Knowledge base » Billing » Billing Go Live checklist for new EpiSoft sites
Billing Go Live checklist for new EpiSoft sites
Medicare and health fund setup for billing - new site
Have you been given a Minor Customer ID for your site by EpiSoft? If not, please request this from us as a first step. In some cases, you may only require one for the various practice locations you work out of, in other cases, you will require a minor customer ID per site.
Processing paperwork / applications can take up to 2 weeks for Medicare so please allow plenty of time to avoid issues with cash flow.
Have you applied for a PKI (public key infrastructure) certificate quoting this Minor Customer ID?
Have you received the PKI certificate on a CD and provided it to EpiSoft? Please send to Suite 216, 20 Dale Street Brookvale NSW 2100 along with password for installation which should be provided on some paperwork with the Disk, ideally via registered post.
New Doctor or Allied Health Provider with Medicare prov number
Has Medicare and the funds got the bank account details of the Doctor?
Has Medicare and the funds linked the Provider Number to the minor customer ID?
Medicare and health fund setup for billing - existing site with current PKI certificate issued by another software vendor, have you:
Contacted Medicare eBusiness to get the form required to convert this Certificate from current software customer ID to one issued by EpiSoft? Please ensure that the date for change over is clearly understood by Medicare to avoid issues with your current billing vendor being switched off too soon.
You may need to have your PKI certificate reissued and this is the likely form but please check first with Medicare that this is the latest:
https://www.humanservices.gov.au/health-professionals/forms/hw003
Once received please send together with paperwork including password to Suite 216, 20 Dale Street Brookvale NSW 2100 (or we can set up a Google Drive for you to share if easier) along with password for installation which should be provided on some paperwork with the Disk, ideally via registered post otherwise express post and notify us that is has been sent. We can return it to your practice after successfully installed on the EpiSoft servers or keep it securely stored on our premises.
Have you filled in all the Bank Details forms for the various providers (medical practitioners and hospital if applicable) to ensure Medicare can pay you directly? If a new Doctor or provider who will be billing Medicare starts at your practice, please ensure that you contact Medicare eBusiness citing your EpiSoft Minor Customer ID so that Medicare can link this new provider to the Customer ID you have been issued.
Medicare eBusiness contact details 1800 700 199
ECLIPSE sites (Medical services for hospital inpatients)
Have you contacted all the Health Funds separately to notify which providers will be transacting through Eclipse? For Alliance group of funds, you only need to contact the Alliance for Medical.
Have you obtained Payee IDs for each provider from BUPA? Bupa does not use the provider number but rather their allocated Payee ID to identify providers for Eclipse.
Are all your contracts setup correctly with No Gaps and/or scheme?
Medibank Private - tick Scheme on the contract
There are a few others which require Scheme ticked on the contract but it might vary based on whether the hospital is billing for the Dr or the Dr is getting payment direct into their bank account. Please ask the fund which category your facility falls into before you start submitting claims.
ECLIPSE sites (Hospital services for hospital inpatients)
1. Have you contacted Medicare eBusiness contact details 1800 700 199 and advised that you are about to Go Live with Inpatient Hospital Claims citing your minor Customer ID and Hospital Provider Number? If this is not done, there will be a problem on the Medicare Eclipse gateway and you will not receive an error message. The claim will look like it has been submitted but will not get paid. Please ensure Medicare eBusiness is also aware that you will be transacting DVA hospital claims through the DVA channel too.
2. Have you contacted all of the health funds (INDIVIDUALLY) to notify them your hospital will now be sending Inpatient Hospital Claims (IHCs)?
When you contact them, please ask if you have to notify them again just before Go Live (via email), as some funds do a partial setup of your hospital in their system as an Eclipse hospital and then require a separate email confirmation just before Go Live.
IMPORTANT: If you are commencing Eclipse WITHOUT HOSPITAL CONTRACTS in place, this is known as the 2nd Tier Default Benefit arrangement and it has some special issues; Sites doing 2nd tier default claims: please confirm with the funds whether they
1) accept IHC claims or if you have to submit manually
2) assuming yes to 1 above, will they send an electronic reconciliation (statement of benefit).
3) assuming yes to 1 and 2 above, will they PAY into your bank account or send you a cheque.
You can then make the call based on the answers to the above whether it is worth doing IHC during a 2nd tier period or just submit everything manually till you have the contracts in place rather than straddling multiple payment and submission arrangements none of which are standardised.
Manual submission of IHC if required
1) raise a payor invoice just for the hospital service items
2) send and submit with the HC21 form
3) keep account in status of proforma till paid (we don't have a separate tracking status for manual submission)
3. Australian Unity and a couple of other health funds require you to undergo a parallel run where you need to submit paper claims as well as electronic until they are satisfied the electronic is reflecting the data. If they mention a parallel run, this is what they mean.
4. Please confirm your contract setup for facility (accommodation) fees. Do the funds expect a single value benefit (aka Case Payment) service or is it a Per Diem?
5. Please ensure your charges are correct for Bupa and CBHS. Some funds pay based on the contract regardless of the provider charge, Bupa rejects the claim if the provider charge doesn't match the contract and CBHS pays what you invoice, not what's on the contract (so you may be underpaid).
5. Will you have additional charges on top of facility (accommodation) that you need to itemise? Examples, high cost drugs not on PBS but covered by fund; prosthetic items. Make sure your codes for prosthetic items are setup correctly.
7. Will you be sending through pharmaceuticals on any of these claims ? These are treated differently by some funds who require paper invoices for claims involving pharmaceuticals. Medibank Private will not e-process claims including high cost drugs electronically. These have to be submitted on paper.
8. Have you ensured the port flush and other miscellaneous service transactions are configured exactly as required by the funds? Bupa in particular requires a certain format for their port flush claims or they will not process automatically but rather go to an assessor. Let us know if you want us to double check your setup of these items for BUPA.
9. If you get any claims that either come back as "Not accepted through this channel" message, this is sure-fire signal that something is not set up correctly, all claims to that fund will be blocked and EpiSoft has to help you look into the cause of the blockage
10. If you have not been paid by your major payors in 10-14 days of IHC claim submission, there could be problems on the Medicare gateway which is equivalent to 9) above without the error message
9. Grand United Health Fund (one of the Alliance group of funds) cannot do IHC. This may come back as a valid "Not accepted through this channel" message because they're unable to receive electronic claims.
Admission and Inpatient Billing Process flow checklist
1) Ideally inpatients should be Preadmitted before day of treatment and the Admission Form filled out as far as possible - how do you do this? Go to Tomorrow on Appointment List, where patient = I (inpatient) set status to Preadmitted. A P will then appear on right hand side of appointment list. Click that to fill in as much data as possible prior to admission. This includes a provisional ICD10AM code principal diagnosis and a provisional procedure code.
1) Prior to patient attending hospital, contact the fund to check patient's eligibility with the fund. Are they financial? This is known as the eligibility check. We don't have this electronically enabled in EpiSoft at the moment so it requires login to a fund website or a telephone call to fund. The fund will tell you: if the patient is not financial at all (in which case they will be a self-pay account or 2) if the patient is eligible but has an excess or co-pay, click the $ sign next to the P column to 1) create account ahead of admission and 2) record record excess or co-pay in the entitlements section. An excess means the patient pays it once annually and then that is it. If it's higher than the provider charge, you will have to amortise it over multiple visits. It cannot be higher than the accommodation service provider charge or the account will end being negative and unable to reconcile. If first treatment = $250 and patient excess per annum is $500, take payment for the excess of $250 (NOT $500) and make note to charge $250 next time too. Recommend use Private Notes module for this. Co-pay is per visit. There are other complications around health fund products such as exclusions for certain conditions but these exclusion tables rarely apply to cancer patients in our experience. All this means you now have the admission paperwork partly done and the account partly created prior to day of admission.
2). On day of treatment patient arrives. Clerical staff click booking status of "Admit". The P on the right hand side will change to A. Open the Admission Form and complete remaining data.
3) Print the HC21 form from Billing Documents tab. What is this? HC21 aka Hospital Claim 21 form is an "Assignment of Benefits" form between you (hospital) and patient (health fund member) authorising you (hospital) to claim for hospital benefits on patient's behalf. This is normally sent as the paper claim. You do not have to send it to the fund if you are doing Inpatient Eclipse (IHC) but you still must keep it on file - signed by the patient for audit. There is a page 1 and page 2. The page 1 should be signed by the patient prior to admission. Although it looks as though there is further information that needs to be signed by the patient on discharge such as their mode of discharge (going home, going to another hospital etc) patient signature on discharge is not done by any hospital. Patient signature on admission is adequate.
4) Make sure the patient has signed HC21 on admission and you have printed/kept a copy on file.
5) Nursing staff, tick Attended on Appointment (or if more than one treatment, attend multiple appointments) and complete clinical data record.
6) Complete the discharge details Visit Form which records mandatory fields of discharge time and mode of discharge.
7) Admission Coding (could be done by clinical coder or other person) - complete the Admission Coding form which records the principal Diagnosis, principal procedure, additional Dx , Prx and any cancer morphologies. NB Health funds do not receive cancer morphologies; these are for state-based statistical collections only. For QLD sites, the sequencing of Dx relative to morphologies is important. Fill in the DRG and version and click coding complete, ready to invoice.
8) On billing tab, if the above step 7 is not done, then the account will be in status "Awaiting Coding". Clerical staff can still add the services provided, both medical and hospital and generate the certificate. Check the entitlements section is finalise (excess and copay recorded if applicable). However they can't submit the claim till the coding is complete / ready to invoice.
9) We recommend you generate 2 x separate invoices for medical and other. That way if you need to send a paper invoice to the health fund, you have the right content. To do this, check the service items you want to invoice before you hit Generate Invoice. Once done, do same for remaining service items. The invoice selection is then available as a dropdown list.
10) Accommodation & medical is the item selected at the top if there are both. EpiSoft will split the medical and accom CLAIMS separately even if these are on one account. If you accidentally add the medical and hospital to the same invoice, don't worry as we will still split the claims.
2) Patient paying in full for this service = NO.
3) Certificate - generate a Same-Day Certificate on the Account / billing tab page if there is any hospital / accom service. While some same-day procedures do NOT required a supporting certificate, the rules are so complicated about which ones don't, just generate a certificate for all accounts with an accommodation/facility fee to be on the safe side. The electronic certificate attaches to the electronic IHC.
3) Don't forget for any sites where medical Eclipse billing only (e.g. sites the Doctor works out of that are not the primary site) these should be flagged as medical only - these should NOT have an accommodation service item and they should NOT have a same-day certificate.
Reconciliation process
In the same way as medical Eclipse, EpiSoft receives 2 reports upon which we attempt to reconcile an IHC claim and mostly can do so but not always:
1 = the processing report which is akin to a statement of benefit or INTENT to pay. The INTENT word is important as it means the date of this report hence date of Actual Benefit Paid may not always align with $ in the bank account. The amount on this report gets imported by EpiSoft into the Actual Benefit Paid field on the line item on the account. If a medical or hospital component rejects or is unpaid, EpiSoft will not set the claim paid status until an amount is provided against both hospital and medical. If the hospital amount returned is less than the Provider Charge or even is a $0, this means the status will be set to claim paid (as both hospital and medical have been paid) but the account may still have an outstanding amount. This is because the status of claim paid is set on receipt of a "successful" processing report which the funds may report even if they then set an actual benefit paid of $0 against the item.
There are sometimes issues with reconciling this processing report. For example, BUPA sends the actual benefit paid on the service as the amount less co-pay whereas if there is an excess they have a different rule about what they send in what field. Hence claims with co-pay automatically pay off neatly in EpiSoft, claims with excesses don't.
HCF sometimes sends us service item level benefits and sometimes just a total. The rules about when service level amounts are sent remain unclear so automatically setting the actual benefit paid on HCF claims is still a work in progress.
DVA acommodation claims don't go through Eclipse but an older bulk bill channel so the DVA contract MUST have the bulk bill flag ticked ; make sure the accommodation codes are as per DVA expects - these are DVA codes, not MBS item numbers and the claim will reject if the service code is not known.
Medibank Private will still pay an unrecognised service code but won't send a Processing Report if they can't match the service code hence reconciliation ends up being manual. If there is a code mismatch, the fund will still pay the claim but will not send an electronic processing report. Hence the ERA report will have an amount paid against this account but the Actual Benefit Paid will be empty. Set the Actual Benefit Paid manually in this case.
The ERA report (Electronic Reconciliation Advice)
This is the detail of what has gone into your bank account and is the most accurate source of truth about what you've been paid when. The only issue is ERA doesn't report at the line item of an invoice, only at the total for a transaction.
There is still a reference to the account number and splits hospital and medical. Eclipse transactions where the account number is prefaced with an MC mean it's a Medical Claim. Eclipse transactions where the account number is prefaced with nothing mean it's a Hospital Claim.
The amount columns in the ERA report provide the total amount paid for all accounts in that EFT transaction as well as the individual account amount.
Eclipse is the source of truth as it should match your bank account. It should automatically tally to the Processing Report data (the Actual Benefit Paid) field in MOST cases but not always (see above) so where there is no Actual Benefit Paid BUT the ERA report says you have been paid, you have been paid and you can set the Actual Benefit Paid manually and balance the Account.
Welcome users to the wonderful world of Eclipse. We can only work with what we've got - don't forget we are integrating to claims processing systems that were written when computer servers covered a football field.
Once all that is sorted, it should definitely be a time-saving and cash flow improvement on paper-based claims.
Health fund Eclipse contact details are available via the DHS website at:
https://www.humanservices.gov.au/health-professionals/enablers/health-fund-functionality-and-contact-details
We also have some nice people in the funds who answer our tech support emails about Eclipse for whom we can provide contact details on request.
Hospital Casemix Protocol (HCP)
The HCP dataset is a report that you run from the Reports tab. It is an artefact from when the funds couldn't get enough information about why they were paying the claim (what condition was the health fund member suffering from e.g.) from the paper invoice. Hence a routine extract 6 weeks after end of month and eSubmit to funds.
With the advent of Inpatient Hospital Claims (IHC) where you send all this data anyway, HCP wasn't done away with, either because bureaucratically nobody thought to point out all the data was already received already or it's processed into another system and you have to keep sending it anyway.
Whichever was the case, HCP is basically identical to the IHC dataset sent in batch.
If you have admitted the patient, discharged the patient, coded the patient, claimed for the patient then you shouldn't have to do any data edits to the HCP just run report for the date range for each fund group, download and submit.
Rules for extracting:
Each fund / fund group requires its own extract.
The health fund names for HCP submission vary slightly from what is on the IHC. For example Defence Health is DEF on IHC but for historical reasons you need to use Army Health Benefits (AHB) on the HCP submission for that fund (historical system compatibility reasons). EpiSoft will help you set these up - please let us know when you need this done by.
Submit no later than 6 weeks after end of month. For the month of June for example, extract and submit no later than mid August.
In scope are all inpatient episodes discharged and claimed for (not necessarily fully paid / reconciled) by the end of that calendar month. The HCP report extract will set the scope.
The submission process is set with the funds and EpiSoft is not involved - there is no electronic submit available so it's computer disk or email
PHDB
The Private Hospitals Data Bureau was set up as a de-identified HCP data collection. It is all admitted patients in a date range regardless of fund. It runs from the same Report option but set the radio button to PHDB rather than HCP.
Inpatient Statistical Collections (state by state)
Almost the same dataset as HCP and PHBD but formatted differently and sent to the States by all licensed hospitals.
Have you been given a Minor Customer ID for your site by EpiSoft? If not, please request this from us as a first step. In some cases, you may only require one for the various practice locations you work out of, in other cases, you will require a minor customer ID per site.
Processing paperwork / applications can take up to 2 weeks for Medicare so please allow plenty of time to avoid issues with cash flow.
Have you applied for a PKI (public key infrastructure) certificate quoting this Minor Customer ID?
Have you received the PKI certificate on a CD and provided it to EpiSoft? Please send to Suite 216, 20 Dale Street Brookvale NSW 2100 along with password for installation which should be provided on some paperwork with the Disk, ideally via registered post.
New Doctor or Allied Health Provider with Medicare prov number
Has Medicare and the funds got the bank account details of the Doctor?
Has Medicare and the funds linked the Provider Number to the minor customer ID?
Medicare and health fund setup for billing - existing site with current PKI certificate issued by another software vendor, have you:
Contacted Medicare eBusiness to get the form required to convert this Certificate from current software customer ID to one issued by EpiSoft? Please ensure that the date for change over is clearly understood by Medicare to avoid issues with your current billing vendor being switched off too soon.
You may need to have your PKI certificate reissued and this is the likely form but please check first with Medicare that this is the latest:
https://www.humanservices.gov.au/health-professionals/forms/hw003
Once received please send together with paperwork including password to Suite 216, 20 Dale Street Brookvale NSW 2100 (or we can set up a Google Drive for you to share if easier) along with password for installation which should be provided on some paperwork with the Disk, ideally via registered post otherwise express post and notify us that is has been sent. We can return it to your practice after successfully installed on the EpiSoft servers or keep it securely stored on our premises.
Have you filled in all the Bank Details forms for the various providers (medical practitioners and hospital if applicable) to ensure Medicare can pay you directly? If a new Doctor or provider who will be billing Medicare starts at your practice, please ensure that you contact Medicare eBusiness citing your EpiSoft Minor Customer ID so that Medicare can link this new provider to the Customer ID you have been issued.
Medicare eBusiness contact details 1800 700 199
ECLIPSE sites (Medical services for hospital inpatients)
Have you contacted all the Health Funds separately to notify which providers will be transacting through Eclipse? For Alliance group of funds, you only need to contact the Alliance for Medical.
Have you obtained Payee IDs for each provider from BUPA? Bupa does not use the provider number but rather their allocated Payee ID to identify providers for Eclipse.
Are all your contracts setup correctly with No Gaps and/or scheme?
Medibank Private - tick Scheme on the contract
There are a few others which require Scheme ticked on the contract but it might vary based on whether the hospital is billing for the Dr or the Dr is getting payment direct into their bank account. Please ask the fund which category your facility falls into before you start submitting claims.
ECLIPSE sites (Hospital services for hospital inpatients)
1. Have you contacted Medicare eBusiness contact details 1800 700 199 and advised that you are about to Go Live with Inpatient Hospital Claims citing your minor Customer ID and Hospital Provider Number? If this is not done, there will be a problem on the Medicare Eclipse gateway and you will not receive an error message. The claim will look like it has been submitted but will not get paid. Please ensure Medicare eBusiness is also aware that you will be transacting DVA hospital claims through the DVA channel too.
2. Have you contacted all of the health funds (INDIVIDUALLY) to notify them your hospital will now be sending Inpatient Hospital Claims (IHCs)?
When you contact them, please ask if you have to notify them again just before Go Live (via email), as some funds do a partial setup of your hospital in their system as an Eclipse hospital and then require a separate email confirmation just before Go Live.
IMPORTANT: If you are commencing Eclipse WITHOUT HOSPITAL CONTRACTS in place, this is known as the 2nd Tier Default Benefit arrangement and it has some special issues; Sites doing 2nd tier default claims: please confirm with the funds whether they
1) accept IHC claims or if you have to submit manually
2) assuming yes to 1 above, will they send an electronic reconciliation (statement of benefit).
3) assuming yes to 1 and 2 above, will they PAY into your bank account or send you a cheque.
You can then make the call based on the answers to the above whether it is worth doing IHC during a 2nd tier period or just submit everything manually till you have the contracts in place rather than straddling multiple payment and submission arrangements none of which are standardised.
Manual submission of IHC if required
1) raise a payor invoice just for the hospital service items
2) send and submit with the HC21 form
3) keep account in status of proforma till paid (we don't have a separate tracking status for manual submission)
3. Australian Unity and a couple of other health funds require you to undergo a parallel run where you need to submit paper claims as well as electronic until they are satisfied the electronic is reflecting the data. If they mention a parallel run, this is what they mean.
4. Please confirm your contract setup for facility (accommodation) fees. Do the funds expect a single value benefit (aka Case Payment) service or is it a Per Diem?
5. Please ensure your charges are correct for Bupa and CBHS. Some funds pay based on the contract regardless of the provider charge, Bupa rejects the claim if the provider charge doesn't match the contract and CBHS pays what you invoice, not what's on the contract (so you may be underpaid).
5. Will you have additional charges on top of facility (accommodation) that you need to itemise? Examples, high cost drugs not on PBS but covered by fund; prosthetic items. Make sure your codes for prosthetic items are setup correctly.
7. Will you be sending through pharmaceuticals on any of these claims ? These are treated differently by some funds who require paper invoices for claims involving pharmaceuticals. Medibank Private will not e-process claims including high cost drugs electronically. These have to be submitted on paper.
8. Have you ensured the port flush and other miscellaneous service transactions are configured exactly as required by the funds? Bupa in particular requires a certain format for their port flush claims or they will not process automatically but rather go to an assessor. Let us know if you want us to double check your setup of these items for BUPA.
9. If you get any claims that either come back as "Not accepted through this channel" message, this is sure-fire signal that something is not set up correctly, all claims to that fund will be blocked and EpiSoft has to help you look into the cause of the blockage
10. If you have not been paid by your major payors in 10-14 days of IHC claim submission, there could be problems on the Medicare gateway which is equivalent to 9) above without the error message
9. Grand United Health Fund (one of the Alliance group of funds) cannot do IHC. This may come back as a valid "Not accepted through this channel" message because they're unable to receive electronic claims.
Admission and Inpatient Billing Process flow checklist
1) Ideally inpatients should be Preadmitted before day of treatment and the Admission Form filled out as far as possible - how do you do this? Go to Tomorrow on Appointment List, where patient = I (inpatient) set status to Preadmitted. A P will then appear on right hand side of appointment list. Click that to fill in as much data as possible prior to admission. This includes a provisional ICD10AM code principal diagnosis and a provisional procedure code.
1) Prior to patient attending hospital, contact the fund to check patient's eligibility with the fund. Are they financial? This is known as the eligibility check. We don't have this electronically enabled in EpiSoft at the moment so it requires login to a fund website or a telephone call to fund. The fund will tell you: if the patient is not financial at all (in which case they will be a self-pay account or 2) if the patient is eligible but has an excess or co-pay, click the $ sign next to the P column to 1) create account ahead of admission and 2) record record excess or co-pay in the entitlements section. An excess means the patient pays it once annually and then that is it. If it's higher than the provider charge, you will have to amortise it over multiple visits. It cannot be higher than the accommodation service provider charge or the account will end being negative and unable to reconcile. If first treatment = $250 and patient excess per annum is $500, take payment for the excess of $250 (NOT $500) and make note to charge $250 next time too. Recommend use Private Notes module for this. Co-pay is per visit. There are other complications around health fund products such as exclusions for certain conditions but these exclusion tables rarely apply to cancer patients in our experience. All this means you now have the admission paperwork partly done and the account partly created prior to day of admission.
2). On day of treatment patient arrives. Clerical staff click booking status of "Admit". The P on the right hand side will change to A. Open the Admission Form and complete remaining data.
3) Print the HC21 form from Billing Documents tab. What is this? HC21 aka Hospital Claim 21 form is an "Assignment of Benefits" form between you (hospital) and patient (health fund member) authorising you (hospital) to claim for hospital benefits on patient's behalf. This is normally sent as the paper claim. You do not have to send it to the fund if you are doing Inpatient Eclipse (IHC) but you still must keep it on file - signed by the patient for audit. There is a page 1 and page 2. The page 1 should be signed by the patient prior to admission. Although it looks as though there is further information that needs to be signed by the patient on discharge such as their mode of discharge (going home, going to another hospital etc) patient signature on discharge is not done by any hospital. Patient signature on admission is adequate.
4) Make sure the patient has signed HC21 on admission and you have printed/kept a copy on file.
5) Nursing staff, tick Attended on Appointment (or if more than one treatment, attend multiple appointments) and complete clinical data record.
6) Complete the discharge details Visit Form which records mandatory fields of discharge time and mode of discharge.
7) Admission Coding (could be done by clinical coder or other person) - complete the Admission Coding form which records the principal Diagnosis, principal procedure, additional Dx , Prx and any cancer morphologies. NB Health funds do not receive cancer morphologies; these are for state-based statistical collections only. For QLD sites, the sequencing of Dx relative to morphologies is important. Fill in the DRG and version and click coding complete, ready to invoice.
8) On billing tab, if the above step 7 is not done, then the account will be in status "Awaiting Coding". Clerical staff can still add the services provided, both medical and hospital and generate the certificate. Check the entitlements section is finalise (excess and copay recorded if applicable). However they can't submit the claim till the coding is complete / ready to invoice.
9) We recommend you generate 2 x separate invoices for medical and other. That way if you need to send a paper invoice to the health fund, you have the right content. To do this, check the service items you want to invoice before you hit Generate Invoice. Once done, do same for remaining service items. The invoice selection is then available as a dropdown list.
10) Accommodation & medical is the item selected at the top if there are both. EpiSoft will split the medical and accom CLAIMS separately even if these are on one account. If you accidentally add the medical and hospital to the same invoice, don't worry as we will still split the claims.
2) Patient paying in full for this service = NO.
3) Certificate - generate a Same-Day Certificate on the Account / billing tab page if there is any hospital / accom service. While some same-day procedures do NOT required a supporting certificate, the rules are so complicated about which ones don't, just generate a certificate for all accounts with an accommodation/facility fee to be on the safe side. The electronic certificate attaches to the electronic IHC.
3) Don't forget for any sites where medical Eclipse billing only (e.g. sites the Doctor works out of that are not the primary site) these should be flagged as medical only - these should NOT have an accommodation service item and they should NOT have a same-day certificate.
Reconciliation process
In the same way as medical Eclipse, EpiSoft receives 2 reports upon which we attempt to reconcile an IHC claim and mostly can do so but not always:
1 = the processing report which is akin to a statement of benefit or INTENT to pay. The INTENT word is important as it means the date of this report hence date of Actual Benefit Paid may not always align with $ in the bank account. The amount on this report gets imported by EpiSoft into the Actual Benefit Paid field on the line item on the account. If a medical or hospital component rejects or is unpaid, EpiSoft will not set the claim paid status until an amount is provided against both hospital and medical. If the hospital amount returned is less than the Provider Charge or even is a $0, this means the status will be set to claim paid (as both hospital and medical have been paid) but the account may still have an outstanding amount. This is because the status of claim paid is set on receipt of a "successful" processing report which the funds may report even if they then set an actual benefit paid of $0 against the item.
There are sometimes issues with reconciling this processing report. For example, BUPA sends the actual benefit paid on the service as the amount less co-pay whereas if there is an excess they have a different rule about what they send in what field. Hence claims with co-pay automatically pay off neatly in EpiSoft, claims with excesses don't.
HCF sometimes sends us service item level benefits and sometimes just a total. The rules about when service level amounts are sent remain unclear so automatically setting the actual benefit paid on HCF claims is still a work in progress.
DVA acommodation claims don't go through Eclipse but an older bulk bill channel so the DVA contract MUST have the bulk bill flag ticked ; make sure the accommodation codes are as per DVA expects - these are DVA codes, not MBS item numbers and the claim will reject if the service code is not known.
Medibank Private will still pay an unrecognised service code but won't send a Processing Report if they can't match the service code hence reconciliation ends up being manual. If there is a code mismatch, the fund will still pay the claim but will not send an electronic processing report. Hence the ERA report will have an amount paid against this account but the Actual Benefit Paid will be empty. Set the Actual Benefit Paid manually in this case.
The ERA report (Electronic Reconciliation Advice)
This is the detail of what has gone into your bank account and is the most accurate source of truth about what you've been paid when. The only issue is ERA doesn't report at the line item of an invoice, only at the total for a transaction.
There is still a reference to the account number and splits hospital and medical. Eclipse transactions where the account number is prefaced with an MC mean it's a Medical Claim. Eclipse transactions where the account number is prefaced with nothing mean it's a Hospital Claim.
The amount columns in the ERA report provide the total amount paid for all accounts in that EFT transaction as well as the individual account amount.
Eclipse is the source of truth as it should match your bank account. It should automatically tally to the Processing Report data (the Actual Benefit Paid) field in MOST cases but not always (see above) so where there is no Actual Benefit Paid BUT the ERA report says you have been paid, you have been paid and you can set the Actual Benefit Paid manually and balance the Account.
Welcome users to the wonderful world of Eclipse. We can only work with what we've got - don't forget we are integrating to claims processing systems that were written when computer servers covered a football field.
Once all that is sorted, it should definitely be a time-saving and cash flow improvement on paper-based claims.
Health fund Eclipse contact details are available via the DHS website at:
https://www.humanservices.gov.au/health-professionals/enablers/health-fund-functionality-and-contact-details
We also have some nice people in the funds who answer our tech support emails about Eclipse for whom we can provide contact details on request.
Hospital Casemix Protocol (HCP)
The HCP dataset is a report that you run from the Reports tab. It is an artefact from when the funds couldn't get enough information about why they were paying the claim (what condition was the health fund member suffering from e.g.) from the paper invoice. Hence a routine extract 6 weeks after end of month and eSubmit to funds.
With the advent of Inpatient Hospital Claims (IHC) where you send all this data anyway, HCP wasn't done away with, either because bureaucratically nobody thought to point out all the data was already received already or it's processed into another system and you have to keep sending it anyway.
Whichever was the case, HCP is basically identical to the IHC dataset sent in batch.
If you have admitted the patient, discharged the patient, coded the patient, claimed for the patient then you shouldn't have to do any data edits to the HCP just run report for the date range for each fund group, download and submit.
Rules for extracting:
Each fund / fund group requires its own extract.
The health fund names for HCP submission vary slightly from what is on the IHC. For example Defence Health is DEF on IHC but for historical reasons you need to use Army Health Benefits (AHB) on the HCP submission for that fund (historical system compatibility reasons). EpiSoft will help you set these up - please let us know when you need this done by.
Submit no later than 6 weeks after end of month. For the month of June for example, extract and submit no later than mid August.
In scope are all inpatient episodes discharged and claimed for (not necessarily fully paid / reconciled) by the end of that calendar month. The HCP report extract will set the scope.
The submission process is set with the funds and EpiSoft is not involved - there is no electronic submit available so it's computer disk or email
PHDB
The Private Hospitals Data Bureau was set up as a de-identified HCP data collection. It is all admitted patients in a date range regardless of fund. It runs from the same Report option but set the radio button to PHDB rather than HCP.
Inpatient Statistical Collections (state by state)
Almost the same dataset as HCP and PHBD but formatted differently and sent to the States by all licensed hospitals.
