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Hospital claiming tips and tricks
Hospital claiming tips and tricks
As health funds introduce changes to their contracts, the way you submit in-hospital claims for your admitted patients may change.
Golden rule #1:
Is there an accomm service? A hospital claim cannot be submitted without an accommodation service aka facility fee. You cannot submit a miscellaneous, prosthesis, pharmacy or procedure service line item without an accomm service.
2 main types of accommodation services:
An accommodation service that is 'per diem' is typically an itemised claim and would almost always be accommodated with other line items such as a miscellaneous service.
An accommodation service that is a case payment (aka Single Value Benefit - or SVB aka episodic claim) WAS typically submitted by itself as a single accomm service line item. However, since the beginning of 2021 (and in the case of HBF earlier than this), this general rule of thumb is out the window - the funds are asking for more data in other parts of the message to accompany their case payment claims.
Below are some some examples of new flavours of hospital claims:
AHSA
Latest AHSA contracts require a single value benefit but using a code flagged as miscellaneous. To be clear, this is different to sending the $ on a miscellaneous service with an accommodation of $0.
To achieve this Go to Maintain Services, add a new master service of type Accommodation and detail of “Other coded miscellaneous service”.
Apply the appropriate misc code to the accomm service e.g. OT00004163C and a relevant description e.g. CHEM 1 (13090) – <add meaningful desc for your use> - we suggest add (SVB) to your case payment Descriptions so it’s clear once it gets to the patient billing tab what type of accom service it is. Add the $ against provider charge and expected benefit paid as agreed with the fund. Repeat for CHEM 2 service.
Once saved on the master services, add to the AHSA contract.
The AHSA funds may also want you to submit the MBS Item along with the above. If this is the feedback, please see under NIB for further instruction on how to do this secondary step.
NIB
NIB have recently rejected claims because they want to see the $ applied to a case payment accommodation service with a miscellaneous code (so as per the AHSA comment above) BUT they want to receive the MBS Item ‘in the theatre fee section’.
To set up this second line item, go to Maintain Services, select "Procedure" from the service type, and MBS Coded Procedure from the service type detail.
Lookup to select the MBS Item (13090 e.g.) and add a meaningful description for your use.
Add with a $0 value (because the $ will be submitted on the accompanying accommodation service)
On the patient claim you should see 2 x line items (at least 2):
One accommodation and one procedure.
HBF
To our knowledge HBF Is the only fund to require TWO accommodation services for certain claim types although other funds may require it in the future. This setup is required for miscellaneous services (non chemo) services such as iron infusions and the like.
HBF have required 1 x miscellaneous service with the misc service code applied and the $ on this item, 1 x accommodation of other coded per diem with the same service code as the misc item and a provider charge and benefit of $0, and a second 1 x accommodation of other coded case payment with provider charge and benefit of $0 (dont forget to add SVB to this service item description so you can distinguish it from the per diem one above).
Add items to HBF contract.
On the patient claim, you hould have 3 x line items (at least 3), 2 accommodation (one with SVB in the service description) with $0 in the provider charge and one Miscellaneous service with the $ amount applied here.
HBF Pharmacy:
If you need to include itemised pharmacy in an HBF claim, this needs to go as a miscellaneous service; below 2 codes are applicable.
Non PBS Phar = DR00002001N
PBS = DR00002012N
General comment:
Since there is no standardisation on how to submit certain claim types among the different funds and the contract wording is often unclear, we can’t guarantee new claim configurations will be completely right under your contract terms so this article will include more detail as we get more definitive responses from the funds or you get new claim setups paid without rejection, but we are happy to help any hospitals struggling with setup. Meantime, to assist with future contract changes, some questions that could be asked below:
Questions for the funds at contract time
Is the facility fee (accom service) to be submitted on a per diem or episodic / case payment arrangement?
What code is to be used on the item containing the charge amount (MBS, miscellaneous code, custom code, DRG?)
Can any meaningful description be included - or does the fund expect a certain description - or certain keywords in the description?
Are there any types of services that cannot be submitted electronically?
If Info only ($0) sections are required to process this service, which parts of the message need to be transmitted as info only?
If yes to the above, how are these info only sections to be coded- and exactly which message segment should the $ be included?
If the above information was included in the contracts, this would save weeks of guesswork and support tickets as claims are rejected owing to lack of the above information.
DVA
Some DVA IHC claims require prior approval for a billing item, for example, H523. The form can be found at
https://www.dva.gov.au/sites/default/files/dvaforms/d1328.pdf . It needs to be emailed to health.approval@dva.gov.au.
As health funds introduce changes to their contracts, the way you submit in-hospital claims for your admitted patients may change.
Golden rule #1:
Is there an accomm service? A hospital claim cannot be submitted without an accommodation service aka facility fee. You cannot submit a miscellaneous, prosthesis, pharmacy or procedure service line item without an accomm service.
2 main types of accommodation services:
An accommodation service that is 'per diem' is typically an itemised claim and would almost always be accommodated with other line items such as a miscellaneous service.
An accommodation service that is a case payment (aka Single Value Benefit - or SVB aka episodic claim) WAS typically submitted by itself as a single accomm service line item. However, since the beginning of 2021 (and in the case of HBF earlier than this), this general rule of thumb is out the window - the funds are asking for more data in other parts of the message to accompany their case payment claims.
Below are some some examples of new flavours of hospital claims:
AHSA
Latest AHSA contracts require a single value benefit but using a code flagged as miscellaneous. To be clear, this is different to sending the $ on a miscellaneous service with an accommodation of $0.
To achieve this Go to Maintain Services, add a new master service of type Accommodation and detail of “Other coded miscellaneous service”.
Apply the appropriate misc code to the accomm service e.g. OT00004163C and a relevant description e.g. CHEM 1 (13090) – <add meaningful desc for your use> - we suggest add (SVB) to your case payment Descriptions so it’s clear once it gets to the patient billing tab what type of accom service it is. Add the $ against provider charge and expected benefit paid as agreed with the fund. Repeat for CHEM 2 service.
Once saved on the master services, add to the AHSA contract.
The AHSA funds may also want you to submit the MBS Item along with the above. If this is the feedback, please see under NIB for further instruction on how to do this secondary step.
NIB
NIB have recently rejected claims because they want to see the $ applied to a case payment accommodation service with a miscellaneous code (so as per the AHSA comment above) BUT they want to receive the MBS Item ‘in the theatre fee section’.
To set up this second line item, go to Maintain Services, select "Procedure" from the service type, and MBS Coded Procedure from the service type detail.
Lookup to select the MBS Item (13090 e.g.) and add a meaningful description for your use.
Add with a $0 value (because the $ will be submitted on the accompanying accommodation service)
On the patient claim you should see 2 x line items (at least 2):
One accommodation and one procedure.
HBF
To our knowledge HBF Is the only fund to require TWO accommodation services for certain claim types although other funds may require it in the future. This setup is required for miscellaneous services (non chemo) services such as iron infusions and the like.
HBF have required 1 x miscellaneous service with the misc service code applied and the $ on this item, 1 x accommodation of other coded per diem with the same service code as the misc item and a provider charge and benefit of $0, and a second 1 x accommodation of other coded case payment with provider charge and benefit of $0 (dont forget to add SVB to this service item description so you can distinguish it from the per diem one above).
Add items to HBF contract.
On the patient claim, you hould have 3 x line items (at least 3), 2 accommodation (one with SVB in the service description) with $0 in the provider charge and one Miscellaneous service with the $ amount applied here.
HBF Pharmacy:
If you need to include itemised pharmacy in an HBF claim, this needs to go as a miscellaneous service; below 2 codes are applicable.
Non PBS Phar = DR00002001N
PBS = DR00002012N
General comment:
Since there is no standardisation on how to submit certain claim types among the different funds and the contract wording is often unclear, we can’t guarantee new claim configurations will be completely right under your contract terms so this article will include more detail as we get more definitive responses from the funds or you get new claim setups paid without rejection, but we are happy to help any hospitals struggling with setup. Meantime, to assist with future contract changes, some questions that could be asked below:
Questions for the funds at contract time
Is the facility fee (accom service) to be submitted on a per diem or episodic / case payment arrangement?
What code is to be used on the item containing the charge amount (MBS, miscellaneous code, custom code, DRG?)
Can any meaningful description be included - or does the fund expect a certain description - or certain keywords in the description?
Are there any types of services that cannot be submitted electronically?
If Info only ($0) sections are required to process this service, which parts of the message need to be transmitted as info only?
If yes to the above, how are these info only sections to be coded- and exactly which message segment should the $ be included?
If the above information was included in the contracts, this would save weeks of guesswork and support tickets as claims are rejected owing to lack of the above information.
DVA
Some DVA IHC claims require prior approval for a billing item, for example, H523. The form can be found at
https://www.dva.gov.au/sites/default/files/dvaforms/d1328.pdf . It needs to be emailed to health.approval@dva.gov.au.
