Patient Eligibility Check

3

Contents 1 INTRODUCTION .................................................................................................................. 5 2 SYSTEM ACCESS................................................................................................................ 5

2.1 Registration ..................................................................................................................... 5 2.2 Access ............................................................................................................................ 5 2.3 Availability ....................................................................................................................... 6 2.4 Logon .............................................................................................................................. 6 2.5 Log Off ............................................................................................................................ 7

3 RULES AND REQUIREMENTS ............................................................................................ 7 3.1 Patient Authorisation ....................................................................................................... 7 3.2 Submission ..................................................................................................................... 8 3.3 Multiple Eligibility Checks for the Same Patient ............................................................... 8 3.4 Patient Information Checking .......................................................................................... 8 3.5 Disclaimer ....................................................................................................................... 9

4 EPISODE ‘REQUEST’ INFORMATION ............................................................................... 10 4.1 Patient Information ........................................................................................................ 10

4.1.1 Fund ......................................................................................................................................... 10

4.1.2 Fund Membership Number ...................................................................................................... 11

4.1.3 Patient Identifier ....................................................................................................................... 11

4.1.4 Patient Information ................................................................................................................... 11

4.2 Hospital Information ...................................................................................................... 11 4.2.1 Facility Identifier ....................................................................................................................... 12

4.2.2 Admission Date ........................................................................................................................ 12

4.2.3 Emergency Admission Indicator .............................................................................................. 12 4.2.4 Same Day Indicator ................................................................................................................. 13

4.2.5 Estimated Length of Stay ......................................................................................................... 13

4.2.6 Hospital Admission Number .................................................................................................... 13

4.2.7 Presenting Illness..................................................................................................................... 13

4.2.8 Accident Indicator .................................................................................................................... 13 4.2.9 Compensation Claim Indicator ................................................................................................. 14

4.2.10 Pre-Existing Conditions ......................................................................................................... 14

5 RETRIEVING FUND RESPONSES .................................................................................... 15 5.1 Response availability .................................................................................................... 15 5.2 Search Status ............................................................................................................... 16 5.3 Fund Status .................................................................................................................. 16

6 FUND ELIGIBILITY RESPONSE INFORMATION ............................................................... 17 6.1 The overall response .................................................................................................... 17

4

6.2 Level of Cover ............................................................................................................... 18 6.2.1 Table Name ............................................................................................................................. 19

6.2.2 Table Description ..................................................................................................................... 19

6.2.3 Table Scale .............................................................................................................................. 19

6.3 Details applicable to admission ..................................................................................... 19 6.3.1 Financial Indicator .................................................................................................................... 19

6.3.2 Potential PEA Indicator ............................................................................................................ 20

6.3.3 Co-payment Amount, Description & Days Remaining ............................................................. 20 6.3.4 Excess Amount, Description and Excess Bonus ..................................................................... 20

6.3.5 Exclusions ................................................................................................................................ 20

6.3.6 Benefit Limitations - this section MUST be read carefully. ...................................................... 20

6.4 Print Responses ........................................................................................................... 21 7 PRESENTING ILLNESS ..................................................................................................... 22 8 KEY CONTACTS ................................................................................................................ 23

8.1 Processing error messages .......................................................................................... 23 8.1.1 Processing Messages .............................................................................................................. 23

5

1 Introduction

This guide has been developed to explain BUPA Australia’s online Patient Eligibility Checking system and how it can assist hospitals in determining the patient’s out of pocket expenses for in-hospital care. It also provides an overview of the information required to ensure the most accurate assessment is provided and that the assessment data is clearly interpreted. Before a Patient Eligibility Check can be performed, consent must be obtained from the patient or a legally authorised representative.

The Patient Eligibility Check will determine whether the patient is eligible for a selected presenting illness/condition as at the admission date. It will detail the out of pocket expenses a patient has for excess and co-payments associated with the hospital product.

To simplify documentation, this manual will be split into five sections:

• System Access,

• General Rules and Requirements

• Episode ‘Request’ information

• Retrieving Fund Responses

• Fund ‘Response’ information

2 System Access

2.1 Registration

Each facility wishing to use BUPA Australia’s web Patient Eligibility System must first register and agree to the terms and conditions of usage.

Once the registration process is complete. BUPA Australia will issue each facility with a password to access the web system.

2.2 Access

Access to the system will be via an Internet Web application hosted by Civica. The web application has been implemented using the latest Microsoft technology and Web technology, as well as Medicare Australia’s Eclipse server adaptor.

The web application has been designed to work with mainstream browsers and can adapt to various screen sizes. The system can be accessed on https://eclipse.civica.com.au/ECFWeb (please note there is NO www).

Access to the system will be restricted to registered Hospitals. System security will only permit access from the nominated IP address using the nominated password. It is anticipated that Hospitals will use their internal security mechanisms to control unauthorised access to these terminals and passwords by individuals at the hospital.

6

2.3 Availability

The system will be available 24 hours a day 7 days a week apart from scheduled outages at either Medicare Australia, the Fund or CIVICA.

Whilst the system is available it will only be supported during normal business hours 9.00am – 5.00pm. If the system incurs a down time outside normal business hours it will not be attended to until the next working day.

2.4 Logon

STEP 1 Logon to https://eclipse.civica.com.au/ECFWeb

STEP 2 Select your facility Id (provider number)

STEP 3 Input the password issued by BUPA Australia.

7

STEP 4 You are now logged onto the BUPA Australia Patient Eligibility Home Page

STEP 5 Click on ‘ECF Web Request’ to commence sending Patient Eligibility Requests.

Please note: You will be automatically logged off the web site after 20 minutes of inactivity.

2.5 Log Off

Click ‘Logout’ from any screen and you will be immediatedly logged off from the Patient Eligibility website.

3 Rules and Requirements

3.1 Patient Authorisation

Before submitting a Patient Eligibility check, the patient or other lawfully authorised person (ie guardian, power of attorney appointee) must consent to the check being performed. The method of acknowledgment, that the patient has given their consent, must be sent in the electronic request. This will be done via a tick box.

A request will be rejected if it has not been authorised.

Click ‘New ECF Request’ to commence input

Click ‘Logout’ to exit the system

Useful Help down loads

8

3.2 Submission

A Patient Eligibility Check can be submitted for an anticipated admission date up to 12 months in the future or up to 7 days in the past for an Emergency admission.

The information returned in the Patient Eligibility check will be the product and benefit information that will apply as at the admission date as it is known on the day the check is submitted.

The benefit amounts are the amounts that apply on the day you submit the Eligibility check, based on the patient’s history and level of cover.

It is recommended where an admission date is well into the future that a second check is performed no more than 48 hours prior to the patient admission. This highlights any changes in benefits that may impact on the patient’s out-of-pocket expenses and their financial status.

Note: The results of the Eligibility check processing will be available within 20 minutes of the transmission. If the health fund systems are unavailable, or cannot complete processing within 20 minutes, a message will be returned advising that the Eligibility Check was not completed successfully and must be processed again.

3.3 Multiple Eligibility Checks for the Same Patient

If necessary, Eligibility Checks can be repeated for the same patient. Each Eligibility check is assessed in its’ own right and does not take any previous Eligibility checks for the patient into consideration. Eg. In other words, if two checks are done for the same admission date then the Hospital excess and/or co-payment will be shown on both responses as payable, however it is only payable per admission.

3.4 Patient Information Checking

A Health Fund membership number is required when processing a patient eligibility check via this system. Hence all patients should be encouraged to bring in their membership card or quote their membership number at the time of making the hospital booking or on admission.

The first step in the Patient Eligibility check is a validation check against the health fund to ensure that the patient can be identified. If the patient details are correct the ECLIPSE system will accept the Eligibility check for processing.

If the patient cannot be identified at the health fund, the Eligibility check will not be accepted for processing and a response will be returned advising the reason that the patient cannot be matched.

Reasons that the patient cannot be identified may be:

• The patient is unable to be uniquely identified via the data input

• The patient is known to the health fund, but personal or membership details in the transmission differ from the health fund’s records.

9

• The patient does not have hospital cover.

Where the patient details are incorrect, verify the details with the patient and update your hospital records, then re-submit the Eligibility check. See Error Messages for a full list of error codes.

3.5 Disclaimer

The result of a Patient Eligibility Check is based on patient information and episode data supplied at the time the Eligibility Check is submitted.

Given that many products now have an excess, hospitals should reconfirm members eligibility within 48 hours of the planned admission date. If a membership check is carried out further in advance than this, member's excess liability or financial status with BUPA Australia may have changed, resulting in the hospital not having current information.

Where a member check has been conducted no more than 48 hours before a patient is admitted, and BUPA Australia has given the hospital written advice on such matters as eligibility, excess payable, exclusions, etc, BUPA Australia will honour that advice.

10

4 Episode ‘request’ Information

Input elements can be broken down into three sections;

• 4.1 Patient Information

• 4.2 Hospital Information

• 4.3 Sender Information

4.1 Patient Information

4.1.1 Fund

BUPA Australia trades under the following Health Insurance brands, all of which can be accessed for Patient Eligibility via the ECLIPSE web sytem. A copy of the membership cards can be found at the back of this manual.

• BUP (BUP)

• HBA (HBA)

• Mutal Community (MCL)

• MBF (MBF)

• SGIC (SGI)

11

• SGIO (SGI)

• NRMA (SGI)

• Health Cover Direct (HCD)

• ANZ Health (ANZ)

4.1.2 Fund Membership Number

The fund membership number MUST be input to enable a Patient Eligibility Request. The patient’s membership number is displayed on the front of their membership card.

4.1.3 Patient Identifier

The patient identifier is a 2 numeric code that is displayed alongside the patient’s name on their Health Fund Membership card. Input of this information is optional’ however’ if known it should be supplied to enhance the patient matching criteria.

4.1.4 Patient Information

Fields within this section are self explanatory. If an error is encountered with the patient information you will need to correct it and resubmit.

All fields within the section are mandatory with the exception of;

• Patient Identifier, and

• Patients’ second initial

Whilst these elements are optional they should be supplied if known, as they will assist in the patient matching process. The patient identifier can be obtained from the patient membership card.

Refer to Attachment A for a list of error codes and conditions that can be returned from this data.

4.2 Hospital Information

The following elements are used to determine whether an inpatient hospital claim is payable by the fund.

12

4.2.1 Facility Identifier

This is the hospital provider number where the anticipated admission is to be undertaken. Only the facility Id’s your IP address has access to will display in the drop down list.

4.2.2 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 7 days in the past for emergency admissions.

NOTE: This date is used to determine the member’s eligibility to have the presenting illness/ condition treated.

4.2.3 Emergency Admission Indicator

Should be set to ‘Y’ if the admission was as a result of an emergency. Otherwise the eligibility check may not necessarily be done in advance.

Patient identifier as known by the hospital Determines excess,

co-payment/ product information

Determines Waiting Periods & product information

Determines whether admission is covered by the health product

May override waiting period rules

Used to advise that the treatment may be classed as a Pre-Existing Conditions

Hospital provider number

13

4.2.4 Same Day Indicator

The same day indicator advises the Fund whether the patient will be admitted overnight in the facility. This information is used to determine excess or co-payment arrangements payable under the patients cover.

4.2.5 Estimated Length of Stay

This information is used as a guide only and must be completed if it is an overnight stay. The information supplied is NOT used to make any calculations for excess or co-payment information.

4.2.6 Hospital Admission Number

This is a reference number allocated by the hospital for the purpose of identifying the patient in the eligibility request.

This number will be returned to you in the response.

4.2.7 Presenting Illness

The presenting illness will be used to determine the waiting periods, exclusions and any reduced benefits payable.

Many presenting illnesses are for specific treatments or conditions and will result in very specific responses from funds. However, if a general presenting illness is provided eg. Medical admission (unknown) - 420 or Unknown or other surgery - 499 the Health Fund will provide a general response that will detail ALL exclusions or reduced benefits applicable under the patients cover.

Note: A general response of this nature will need you to review all information within that response to make your own assessment of whether there are any restrictions or exclusions applicable before supplying details to the patient. It is recommended that if a presenting illness/condition is documented in the response and it does apply then the eligibility check should be repeated with the specific illness/condition to ensure accurate patient’ entitlement is obtained..

See section 7 for a list of Presenting illness/condition codes

4.2.8 Accident Indicator

Care MUST be taken when setting the accident indicator to ‘Y’ as this will override normal waiting periods applicable for the presenting illness/condition.

It is recommended that this indicator is always set to ‘N’ in the first instance and only IF waiting periods apply and for treatment that is as a result of an accident should this be set to ‘Y’. As the assessed results may change.

Note: Health Fund approval of the accident certificate MUST be obtained to ensure claim benefits are payable.

14

4.2.9 Compensation Claim Indicator

The compensation indicator should be set to ‘N’ unless you know the claim is possibly payable by another source.

4.2.10 Pre-Existing Conditions

Benefits paid by the health fund may be determined 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 or not.

A two-step process has been developed to help resolve a possible PEA claim. It is suggested that you always set the PEA indicator to ‘N’ (not pre-existing). This will allow the Fund to determine whether the presenting illness/condition could be deemed as possible pre-existing. This information will be returned to you in the response with a Warning on the assessment.

If you receive a warning on an eligibility response with the PEA result of ‘Y’ (possible pre-existing) you should repeat the eligibility check with the PEA indicator set to ‘Y’. The fund will then 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.

15

5 Retrieving Fund Responses

5.1 Response availability

Fund responses will be available anywhere within 5 to 20 minutes from the time you submitted the request. Generally most requests will be available within 5 minutes.

There are two ways to retieve the responses. The first is to click on the ‘ECF Web result’ tab at the top of the screen.

This will display your last 20 responses. You may increase the number of responses you wish to see by selecting a number required at the bottom of the screen

Reponses will be available in request date and time order. This sort can be varied. Any column heading that is underlined can be selected to vary the sort. To change the sort order click on the underlined column heading you require.

To view the results of the request, click on the see details fields alongside the request required.

The second method is to search for a response.

To find a specific response click on ‘Search’ at the top of the screen and enter at least two pieces of search data.

To sort the screen in a different order. Click any underlined column heading.

To search for a response.

16

The more data you enter as search criteria the better the match will be and hence you will retrieve less responses in return.

An * can be used as a wildcard character if you are unsure of the spelling of the name ie Hodge* will return responses for Hodges, Hodgeson, Hodgeman etc.

5.2 Search Status

There are 3 status results available when you retrieve a response;

• Results Available (you can view the reponse)

• In Progress (no results available yet, try again later)

• Failed (the request needs to be re-submitted as the fund system was unavailable at the time of the original request)

5.3 Fund Status

Any code displayed in this column other than 0 will indicate there is a problem with either the data submitted or that the fund system is unavailable.

Refer to the ‘Processing Error Code’ sections for code meanings.

17

6 Fund Eligibility Response Information

It is important you understand how to interpret the eligiblity response information

The response is broken up into three main areas;

• Overrall response

• Level of Cover

• Details applicable to admission

The information below is an example only and does not include all data elements. Those shown are the key information requirements that determine the eligibility response.

6.1 The overall response

The response code will advise you whether the eligibility check has been successful or not.

This code is the most important as it indicates the overall eligibility result

Details the result obtained

18

A response code of;

Eligibility Response Code

What it means What you need to do

A – Accepted The patient is eligible to claim for the presenting illness specified as at the admission date.

• Check the product description for what is payable.

W – Warning This indicates that the patient maybe eligible to claim for the presenting illness specified however there are certain conditions detailed within the response that must be satisfied before the patient is admitted.

• Check the response as conditions apply ie the member may not be financial, benefit limitations may apply or the presenting illness could possibly be pre-existing.

R – Rejected The patient is not eligible to claim for the presenting illness specified as at the admission date.

• Inform the patient that nothing is payable by the health fund towards the cost of treatment for the presenting illness/condition.

A response of ‘A’ or ‘R’ is reasonably straight forward however an assessment response of ‘W’ means there are conditions that MUST be noted as they will affect the payment of benefits. The message detail section MUST be checked carefully for a response of ‘W’.

6.2 Level of Cover

You will need to check the table description carefully as this will detail whether there are any room restrictions ie shared room only payable or what is payable for a benefit limitation.

Product information used for assessment.

19

6.2.1 Table Name

This will detail the Table name that has been used to make the assessment. Generally this will be the patient’s level of cover as 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: Both of these situations will be clearly visible in the assessment text, displayed in the overall response.

6.2.2 Table Description

Detailed description of the table that the patient is covered by for the admission.

6.2.3 Table Scale

The membership type ie Family, Family Plus, Single, Couple, Sole Parent, or Sole Parent Plus etc.

6.3 Details applicable to admission

6.3.1 Financial Indicator

The reponse shown in this field details whether,the patient is financial as at the admission date. A response of ‘N’ unfinancial means that the patient MUST be financial at the date of admission for the claim to be paid.

Financial status as at admission date

This indicates the eligibility check could result in a different response if the condition is deemed PEA

20

Note: It is recommended that you advise the patient in ALL circumstances that the payment of the claim will be subject to financial status.

6.3.2 Potential PEA Indicator

If the Fund has responded that the presenting illness/condition could be deemed as possible pre-existing, a PEA indicator of ‘Y’ will be returned with a Warning on the assessment.

When a warning response is received with the PEA indicator of ‘Y’ (possible pre-existing) the eligibility check should be repeated with the PEA indicator set to ‘Y’. The fund will then 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 to be known depending on the outcome of the PEA determination.

6.3.3 Co-payment Amount, Description & 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 enable you to calculate the co-payment amount that will be payable.

The estimated length of stay submitted in the request is NOT used to perform any co-payment calculations.

6.3.4 Excess Amount, Description and Excess Bonus

The Excess Amount (if displayed) will be the total excess payable for the admission. If the Excess amount is $0.00 it means that no excess is payable.

When a dollar amount appears in the Excess Bonus Used field, it indicates that an Excess Bonus has been applied and the Excess Amount has been reduced by the bonus value shown.

6.3.5 Exclusions

No benefits will be payable for any presenting illness/condition shown in this field. Care must be taken to ensure the patient is NOT being treated for one of these illnessess/conditions, otherwise the patient is liable for payment.

6.3.6 Benefit Limitations - this section MUST be read carefully.

This section will detail any restricted benefits that apply as at the admission date which may affect the benefit payable.

NOTE: If the eligibility check submitted was for presenting illnessess 420 (medical admission) or 499 (unknown or other surgery) and information is displayed in the Benefit Limitations field it is recommended that the eligibility check should be repeated with the specific illness/condition to ensure accurate patient’ entitlement is obtained.

21

6.4 Print Responses

You can either print the current page you are viewing by clicking the ‘Print current page button or you can select to print the full report by clicking the ‘Export’ button. This will enable you to select a PDF print option or an Excel format for saving on your PC.

No benefits are payable for anything shown here

Restricted benefits (generally basic benefits) will apply for anything shown here

Click to print the current page view only

To print the full report including request data via a PDF format or export the data to an Excel

Use all three co-payment fields to determine co-payment amount payable.

If an excess amount (= or > 0) is displayed this is the excess amount payable.

22

7 Presenting Illness The following lists all allowable presenting illnesses. This will be accessed via a drop-down menu on your input screen.

Code OEC Description

400 Miscarriage and termination of pregnancy 401 Gynaecology 402 Assisted reproductive services 403 Pregnancy and birth 404 Male reproductive system 405 Cataracts 406 Eye (not cataracts) 407 Eye Laser 408 Lung and chest 409 Heart and vascular system 410 Hospital psychiatric services 411 Rehabilitation 412 Palliative care 413 Kidney and bladder 414 Dialysis for chronic kidney failure 415 Chemotherapy, radiotherapy and immunotherapy for cancer 416 Blood 417 Bone Marrow Transfusion or Transplant 418 Dental surgery 419 Podiatric surgery (provided by a registered podiatric surgeon) 420 Medical admission (unknown) 423 Back, neck and spine 424 Bone, joint and muscle 425 Joint reconstructions 426 Joint replacements (other than Hip & Knee) 427 Joint replacements (Hip & Knee) 430 Gastrointestinal endoscopy 431 Hernia and appendix 432 Digestive system 433 Weight loss surgery 441 Pain management 442 Pain management with device 451 Insulin pumps 452 Diabetes management 460 Sleep studies 461 Tonsils, adenoids and grommets 462 Ear, nose and throat 463 Implantation of hearing devices 470 Plastic and reconstructive surgery (medically necessary)

23

Code OEC Description

471 Skin 475 Cosmetic surgery 478 Breast surgery (medically necessary) 493 Brain and nervous system 495 Organ transplant 499 Unknown or other surgery

8 Key Contacts

Information Request or Response data 1300 663.590 Obtain Registration Form CS-TransactionOptimisationTeam@bupa.com.au

System Unavailable Medicare Help Desk Mon to Frid 8.30am - 5.00pm 1300 550 115

After hours No support available

Log On Issues 1800 063 654

8.1 8.1 Processing error messages

8.1.1 Processing Messages

For ease of locating, messages have been listed in numerical order. Code Message Reason Action Required

0 Patient known to fund Patient details supplied are correct as at the day processed. Patient details can be used to;

1. Obtain an eligibility check

2. Process a hospital claim

1005 Facility Id not known to Fund

The facility Id supplied is;

1. Not registered at the Fund

2. Not current.

Check the Facility Id, if correct contact the Fund, if incorrect resubmit with corrected data.

1007 Account Reference Id or Hospital Admission number required

The account reference or hospital admission id is missing.

Add the account reference or hospital admission id and then

24

Code Message Reason Action Required

resubmit.

1100 Not eligible for service selected

The Patient is not eligible to have treatment for the presenting illness or item according to the information supplied in the eligibility check.

Inform the patient that they are not eligible for the service.

1101 Eligible for service selected

Patient is eligible for the presenting illness or item according to information supplied in the eligibility check

1102 Eligible subject to conditions

Patient maybe eligible for the presenting illness or item according to the information supplied in the eligibility check however there is a condition you will need to note before you proceed. This could be (not exhaustive);

1. Financial status

2. Reduced benefit is payable

3. Possible pre-existing condition

Refer to OEC guide for assistance on what areas to check.

1103 Resubmit for new assessment if presenting illness is shown

A general presenting illness or item was input on the request and therefore a general answer displaying all benefit limitation or restriction that apply to the patient’s cover was returned in the response.

Check the Eligibility response carefully and resubmit if the actual presenting illness or item is displaying to obtain an accurate assessment.

1104 Eligible for service selected at previous cover

The patient is eligible for the presenting illness or item as input on the incoming eligibility request however 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.

The patient is eligible for the service on their previous level of cover.

1105 Not eligible for service selected – Wait period applied

The patient is not eligible for the presenting illness or item as they have not completed serving their required waiting periods.

1106 Eligible for service selected at previous cover – Wait period applied

The patient is eligible for the presenting illness or item as input on the incoming eligibility request however not at their

25

Code Message Reason Action Required

current cover. This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover.

1107 Not eligible for service selected – Pre Existing Ailment

The patient is not eligible for the presenting illness or item if it IS deemed to be a pre-existing condition

Ask the member to contact the Fund to get the pre-existing ailment process started.

1108 Eligible at previous cover subject to conditions

The patient is eligible for the presenting illness or item as input on the incoming eligibility request however 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.

1109 Eligible subject to approval of accident certificate

Fund will not guarantee payment of the service until an accident certificate has been supplied and approved.

Ask member to contact the Fund.

1110 Eligible subject to conditions and approval of accident certificate

Fund will not guarantee payment of the service until an accident certificate has been 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

3. Reduced benefit is payable

Ask member to contact the Fund regarding the accident certificate and to verify the other conditions as per the eligibility response.

1112 Use PI Codes in Range 400-499

You have submitted a presenting illness code in the range 300-399. These codes are no longer supported by Bupa.

Please resubmit the eligibility check using a presenting illness in the range 400-499

1114 Use Pres Ill/Primary MBS Code

You have requested an eligibility using an MBS code that is not associated to a primary presenting condition

Please resubmit the eligibility check using either the Primary MBS code or a presenting illness code in the range 400-499

1999 Contact Fund

26

Code Message Reason Action Required

3040 RHBO system unavailable or service problems

RHBO system may be undergoing scheduled maintenance or experiencing service difficulties. (May be set by hub or health fund system.)

Try again later

9663 Member Number not recognised by fund

Member number not known by the Fund the claim was submitted to. No other patient data checked at this time

Check member number and fund, correct whichever is in error and try again

9665 Patient not recognised on the membership

Member number is valid.

Cover for membership number is okay

Either no patient is identified, or multiple patients are identified.

Check patient details and re-submit. (Make change to the alias name if Medicare have sent back a successful response).

(Provide sufficient patient details to ensure unique match within membership.

9666 Member to contact fund Possible fraud or accident claim or membership issues

Member to contact fund

9667 Cover is suspended or cancelled

Member Number is valid Cannot lodge a medical claim, as member is not covered for that service. Check with member.

9668 Inappropriate Cover Cover is either Ancillary or Ambulance only

Cannot lodge a medical claim, as member is not covered for that service. Check with member.

9669 Patient is ceased or pending cessation

Member Number is valid.

Appropriate cover for membership number.

Patient details matched.

Member to contact fund.

Patient may not have current student registration

9671 Location/provider not authorised to use channel at fund

Location/Provider could be suspended or not registered for ECLIPSE

Provider to contact fund

9686 Baby not known at Fund No patient match can be found and the DOB of the patient is LESS than 29 days from the earliest date of service in the OPV.

Member needs to register the baby at the fund.

27

Membership card samples

Please use the logo on the card presented to determine the heath fund identifier to submit to.

1 Introduction2 System Access2.1 Registration2.2 Access2.3 Availability2.4 Logon2.5 Log Off

3 Rules and Requirements3.1 Patient Authorisation3.2 Submission3.3 Multiple Eligibility Checks for the Same Patient3.4 Patient Information Checking3.5 Disclaimer

4 Episode ‘request’ Information4.1 Patient Information4.1.1 Fund4.1.2 Fund Membership Number4.1.3 Patient Identifier4.1.4 Patient Information

4.2 Hospital Information4.2.1 Facility Identifier4.2.2 Admission Date4.2.3 Emergency Admission Indicator4.2.4 Same Day Indicator4.2.5 Estimated Length of Stay4.2.6 Hospital Admission Number4.2.7 Presenting Illness4.2.8 Accident Indicator4.2.9 Compensation Claim Indicator4.2.10 Pre-Existing Conditions

5 Retrieving Fund Responses5.1 Response availability5.2 Search Status5.3 Fund Status

6 Fund Eligibility Response Information6.1 The overall response6.2 Level of Cover6.2.1 Table Name6.2.2 Table Description6.2.3 Table Scale

6.3 Details applicable to admission6.3.1 Financial Indicator6.3.2 Potential PEA Indicator6.3.3 Co-payment Amount, Description & Days Remaining6.3.4 Excess Amount, Description and Excess Bonus6.3.5 Exclusions6.3.6 Benefit Limitations - this section MUST be read carefully.

6.4 Print Responses

7 Presenting Illness8 Key Contacts8.1 8.1 Processing error messages8.1.1 Processing Messages