid their benefit to the billing agents 25 ECLIPSE Eligibility processing report An eligibility processing report provides information on the hospital out of pocket expenses prosthesis and medical services requested in a check If the OEC is accepted Medicare and private health insurer assessing is conducted as required The results will be available for retrieval within 20 minutes of the OEC receipt If the results aren t returned to the Hub within the 20 minutes the request is cancelled OEC reports are only available for seven days after the completed time The presentation and structure of this report will depend on th
32. ant surgeon services it must also include the services for the principal surgeon Assistance can be provided during operations a caesarean section or specified interventional obstetric procedures The assistant surgeon can t be the surgeon the anaesthetist or the assistant anaesthetist Assistant surgeon item numbers are found in Category 3 Group T9 of the MBS Note An independent assistant surgeon check cant be performed on ECLIPSE 10 Interpreting eligibility response information It is important you understand how to interpret the The following example shows the key information eligibility response information requirements that determine an eligibility response but doesn t include all data elements The response is broken up into the following overall response level of cover details applicable to admission and medical benefits payable for the admission if this is requested in the check Overall response Response Code A Assessment Code 1101 Assessment Text Eligibility confirmed for the selected service Level of Cover Table Name Hospital Saver with General Extras Table Description Full cover for hospital accommodation and theatre fees at participating private hospitals and public hospitals in a shared room Basic benefits are payable for benefit limitations if any No excess or co payment applies if basic benefits are payable No benefits are payable on exclusions Table Scale Family
33. being paid for the claim The claim id of claim The date of lodgement of the claim The channel of the claim ECLIPSE Note Online Technical Support Helpdesk OTS will perform the following steps for missing ECLIPSE Remittance Advices ERAs 1 If a software vendor submits a request to OTS for an ERA search on behalf of the site and they provide the IMC transaction ID information via email OTS will check the IMCs to confirm if they are successful claims and the date of lodgement 2 If claims are under 30 days old from date of lodgement between one and 25 actual days OTS will advise the software vendor to keep trying 3 If the request is for a rejected claim OTS will advise that no ERA is available for rejected claims 4 f claims that are successfully assessed by the private health insurer and Medicare are 30 days or older OTS will escalate the issue to the appropriate private health insurer for further investigation 5 OTS will wait for a response from the private health insurer and update the request every 48 72 hours 6 When information has been supplied the ERA is checked and the transaction IDs are emailed back to the software vendor for retrieval 7 Requests for claims older than six months to two years are questioned because of the time between submission and requesting of reports 8 Advice will be provided to the software vendor requesting ERA s for rejected IMCs COMPLETED Processing messages
34. card number is known to Medicare but the first name individual reference number IRN or card issue number in the transmission differs from Medicare records the patient is known to the private health insurer but personal or membership details in the transmission differ from the private health insurer s records the patient doesn t have hospital cover with the private health insurer 5 Where the patient details are incorrect check the details with the patient and update your practice or hospital records then re submit the check Refer to page 38 for a list of patient verification error messages Medical and Eligibility User Guide V2 2 for Medical Practitioners Disclaimer The check is the best estimate of benefits payable that Medicare and the private health insurer can provide This is paid on the information supplied at the time the check is submitted The information from the check isn t a commitment by either Medicare or the private health insurer to pay the claim Medicare and the private health insurer may decline a claim based on eligibility or other conditions that apply at the time the claim is made including pre existing ailments waiting periods not being served product exclusions accident or compensable claim where damages can be claimed from another source cancelled suspended or non financial memberships patient s history or changes to the Medicare Benefits Schedule MBS items ru
35. d into the hospital after the restriction on the item number expires but the earlier check would show the restriction ECLIPSE Anaesthesia The RVG is based on an anaesthetic unit system which reflects the difficulty and the total time of the service Under the RVG the MBS fee for anaesthesia in connection with a procedure is comprised of up to three components basic units allocated to each anaesthetic procedure reflecting the degree of difficulty of the procedure Initiation of Management of Anaesthesia atime unit reflecting the total time of the anaesthetic and e modifying unit s recognising certain added complexities The Department of Health and Ageing has incorporated the Relative Value Guide RVG for Anaesthesia into the Medicare Benefits Schedule book This guide as an outline of the RVG system some recommended billing guidelines example accounts example Medicare benefit statement information reason code explanations and contact details This information is available at humanservices gov au then For health professionals Information by program Medicare Assisting anaesthetist The RVG provides for a separate benefit to be paid for the services of an assistant anaesthetist in connection with an operation or series of operations in specified circumstances The assistant anaesthetist can t be the surgeon assistant surgeon or principal anaesthetist that is the doctor can act in one capacity only at
36. dgement date more than two years after the date of service and Medicare Claims Review Panel MCRP items MCRP items are listed in the MBS with an item description wording where it can be demonstrated Claims for these services require full clinical details and in some cases pre operative colour photos Claims with a date of service more than two years old can be claimed by the patient at a Human Services Service Centre via Simplified Billing by lodging the claim with the completed late lodgement form or via the private health insurer Medical and Eligibility User Guide V2 2 for Medical Practitioners 17 IMC In patient medical claim Agreements AG and Scheme SC claims We will assess the Medicare component of the claim before sending it to the patient s private health insurer for completion ECLIPSE in patient medical claiming AG SC Note A private health insurer can t make functionality allows a practice to electronically submit a payments for MBS items that Medicare has claim to Medicare and the private health insurer for an rejected When all items are rejected by Medicare in patient service where the service is provided under an a claim won t be forwarded to the private health Approved Gap Cover Scheme SC or insurer for assessment Agreement AG MPPA HPPA PA verbal or signed agreements Only unpaid in patient medical claims can be submitted under these claim types Claim Types
37. e Charged The above information is an example of the key information requirements of the data in a hospital and medical eligibility request It doesn t include all data elements Presenting illness The presenting illness is used to determine the waiting periods exclusions and any reduced benefits payable Some presenting illnesses are for specific treatments or conditions and will result in detailed responses from private health insurers However if a general presenting illness such as medical admission 320 or unknown or other surgery 399 is provided the private health insurer will give a broad response detailing all exclusions or reduced benefits applicable under the patient s cover Note In this case you need to review all information provided to assess any restrictions or exclusions before providing the information to the patient If a presenting illness condition is documented in the response and does apply you should repeat the check with the specific illness condition to ensure an accurate patient entitlement is obtained For more information go to privatehealthcareaustralia org au ECLIPSE Accident indicator You must take care when setting the accident indicator to Y because this will override the normal waiting periods that apply to the presenting illness condition To see if the assessed result changes it is recommended that this indicator is remains set to N and only set to Y i
38. e does ECLIPSE fit in with Medicare Online claiming Many practices currently use Medicare Online claiming and enjoy the benefits it provides to patients and practices Medicare Online claiming can be used for bulk bill claims and paid and unpaid patient claims These are lodged directly with Human Services through the practice management software ECLIPSE is an extension of Medicare Online claiming that incorporates direct communication between providers Human Services and private health insurers in the one transaction This process allows hospitals billing agents and providers to lodge in patient medical claims and in hospital claims directly to Human Services and the private health insurers in one simple transaction Benefits of using ECLIPSE ECLIPSE allows healthcare providers and billing agents to submit claims securely over the internet to Human Services and private health insurers saving time and money The benefits for health care providers includes easier way to obtain informed financial consent from patients paperless interaction with Human Services and private health insurers quicker processing times reduction from weeks to days reduced administration time resulting in reduced management costs faster resolution of complex claims better data quality with fewer errors and speedier resolutions one system for all private health insurers aone stop shop for electronic business access to Human Services Aust
39. e iere dietis etus e itte egi ne fetten eie iure tete teer oett 52 ECLIPSEREICIS ES cuente ean mut ML LM M M EM MU EU 52 EGLUIPSEBeled5e6 iet etiam o tales date fateor tete s nta to aeree 53 Appendix Boussssnin vnnd UR EE EI On RUNE CER Eri 54 Whatis PAE EVO os eee etre estem dieere ituri tesi erede even sees ISI Rene eet dires eene 54 Types of Online Patient Verifications iii e cie tere he m pe e e edd teed ree e tige 55 Appendix A NIIT RR AA EE aaa SEA eA TETEE N iE Eare apie TENENT 56 Introduction Medicare Online claiming including ECLIPSE was developed by the Department of Human Services Human Services in collaboration with the health care industry and the medical software industry Medicare Online claiming can be used by Health Sector Entities HSEs to communicate health information and medical and hospital claims between connected entities Medicare Online claiming processes conform to current privacy and legislative requirements as determined under the Health Insurance Act 1973 and relevant Human Services and industry guidelines and policies ECLIPSE About ECLIPSE What is ECLIPSE Electronic Claim Lodgement and Information Processing Service Environment ECLIPSE is an extension of Medicare Online claiming It offers a secure connection between practices public and private hospitals billing agents Human Services health care providers private health insurers and the Department of Veterans Affairs DVA Wher
40. e private health insurers Fund Payee Id The Fund Payee Id is used by some private health insurers to determine the benefit rate payable for an AG or SC claim Principal Provider The principal provider is the provider who will be paid for the service Generally the principal provider will be one of the servicing providers However this may not be the case for a locum Medical and Eligibility User Guide V2 2 for Medical Practitioners Servicing Provider The servicing provider is the provider who will perform the service There can only be one servicing provider per eligibility check unless an assistant provider is required Note Separate eligibility checks must be performed when there is more than one health care provider other than an assistant involved in the treatment for example a surgeon and an anaesthetist MBS Item Number s All MBS item numbers for services that will be performed during the in patient treatment should be submitted in one eligibility check to ensure full out of pocket expenses are identified Fee Charged The fee charged relates to the fee that will be charged for the medical service 42 43 Anaesthesia The Relative Value Guide RVG is based on an anaesthetic unit system that reflects the difficulty and the total time of the service Under the RVG the MBS fee for anaesthesia for a procedure is made of up to three components basic units allocated to each anaesthetic procedure
41. e software used by the practice but should return the following details Data Description Account Reference Id This was set by the location when the claim was transmitted Benefit Limitations Description of waiting period and benefit limitations applicable at anticipated admission date Claim Fund Assessment Code The assessment status of a claim on its return to the Hub from the Fund CoPayment Amount The amount of product co payment dollars to be paid for a predefined period in the Co Payment Amount Description There may be circumstances where the dollar amount cant be calculated from the OEC information In this case the dollar amount may be left blank and the circumstances are covered in the co payment amount description CoPayment Days Remaining The number of days remaining that the patient has a co payment amount applied to their cover CoPayment Description This is a free text field that holds the description of the co payment and how it is applied Current Patient First Name Patient s first name recognised by Medicare Returned when this information differs to that sent by the client system Current Patient Medicare Card Medicare Card number recognised by Medicare Number Returned when this information differs to that sent by the client system Current Patient Reference The patient s individual Reference Number as known by Medicare Number Returned when this information differs to that sent by the client system Current Vet
42. ease for subsequent releases Medicare Card Flag Code An indicator that details the problem Medicare has with the submitted Medicare card Medicare Status Code Return Code associated with OPV request Patient Family Name The patient s family name Patient First Name The patient s first given name Where a patient has only one name that name should appear in the PatientFamilyName field and the word Onlyname be entered in the PatientFirstName field Patient Medicare Card Number The patient s Medicare Card Number Patient Reference Number The patient s Medicare Reference Number This number appears to the left of the patient s name on their Medicare card Medical and Eligibility User Guide V2 2 for Medical Practitioners 24 Data Description Process Status Code A code to indicate the processing status of the claim request Claim Fund Explanation Code The Fund s explanation reason code for the claim assessment status Claim Fund Explanation Text The Fund s explanation text for the specified Claim Fund Explanation Code Charge amount The amount charged for the service in cents Date of service The date the service was provided to the patient or the patient was assessed Fund Benefit Amount The Fund benefit paid payable for this individual service in cents Item Number A number that identifies the services provided to enable assessment of the claim for benefit Medicare Benefit Amount The Medicare benefit paid payable for this individu
43. eir complexity resulting in a delay of up to six days If you have a claim that is outstanding for more than six days use the status report to highlight whether to contact Medicare or the private health insurer EFT from the private health insurer Refer to the Reports section on page 23 for more information All private health insurers will supply a paper report for any Release 3 sites ECLIPSE Things to check with private health insurers before processing for each provider It is important you check the following information with private health insurers before submitting your first IMC AG or SC claim 1 The type of simplified billing arrangement you have with the private health insurer e g agreements or schemes Whether you need to quote a Fund Payee Id to direct payment and if so make sure you know what it is that your EFT banking details are registered with the private health insurer This is a mandatory requirement for submitting claims through ECLIPSE Payee provider A payee or principal provider is the health care provider who is paid for the services that they or another servicing provider has performed Providing the following details within the claim will direct payment based on the following hierarchy Billing agent number if present all payments will be directed to the billing agent on behalf of the private health insurer payee or principal provider Fund Payee Id if present all pay
44. enefit payable for pre existing ailments 2002 Service is within the No benefit payable required waiting period 2003 Service was provided No benefit payable before commencing this level of cover 2004 Service occurred while No benefit payable membership was suspended 2005 Service occurred No benefit payable Verify the cover details with after patient ceased the member membership or reached policy age limit 2006 Benefit not payable for No benefit payable services claimed or requested 2007 Incorrect charge Charge input is greater than the Check the charge amount charge exceeds agreed rate for an agreement or and claim type correct the allowable amount for scheme claim error and re submit claim type 2008 Public hospital table No benefit payable nil benefit 2009 A benefit is not No benefit payable payable under this level of cover 2010 Membership not financial at service date 2011 Submit service Fund can t process the service until Manually send the claim manually accident an accident certificate is obtained to the fund for processing certificate required from the member outside the ECLIPSE system from member Medical and Eligibility User Guide V2 2 for Medical Practitioners 34 5 Response Code 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Message Submit service manually pre existing certificate required from member Charge is equal
45. ent and rounded up to the nearest five cents RVG and RMFS Please refer to the DVA Fee Schedules for Medical Services book for correct fees Corrections and updates particularly to derived fees to published fees are available from the DVA website at dva gov au service_ providers Fee_schedules Pages index aspx Specialist consultation items Specialist consultations should be claimed using ServiceTypeCde set to S to ensure the claim is processed correctly with referral details Please note that providers should refer to the MBS to determine the requirement for request and or referral details and to determine whether an override is applicable ECLIPSE Anaesthetist claims RVG Anaesthetic Items should only be claimed using ServiceTypeCde set to S RVG items must be transmitted in the correct order to be paid Refer to the Relative Value Guide for Anaesthesia in the MBS book for further details RVG items must be presented together on the voucher The non RVG items in these claims are to be presented either first or last or on a separate voucher and not in between RVG items Refer to the Relative Value Guide for Anaethesia for further details Refer to the DVA Fee Schedules for Medical Services book for correct fees Pathology claims PmsClaimld The use of a hash value in the PmsClaimld is only valid for in patient pathology service claims e g a patient admitted to hospital All pathology services p
46. eran File Number The patient s individual File Number as known by DVA Returned when this information differs to that sent by the client system Excess Amount The amount of excess the patient will pay for this admission based on the policy information at the date of lodgement Can be blank If blank refer to Excess Amount Description for information Excess Amount Description This is a free text field that holds information on the excess amount and how it is to be applied Excess Bonus Amount Amount in dollars that can be used to reduce the excess amount Medical and Eligibility User Guide V2 2 for Medical Practitioners 26 Data Description 27 Exclusion Description Financial Status Fund Reference Id Fund Status Code Medicare Status Code PEA Potential Indicator Process Status Code Table Name Table Scale Table Description Table Scale Voucher Id Claim Fund Explanation Code Claim Fund Explanation Text Charge Amount Date Of Service Fund Benefit Amount Item Number Medicare Benefit Amount Medicare Explanation Code Service Fund Assessment Code The exclusions that apply to the hospital cover The financial status of a membership at anticipated date of admission This is a reference allocated by the health fund identify an OEC outcome Funds Patient Verification Fund assessment result code Return Code associated with OPV request This is used to indicate whether a potential previously existing ailme
47. f waiting periods apply and the treatment is as a result of an accident Note Private health insurer approval of the accident must be obtained to ensure claim benefits are payable Emergency admission The emergency indicator should be set to Y if the admission results from an emergency In this case the check may not be done in advance Pre existing conditions Determination of benefits paid by the private health insurer could be based on whether the episode of care relates to a pre existing ailment PEA The PEA indicator allows you to advise the fund whether they should treat the admission as a pre existing condition A two step process has been developed to help resolve a possible PEA claim 1 Always set the PEA indicator to N not pre existing This allows the private health insurer to determine whether the presenting illness condition may be deemed as possible pre existing This information will be returned to you in the response with a warning on the assessment 2 If you receive a warning on an eligibility response with a Y PEA possible pre existing result you should repeat the check with the PEA indicator set to Y The private health insurer will use this indicator to respond as if the presenting illness condition was deemed pre existing Note This will allow a best case worst case scenario Medical and Eligibility User Guide V2 2 for Medical Practitioners Important information Eligibility
48. he proposed Medicare and or the private health insurer benefits paid for the services on the date the check was assessed The amounts in all fields should be used to calculate the patient s out of pocket expenses Where a zero benefit is returned by Medicare and or the private health insurer explanation codes and text will be supplied Refer to page 31 for a full list of processing error messages Medical Benefit Item Charge Medicare Fund Benefit Benefit 49527 1 570 80 1 178 10 339 50 49509 739 20 554 40 155 75 57521 43 40 0 00 0 00 Medicare Explanation 162 Service Assess RHBO Service Exp Code 2016 RHBO service exp text Benefit for this service has previously been paid ECLIPSE Submitting in patient medical claims This section covers the submission of the following In patient medical claim types by a medical practice an approved billing agent or a hospital Agreement AG Schemes SC Patient claims PC Billing Agent MB and Billing Agent MO Claim rules A claim can only contain one patient one billing agent if applicable one fund payee id agreement and scheme claims only if applicable one principal provider or single or multiple assisting providers Note Claims not accepted via ECLIPSE The following claims can t be accepted via ECLIPSE and must be lodged manually with Medicare or the private health insurer Claims with a lo
49. ibility User Guide V2 2 for Medical Practitioners 28 ERA report An ERA report provides information relating to the payment for medical services provided in a claim The presentation and structure of this report will depend on the type of software used by the practice but should return the following details Data Payment Run Date Payer Name Remittance Advice Id Payee Location Id Part No Part Total Bank Account Number Bank Account Name BSB Code Payment Reference Deposit Amount Description provided once per remittance This is the payment run date This contains the name of the paying organisation The health fund s reference The payee s location id When the remittance advice is large it will be split into parts This number will assist to ensure all parts of the report have been collected When the remittance advice has been split this is the total number of parts The last four digits of the bank account number the monies are being paid into The bank account name the monies are paid to The BSB of the bank the monies are paid to The payment reference on the bank statement The total amount of the EFT deposit Description returned for each claim in the remittance Transaction Id Account Reference Id Benefit Claim Id Date of Lodgement Claim Channel Code 29 The transaction id of the claim being paid The account reference Id of the claim being paid The amount of benefit
50. icator advises the private health insurer if the patient will be admitted overnight in the facility This information is used to determine excess or co payment arrangements payable under the patient s cover Estimated Length of Stay This information is used as a guide only The information supplied is not used to make any calculations for excess or co payment information ECLIPSE Field Notes Medical Information This section is the medical component of the eligibility check The following example shows the key information requirements that determine an eligibility response and does not include all data elements Example only Hospital Input Elements This is the claim processing type The Health Fund identifier for the practitioner The provider who will be paid for the service The provider who will perform the service The date the service was rendered to the patient A number that identifies the service provided Claim Type Code AG Fund Payee Id 123456 Principal Provider 2347869Y Servicing provider 2347869Y Service Date 02 09 2006 Item Number s 57521 Fee Charged 4370 The amount charged for the service in cents Claim Type Code Valid claim types are AG agreement claims SC schemes PC patient claims MB Billing Agent MO Billing Agent Note The claim type will determine the medical benefit type payable by th
51. itial check which is restrictive with the service they are going to receive or checking financial and membership status close to the admission date Note The results of the check will be available within 20 minutes of submission If Human Services Medicare or the private health insurer systems are unavailable or cant complete processing within 20 minutes a message will be returned advising the check was not completed successfully Patient authorisation Before submitting a check consent must be obtained from the patient or other lawfully authorised person e g guardian power of attorney appointee The way the patient consent is obtained will depend on legislative requirements and your software product Multiple eligibility checks for the same patient Multiple checks can be submitted for the same patient This allows for variances that could occur for example different providers item number s or hospitals Each check is assessed in its own right and doesnt take into account any previous checks For example if two checks are done for the same admission date by different providers the hospital excess and or co payment will be shown on both responses as payable although it s only payable for each admission Types of eligibility checks Three types of checks are available in ECLIPSE Hospital only checks ECF used by hospitals and day surgeries to determine whether the patient is eligible for a selected presenting
52. les and restrictions A subsequent claim can have a different outcome to the check For example the patient receives another treatment before the services outlined in the check are performed and the other treatment is restrictive with these services the multiple operation rule is enforced on the operation items in the claim but the services assessed in the check weren t assessed as part of a multiple procedure extra services or a change of the presenting illness condition being performed weren t detailed in the original eligibility check and change of private health insurer membership cover and or entitlements Patient claim information Some mandatory fields are required for successful transmission of claim information and checks These fields can be broken down into the following three sections Patient information Fund Brand Id ABC Membership Number 52647891 Unique Patient Identifier 01 Patient Fred Flintstone Date of Birth 01 01 1900 Gender M Medicare Number 5064786911 IRN 1 Account Reference Id 290876543 Hospital information Facility Id 1354275W Admission Date 02 09 2006 Same Day Indicator N Estimated Length of 05 Stay Presenting Illness Hip replacement Accident Indicator N Emergency Indicator N PEA Indicator N Medical information Claim Type AG Fund Payee Id 123456 Principal provider 2347869Y Servicing Provider 2347869Y Service Date 02 09 2006 Item Number Fe
53. ligibility request but not at their current cover This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover Action required Contact the fund and supply EFT details and re submit the claim Send the claims to the fund for manual processing Tell the patient that they are not eligible for the service Refer to OEC guide for assistance on areas to check Check the eligibility response carefully and re submit if the actual presenting illness or item is display to obtain an accurate assessment The patient is eligible for the service on their previous level of cover 32 Response Code 1105 1106 1107 1108 1109 1110 Wh 33 Message Not eligible for service selected wait period applied Eligible for service selected at previous cover wait period applied Not eligible for service selected pre existing ailment Eligible at previous cover subject to conditions Eligible subject to approval of accident certificate Eligible subject to conditions and approval of accident certificate Unknown presenting item The patient is not eligible for the presenting illness or item as they have not completed serving their required waiting periods The patient is eligible for the presenting illness or item as input on the incoming eligibility request but not at their current cover This message generally
54. mented ECLIPSE Release 6 ECLIPSE Appendix B What is patient verification A patient verification is a quick process that allows a practice to confirm the accuracy of a patient s details The following patient verifications are available 1 Medicare only 2 DVA only 3 private health insurer only and 4 both Medicare and the private health insurer details are checked at the same time It is recommended that a patient verification is performed before an appointment if you have the patient s Medicare or private health insurer details and the private health insurer is an ECLIPSE participant refer to Get Participant section This will make you and or the patient aware of any problems with the patient s Medicare or private health insurer details before the consultation Patient verifications can be performed one at a time Online Patient Verification Request or as a batch of 1 000 EPV The Online Patient Verification Request function is available in all releases of ECLIPSE however the EPV function is only available for those practices on Release 5 or above that have implemented this functionality Medical and Eligibility User Guide V2 2 for Medical Practitioners 54 Types of online patient verifications Note This function is available in all releases of ECLIPSE Online Patient Verification Request online patient verification Description Benefits Timeframes A single patient verification
55. ments will be directed to the fund payee identification if there isn t a billing agent number Principal provider payments will only be directed to the principal provider if there is no fund payee or billing agent number Servicing provider where no principal provider is nominated the servicing provider will become the principal provider if there is only one servicing provider in the claim The claim will be rejected if there is more than one servicing provider Medical and Eligibility User Guide V2 2 for Medical Practitioners Fund Payee Id Some private health insurers issue their own number to enable them to either link providers for payment of claims or allow providers to have multiple banks accounts If this facility is provided by a private health insurer the Fund Payee Id must be entered in to the claim to ensure accurate processing of payments Fee charged An agreement or scheme claim will be rejected where the fee charged for that service is greater than the total benefit Medicare and private health insurer plus any known out of pockets agreed with the private health insurer Where the fee charged is less than the agreed rate for that service private health insurers will only pay up to the fee charged This will ensure the provider has selected the correct claim type at the start of the claiming process and the provider is knowingly opting into the agreement or scheme arrangement A plus or minus 0 0
56. n associated amputation item Referrals A referral is a letter to a specialist or consultant physician requesting investigation opinion treatment and management of a condition or problem performance of a specific examination or test relating to a single course of treatment A single course of treatment involves an initial attendance by a specialist or consultant physician and the continuing management treatment up to the stage where the patient is referred back to the care of the referring practitioner More information on referral details is in the Medicare Benefit Schedule Book A medical practitioner or approved dental practitioner oral surgeon can refer a patient to a specialist or a consultant physician and a registered optometrist can refer a patient to a specialist ophthalmologist For referrals issued by a specialist or consultant physician the referral period is three months from the date of the initial consultation when the patient is not an in patient or three months from the date of the initial consultation or the duration of the hospital admission whichever is longer when the patient is an in patient ECLIPSE For referrals issued by practitioners other than a specialist or consultant physician the referral period is 12 months from the date of the initial consultation with the patient unless the referring practitioner indicates a shorter longer or indefinite period The referral letter note
57. nd private health insurer operating hours If the Medicare system is unavailable the claim will be provisionally accepted by ECLIPSE and a message will be returned to the client advising that the PVM hasnt yet been performed As soon as the Medicare system becomes available the claim will continue normal processing ECLIPSE MB MO claiming has additional benefits for a billing agent Medicare only claims can be accepted The Medicare private health insurer benefits will be paid directly to the billing agent Same day deletes are not available for these claim types A latter day adjustment will be required to amend previously transmitted claim data Refer Adjustments page For most claims an assessed result will be known within 24 hours Some claims may take longer to process because of their complexity resulting in a delayed response of up to six days If you have a claim that is outstanding for more than six days contact the ECLIPSE Helpdesk EFT to the billing agent Refer to the reports section on page 23 for more information Payments to the approved billing agent are made separately by Medicare and the private health insurer ECLIPSE Claim reconciliation All claims submitted under Release 3 will receive a paper based payment report from the health insurer Claims submitted under Release 4 or above will receive an ECLIPSE Remittance Advice ERA Payment reports Patient claims submitted by a billing agent receive a
58. nd receive acknowledgments is available in real time If the Medicare system is unavailable the claim will be provisionally accepted by ECLIPSE and a message will be returned to the client advising that the PVM hasn t yet been performed As soon as the Medicare system becomes available the claim will continue normal processing Patient claiming has the following additional benefits for a practice the claim can be either fully paid or fully unpaid while practices can t sight the claim assessment they can ensure real time lodgement of claims with Medicare and private health insurers greatly improving payment times for unpaid claims Same day deletes are not available A latter day adjustment will be required to amend previously transmitted claim data Refer Appendix C Service line assessment information won t be available for patient claims For the majority of claim you ll know within 24 hours when an assessment has been completed Some claims may take longer to process because of their complexity resulting in a delayed response of up to six days If you have a claim that is outstanding for more than six days contact the ECLIPSE Helpdesk A detailed assessment report is not available A completion notification is supplied The patient claimant is responsible for the account and an ECLIPSE remittance advice is not available for this claim type ECLIPSE Unpaid accounts Where the account is unpaid 75 per cent of the MB
59. nder a Gap Cover Scheme Obtaining informed financial consent For an MPPA or HPPA PA written or verbal IFC must be obtained Written IFC must be obtained under a Gap Cover Scheme Where a practice submits an in patient medical claim IMC under a Known or No Gap Cover Scheme the practice must indicate that IFC has been given before submitting the claim to Medicare for assessment This shows that the practice has informed the patient of any amounts the patient could be expected to pay for treatment and that the patient has acknowledged this advice Where IFC is not required because the patient would not incur any out of pocket expenses under a Gap Cover Scheme the practice uses the Not Obtained option Financial interest disclosure Under an Approved Gap Cover Scheme a servicing practitioner must disclose to an insured patient any financial interest that the practitioner has in any product or service recommended or given to the patient Where an indication of financial disclosure is not evident in an ECLIPSE claim the claim will not be accepted Time dependent restriction override Some MBS items have a time restriction meaning no benefit is payable for an item if it is claimed within a set period of time after it or a related item has previously been claimed In certain cases this restriction needs to be over ridden For example for MBS Item 12201 the restriction can be over ridden if the patient is booke
60. nse of W Medical and Eligibility User Guide V2 2 for Medical Practitioners 48 DVA claiming information Veteran verification Truncation of names The Veteran verification processes will shorten the Veteran s first name to 12 characters and their surname to 18 characters when a request is submitted This is how the details will be reported back to a client system and should be reviewed before the patient records are automatically updated Entitlement information The Veteran verification processes will return the Veteran s card type where known to DVA However in some cases this may be returned as a space where the Veteran is known to DVA but the card type can t be determined In these cases providers should contact the VAP Enquiry Line 1300 550 017 to determine the Veteran s card type and resolve any potential eligibility issues Unknown patient When Veteran details are unknown to DVA and are transmitted in a claim these patient services will be rejected with Reason Code 376 patient cannot be identified from the information supplied In these cases providers should contact the VAP Enquiry Line 1300 550 017 to determine the Veteran s card type and any potential eligibility issues DVA file number validation The DVA file number is used when claiming for persons covered by Department of Veterans Affairs The Veteran file number has nine Characters in total but trailing spaces are permitted on the right hand
61. nt scenario was identified by the Health Fund A code to indicate the processing status of the claim request The table name used for the assessment of the OEC that the patient has hospital cover for This is a free text field that holds information on the table scale For example Single Family etc This is free text field that holds the description of the table that the patient has hospital cover for This is a free text field that holds information on the table scale For example Single or Family Identifies voucher within claim This is the Object Id assigned to the Voucher when created The Fund s explanation reason code for the claim assessment status The Fund s explanation text for the specified Claim Fund Explanation Code The amount charged for the service in cents For Bulk Bill and DVA claims this is the benefit assigned The date the service was provided The amount the health fund is paying for the service A number that identifies the services provided to enable assessment of the claim for benefit The Medicare benefit paid payable for this individual service in cents Medicare Service Explanation Reason Code Provides additional information on the assessment of a service The assessment status of a service determined by the Fund ECLIPSE Data Description Schedule Fee The fee determined in the Medical Benefits Schedule for this individual service Service Code The service number being charged
62. nt application form with certified copies of Evidence of Identity EOI documents and complete an Acceptable Referee Identification Form ARIF These forms are available at humanservices gov au then For health professionals For new software vendors Public Key Infrastructure 4 All ECLIPSE payments will be made via electronic funds transfer EFT Your banking details must be registered with Human Services and the private health insurers You will also need to clarify whether your ECLIPSE claims need to be submitted as Schemes SC or Agreements AG and whether you will need to quote a fund payee ID More information can be found on page 16 Retrieve the Get Participants report by submitting a Get Participant request The report provides the details of all private health insurers participating in ECLIPSE as well as the ECLIPSE transactions they support The report provides the following details of participating private health insurers Fund brand ID trading name of the private health insurer contact number for the private health insurer date the record was last updated ECLIPSE functions supported by the private health insurer 5 Approved billing agents must register for online functionality with the private health insurers they will transmit data to Registration must be done by the approved billing agent For help call 1800 700 199 or visit humanservices gov au Transmitting ECLIPSE claims The f
63. nt matching Where a patient is known by one name only that name should be entered as the patient s last name and the patient s first name should contain Only name Medical and Eligibility User Guide V2 2 for Medical Practitioners Understanding patient verification responses There are five outcomes for a patient verification response Response Action required 1 Medicare details are not valid Check the patient s details against the Medicare card and re submit if an error is found If patient details are correct call the Medicare Provider Enquiry line on 132 150 Patients can call Human Services on 132 011 2 Medicare has matched the The patient is known to Medicare but the first name individual patient but the details reference number IRN or card issue number provided in the submitted by the practice transmission differs to Medicare records need to be updated These details should be checked with the patient before updating practice records If these are confirmed patient records should be updated If patient private health insurer details are still required the Online Patient Verification request will need to be re submitted 3 Medicare details are correct Check patient s details against the private health insurer card Refer to private health insurer details page 31 for private health insurer error codes for appropriate action are incorrect 4 Private health insurer details Check patient s details ag
64. o matinal used 9 Presente Ms id 9 A NN 10 Emergency Admission ii 10 Pre Existing Gol n o ie o LR RERUM 10 Important Me Mal ninia 10 Eligibility Process 10 Interpreting eligibility response information inside 11 Level DOCV cri das 12 Applicable Admission Details ceccssessssssssssessessssecsssssseessnsessuesssnecssnccsssccsuseessecsnsessueessusesunsesssecsnsesssessuseesuesssneesuscesssessucesssecsueeeseessaneesaeeenesees 13 Medical Ben ici ini 15 Submitting in patient medical CLANS sosa ali 16 T E O OOOO 16 AA cauesacnsayctda EENE E E EE ENE SENSER EE Ania eE NEEN EEEa SERE SENEE Ie EH RSEN RAUS 18 Fund Payee lic sects vassseveses vases cvaceucoasswossensobbnyconstsconsshectscsced donee E A ARE EAE AROEN EOE EE ER 18 Fee charged geier ranae a 18 CIAS S ESSEN eiar a A A A A 18 IMC In Patient Medical Claim AG SC seen Ra 19 IMC lInsPatient Medical Claim PG teer ia 19 90 Day Pay Doctor Cheque Sheme iii ieia i a a i e ii ien eai 21 IMC In Patient Medical Claim MO MB ttti ertet tente b bep eb EN eb bebe Fs EEE EE 21 ECLIPSE Remittance Advice ERA ariete a 22 A 1 Reena ORT meee an RS NUON em maT A II E 25 Get Participants Report ninia ie dedo nest an tipo eritis fatemur ttu ta qul duse tiende dodo 23 SEALUS RE POPE Aa OA E E 23 ure 23 acci
65. ollowing steps are recommended to ensure your ECLIPSE claims are successfully transmitted Prior to consultation Request Human Services and private health insurer details When a patient arranges an appointment ask them to bring their current Medicare and private health insurer cards with them The patient can also provide their Medicare and private health insurer details over the phone This will let you submit an Online Patient Verification request using the most current data Patient consent must first be obtained if you intend to submit this request before the patient s appointment Consultation Verify patient details When a patient comes to their initial appointment you should obtain their Medicare and private health insurance card details and check these against your patient records and any other relevant documentation they provide such as the Patient Details Form Perform Online Patient Verification request If an Online Patient Verification request has not been performed before or the results of a previously conducted request were unsuccessful you should check the patient s Medicare and private health insurance details shown on their cards against the information held on your patient records and resubmit For more information refer to Appendix B ECLIPSE Important things to note n When the Medicare and private health insurer patient verifications are performed together the patient s Medicare details
66. ound and the DOB of the patient is less than 29 days from the earliest date of service in the Online Patient Verification Request Rejection reasons will display on individual service lines Action required Member to contact fund Cant lodge a medical claim as member is not covered for that service Check with member Cant lodge a medical claim as member isn t covered for that service Check with member Member to contact fund Patient may not have current student registration Provider to contact fund Correct Medicare information and try again Member needs to register the baby at the fund Check the rejection reason for the individual service line If appropriate remove the rejected service line and resubmit any other accepted service lines ECLIPSE Medicare services contacts eBusiness Service Centre for enquiries about online claiming 1800 700 199 Registration Business support Oncsite visits for providers Assistance with the transmission process Enquiries about grant or incentive payments Changed contact practice details Technical problems missing claims confirmation of transmissions eBusiness Service Centre 1800 700 199 Select one of the following options Option 1 for electronic claiming including online claiming bulk billing and patient claim adjustments Option 2 for digital eCertificates Option 3 for information regarding the health professional online
67. payment report All patient claim payment information submitted by a practice is returned to the patient or claimant ECLIPSE Remittance Advice ERA The private health insurer will initiate an ECLIPSE Remittance Advice to the submitting location when they deposit the EFT funds into your bank account If you have more than one payee submitting per location you will receive a remittance advice for each payee For more information on ERA refer to page 23 Medical and Eligibility User Guide V2 2 for Medical Practitioners 22 Reports The reports currently available to ECLIPSE users are detailed in this section The format and content of these reports depend on the type of software used by the practice Reports can be retrieved using the retrieve report function The availability of each report will depend on the function and the Release used Get Participants report A Get Participants report returns the details of all ECLIPSE enabled private health insurers The report is requested from a practitioner s site anda response is provided in real time The retrieval method depends on the software used New private health insurers come on board regularly and existing private health insurers upgrade to new releases giving you access to more transactions and functionality Request reports regularly to ensure you have access to the latest information and services Status report The status report provides the status of a trans
68. planation A 162 R 2016 Benefit for this service has been previously paid Table Name This is the name used to make the assessment This will generally be the patient s level of cover at the date of admission The only time this may differ is if the PEA indicator is set to Y in the incoming request or the patient has recently upgraded their cover and waiting periods apply on their new level of cover Note This will be clearly visible in the assessment text displayed in the overall response Table Description The table description is the table the patient is covered by at the date of admission Table Scale The table scale relates to the membership type such as Family Single Couple or Sole Parent Applicable admission details Details applicable to admission Co payment Amount Co payment Description 50 00 per day to a maximum of 250 00 per admission Co payment Days Remaining Excess Amount 200 00 Excess Description 200 00 excess payable per hospital admission including same day up to 1000 00 per family _ Use these fields together to determine excess payable Excess Bonus Used 0 00 NEN Exclusion Description 7 No benefits are payable for anything shown here Benefit Limitations Hip Replacement Restricted Benefits generaly Aeon will apply for information shown Financial Status N Financial status at admission date A
69. processing information Restriction override The restriction override should only be set to Y for an eligibility check when in a claim situation service text would normally be supplied For example it should be set to Y for a diagnostic imaging service where two instances of the same item are claimed one for the left side and one for the right side If this override has not been set the check returns a Medicare reason to indicate that there may be a restriction Another check could be submitted with the restriction override set to Y to give the patient a worst case best case scenario Multiple procedures When multiple services are submitted as part of a check Medicare will apply the multiple procedures rule If you are scheduling a patient to undergo two or more operations at different times you must submit separate checks with the item number s for each operation Time dependent restriction override The check is calculated at the date of submission For example the costs and benefits that apply on the date you submit the check may differ from the charges and benefits that actually apply at the time the services are performed If you know that a time restriction applies to a service for a patient but the admission date is after the time that the restriction will apply the time dependent restriction override should be set to Y Assisting provider If you are submitting a check that includes assist
70. ralian Childhood Immunisation Register ACIR and private health insurers in one product electronic remittance advice from private health insurers resulting in efficient reconciliation of your accounts increased patient satisfaction Medical and Eligibility User Guide V2 2 for Medical Practitioners DVA In patient medical claiming If a DVA in patient receives treatment as a private patient the DVA in patient medical claim can be submitted using the DVA function in Medicare Online Online eligibility checking is not required for DVA DVA online patient verification provides the relevant information to verify the Veteran s eligibility for treatment See DVA claiming information section on page 49 Medicare Online to ECLIPSE The technical architecture ECLIPSE is based on is an extension of Medicare Online that provides GPs specialists and other health professionals with an internet based Medicare claiming and reporting capability Online claiming enables a number of transmission functions including the paperless submission of bulk bill and patient claims DVA paperless R5 and later versions Medicare Allied Health and Community Nursing and ACIR A practice must be registered for online claiming before they can use ECLIPSE because of its dependence on Medicare Online claiming technology ECLIPSE was first delivered to the market in 2005 and released in a phased approach As technology evolves so do the ECLIPSE features
71. re If the claim results in an underpayment Medicare will send a cheque for all adjustments processed to the nominated private health insurer or billing agent Medical and Eligibility User Guide V2 2 for Medical Practitioners If the claim results in an overpayment the Statement of Benefit will show details of the adjustment and include the amount of overpayment Medicare will invoice private health insurers and billing agents for overpayments The following ECLIPSE claim types can be adjusted by completing the In patient Medical Claiming Adjustment claim form AG agreement claims SC schemes MB billing agent MO billing agent For a copy of the In patient medical claiming adjustment claim form contact the Simplified Billing and Two Way Enquiry line on 02 6124 2105 or email simplified billing amp humanservices gov au Fax the completed signed form and relevant documentation to the ECLIPSE Program Coordinator If you need us to process an adjustment for a online patient claim online bulk bill or ECLIPSE in patient medical claim patient claim IMC PC please contact the Human Services eBusiness Service Centre on 1800 700 199 56 humanservices gov au 9173 1204
72. re details and private health insurer details and treatment they will receive what items will be billed who will perform them the anticipated admission date the expected length of stay and name of the hospital where the treatment will be performed Hospital eligibility checking allows a patient to provide IFC to the hospital before proceeding with the procedure IMPORTANT To access ECLIPSE Release 5 functionality the practice software and the private health insurer must have implemented ECLIPSE Release 5 52 ECLIPSE Release 6 Functions available in this release 53 IHC In Hospital Claiming allows private and public hospitals and day facilities to lodge claims for a patient s hospital stay direct with a private health insurer or DVA OVS Overseas claims medical claims from overseas student or overseas visitors holding overseas cover with a private health fund can be lodged direct with a participating private health insurer Claims can be made for both in hospital and out of hospital services and Hospital Eligibility Checking has been expanded to allow hospitals to obtain an estimate of a patient s likely out of pocket expenses excess This enables a hospital to provide IFC to the patient before proceeding with the procedure IMPORTANT To access the new ECLIPSE functionality in Release 6 hospital and overseas claims the practice software and the private health insurer must have imple
73. resent in the claim will be assessed as in hospital pathology Mantoux Item 73811 This item can now be set in any position within a voucher It can also occur with or without request details present and other MBS items requested or otherwise Medical and Eligibility User Guide V2 2 for Medical Practitioners ECG Items ECG items can now be created within a pathology claim but must be listed as the first item in the voucher When transmitted in a pathology claim it should be listed with other pathology items This will ensure successful processing and payment Although ECG items do not require a SCPld to be set when transmitted as part of a pathology claim setting the SCPId is mandatory The SCPId should be set to the same SCPId the other pathology items within the same voucher 50 Assistant services The following table lists the ServiceText requirements for claiming for services performed by an assistant surgeon or anaesthetist Lodging Provider ServiceText Requirements Assisting Anaesthetist Must contain principal anaesthetist name and or Provider Number anaesthetic surgical item number s e g Surgeon 1234567X ltem 36842 Assisting Provider Must contain principal provider name and or number principal provider MBS Surgical item Numbers e g Surgeon 1234567X Item 56842 Principal Surgeon Must contain Anaesthetist provider number of the assistant assistant has been
74. results where the patient is still serving the required waiting period applicable on the upgrade in cover The patient is not eligible for the presenting illness or item if it is deemed to be a pre existing condition The patient is eligible for the presenting illness or item as input on the incoming eligibility request but not at their current cover This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover Fund won t guarantee payment of the service until an accident certificate is supplied and approved Fund won t guarantee payment of the service until an accident certificate is supplied and approved and there is another condition that will affect assessment This could be 1 financial status 2 pre existing ailment or waiting period 5 reduced benefit is payable The MBS item could be 1 incorrectly input 2 ceased 5 not on item database at the fund Action required Ask the member to contact the fund to get the pre existing ailment process started Ask member to contact the fund Ask member to contact the fund regarding the accident certificate and to verify the other conditions of the eligibility response Check the item number if correct contact the fund if incorrect amends and re submit ECLIPSE Response Code Message Reason Action required 1999 Contact Fund 2001 Waiting period applies No b
75. rom this data Account Reference Id This is a reference number allocated by the provider to identify the patient in the eligibility request Medical and Eligibility User Guide V2 2 for Medical Practitioners 40 Field Notes Hospital Information The following elements are used to determine if an in patient hospital claim is payable by the private health insurer Example only Hospital Input Elements Facility Id 1354275W Admission Date 02 09 2006 am Same Day Indicator N a Estimated Length of 05 Stay Presenting Illness Hip EN Replacement Accident Indicator N pa Emergency Indicator N PEA Indicator N Facility Id This is the hospital provider number where the anticipated admission is to be undertaken Admission Date The date the patient is expected to be admitted to hospital The admission date can be 12 months in advance of the date you are enquiring or seven days past the date for emergency admissions Note This date is used to determine the member s eligibility to have the presenting illness condition treated 41 Hospital provider number Determines waiting periods and product information Determines excess co payment product information Determines whether admission is payable by product May override waiting period rules Can be used to advise if pre existing conditions exist Same Day Indicator The same day ind
76. side This number is a string and no spaces are allowed between characters The DVA file number contains the following fields state identifier war code numeric field and dependency indicator DistanceKms if set ItemNum must be set to KM if set ChargeAmount cant be set if set must be the last service within the same voucher as the associated item can t be set where it is the only service in the voucher The associated service must be present in the same voucher ReferralOverrideTypeCde and RequestOverrideTypeCde The requirement for a referral or request is determined by legislation and is described for each item in the MBS Override indicators don t apply to all claim or service types and only apply in special circumstances An override indicator shouldn t be set unless an exception to the requirement for referral request is allowed as defined for each item in the MBS The H indicator isn t directly related to the TreatmentLocationCde of H for patients that are admitted to hospital Fees and rounding rules Derived fees rounded up to the nearest five cents REl schedule fee increased by 10 per cent and rounded up or down to the nearest five cents LMO schedule fee increased by 15 per cent and rounded up to the nearest five cents REI and LMO schedule fee increased by 10 per cent and rounded up or down to the nearest 5 cents This is the REI fee The REI fee is increased by 15 per c
77. t Eligibility confirmed for the selected service Details the result obtained The response codes and the appropriate actions to take are outlined below Eligibility What it means What you need to do Response Code A Accepted The patient is eligible to claim Check the product description for what is payable for the presenting illness at the admission date Provide the details to the patient with a copy of the disclaimer as evidence that he she has been informed The patient may choose to provide give informed financial consent to proceed with the surgery W Warning This indicates that the patient Check the response as conditions apply For may be eligible to claim for the example the member may not be financial benefit presenting illness but there are limitations apply or the presenting illness could be certain conditions detailed in the pre existing response that must be satisfied before the patient is admitted R Rejected The patient is not eligible to Inform the patient that the health fund won t pay claim for the presenting illness for the cost of treatment for the presenting illness at the admission date condition Note Medicare benefits may still be payable A response of A or R is reasonably straightforward however an assessment response of W means there are conditions that must be noted which affect the payment of benefits The message detail section must be checked carefully for a respo
78. t is responsible for the claim When this happens the Medicare benefit payment is paid to the responsible person the claimant The claimant doesn t need to be on the same Medicare card number as the patient but must be eligible for Medicare in order to submit their claim through ECLIPSE A claimant who is not eligible for Medicare would need to submit their claim direct to Medicare Note Private health insurers will only make the 25 per cent benefit payable to people on the patient s membership and this may differ to the Medicare claimant 20 IMC In patient medical claim Register your EFT banking details with the Billing Agent MO and MB private health insurer before transmitting your Billing agent claims are only available in first claim This is a mandatory requirement for to submit claims through ECLIPSE Release 4 or above For any in patient service not provided under Gap Cover Arrangements MPPA HPPA PA or Approved Gap Cover Scheme ECLIPSE IMC Patient Claiming allows a billing agent to submit an electronic claim to Medicare only or Medicare and the private health insurer Only unpaid patient claims can be submitted by a billing agent Claim Types Availability Benefits Deletes Timeframes Payments 21 MO Medicare only MB Medicare and private health insurer Submitting claims and receiving acknowledgments are available in real time during the normal Medicare a
79. the request 1 000 patients per transmission can be batched A response to the enterprise patient verification should be provided within 72 hours If either Medicare or a private health insurer is unable to perform the patient verification part or all of the requests will be rejected You will need to re try those particular patients at a later time ECLIPSE Appendix C In patient medical claiming latter day adjustments Definition An adjustment occurs when any detail in any field of a previously processed claim is amended with new altered information An adjustment can only be made when a claim has been assessed and paid by Medicare This process may include changing service details and or deleting services that were included and or adding services omitted during the original assessment This is only possible where the omitted services are part of a multi procedure such as pathology coning service groups or a relative value guide for anaesthetic If the payment of an omitted service doesn t depend on simultaneous assessment of associated services the omitted service should be resubmitted in a new claim Rejected services should also be resubmitted in a new claim unless the above rule applies An adjustment may result in an overpayment underpayment or nil change to the benefit already paid Medicare will record the adjustment and provide the details to the nominated private health insurer or billing agent by Medica
80. to contact the fund Add the fund payee id to the claim and re submit Check the fee charged Check the prosthesis item number if correct contact the fund If incorrect amend and resubmit Check and rectify the eligibility issue then re submit Contact the fund to find out the reason for the error Try again later Location provider to contact fund Check member number and fund correct whichever is in error and try again Check patient details and re submit Make change to the alias name if Medicare has sent back a successful response Provide sufficient patient details to ensure unique match within membership 56 Response Code 9666 9667 9668 9669 9671 9674 9686 9999 37 Message Member to contact fund Cover is suspended or cancelled Inappropriate cover Patient is ceased or pending cessation Location provider not authorised to use channel at fund RHBO system not checked Baby not known at fund Refer to claim lines for rejection Reason Possible fraud or accident claim or membership issues Member Number is valid Cover is either ancillary or ambulance only Member number is valid Appropriate cover for membership number Patient details matched Location provider could be suspended or not registered for EISE RHBO system not checked due to error response from Medicare set by hub not health fund system No patient match is f
81. website ECLIPSE Enquiries 02 6124 2105 Policy and procedures Complaints and disputes Feedback and suggestions n patient Medical Adjustments Medicare Services Enquiries providers 132 150 Medicare card enquiries Provider eligibility Medicare Services Enquiries public 132 011 VAP Enquiry Line 1300 550 017 Medical and Eligibility User Guide V2 2 for Medical Practitioners 38 Private health insurer contacts For the individual functionality and contact details of each private health insurer involved in ECLIPSE refer to the Health Fund Functionality and Contact Details document available at humanservices gov au then For health professionals gt Doing business with Medicare gt Online business gt ECLIPSE 39 ECLIPSE General information Field Notes Patient Information Fields within this section are self explanatory If an error is encountered with the patient information you will need to correct and resubmit it Patient Information Fund ABC Membership Number 52647891 Unique Patient Identifier 01 Data used to identify the fund and patient Patient Fred Flintstone Date of Birth 01 01 1900 Gender M Medicare Number uS o Medicare numbers for the patient not IRN 1 required hospital only check Account Reference Id 290876543 Patient identifier as known by the provider Refer to Attachment A for a list of error codes that are produced f
82. will be checked first The private health insurer details will be checked if the submitted Medicare details are correct Where the name on the Medicare card differs from the private health insurer card the private health insurer details can be entered into the alternate name fields in your software The private health insurer component will indicate that a patient holds a level of hospital cover with the private health insurer on the date the patient verification was made It does not guarantee that benefits are payable for the service s or that the patient will be covered on the proposed service date s A patient verification checks the data entered on the date it is run For example if a patient starts a private health insurer membership from tomorrow and a patient verification is performed today the patient verification will fail with a message advising that the patient is not known to the private health insurer Enter the first name only in the first name field Where there is no field for the second name or initial do not enter it in the first name field Only use hyphens where they are part of the patient s real name The patient s private health insurer unique patient identifier UPI is optional If its on the member card or has been supplied verbally you should use it to assist with the private health insurer matching process Completing any optional data requirements will help with the patie
83. written by the referring provider must contain the following details patient s full name referring provider name and either provider number and or address information concerning the patient s condition period of referral if other than 12 months signature of referring provider and date the letter was written The written referral must be received by the specialist or consultant physician on or before the delivery of the professional service to which the referral relates Referrals for more than 12 months should only be made where the patient s clinical condition requires the continuing care and management of a specialist or a consultant physician for a specific condition s Referrals in hospital If a referral for a privately admitted patient is generated in a hospital for a service in that hospital Medicare benefits will be paid at the referred rate if the H indicator denoting an in hospital referral is used ECLIPSE claims with an in hospital referral can be submitted with either the hospital s provider number facility Id or the hospital name The provision applies to both initial and subsequent attendances for an admitted patient Lost stolen or destroyed referrals If a referral has been made but the letter has been lost stolen or destroyed Medicare benefits will be paid at the referred rate if the appropriate indicator is used or the claim is notated with lost referral in the

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