Patient Eligibility Check

Transcription

1 Patient Eligibility Check

2 Contents 1 INTRODUCTION SYSTEM ACCESS Registration Access Availability Logon Log Off RULES AND REQUIREMENTS Patient Authorisation Submission Multiple Eligibility Checks for the Same Patient Patient Information Checking Disclaimer EPISODE REQUEST INFORMATION Patient Information Fund Fund Membership Number Patient Identifier Patient Information Hospital Information Facility Identifier Admission Date Emergency Admission Indicator Same Day Indicator Estimated Length of Stay Hospital Admission Number Presenting Illness Accident Indicator Compensation Claim Indicator Pre-Existing Conditions RETRIEVING FUND RESPONSES Response availability Search Status Fund Status FUND ELIGIBILITY RESPONSE INFORMATION The overall response

3 6.2 Level of Cover Table Name Table Description Table Scale Details applicable to admission Financial Indicator Potential PEA Indicator Co-payment Amount, Description & Days Remaining Excess Amount, Description and Excess Bonus Exclusions Benefit Limitations - this section MUST be read carefully Print Responses PRESENTING ILLNESS KEY CONTACTS Processing error messages Processing Messages

4 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 (Net release 2) and Medicare Australia s Eclipse server adaptor. The web application has been designed to work with Internet Explorer ie 6 or later. Screen resolution may adversely effect the screen display. We recommend a 1024 x 768 or higher for the best results. The system can be accessed on (please note there is NO www). 5

5 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. 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 STEP 2 STEP 3 Logon to Select your facility Id (provider number) Input the password issued by BUPA Australia. 6

6 Click New ECF Request to commence input Useful Help down loads Click Logout to exit the system STEP 4 STEP 5 You are now logged onto the BUPA Australia Patient Eligibility Home Page Click on ECF Web Request to commence sending Patient Eligibility Requests. 2.5 Log Off Please note: You will be automatically logged off the web site after 20 minutes of inactivity. 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. 7

7 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 hour 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. 8

8 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. 9

9 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 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 HBA Mutal Community MBF SGIC (BUP) (HBA) (MCL) (MBF) (SGI) 10

10 SGIO NRMA Health Cover Direct ANZ Health (SGI) (SGI) (HCD) (ANZ) 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 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 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. 11

11 Determines Waiting Periods & product information Determines excess, copayment/ product information May override waiting period rules Hospital provider number Patient identifier as known by the hospital Determines whether admission is covered by the health product Used to advise that the treatment may be classed as a Pre-Existing Conditions 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 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 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. 12

12 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 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 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 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 (320) or Unknown or Other surgery (399) 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 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. 13

13 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 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. 14

14 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. To search for a response. To sort the screen in a different order. Click any underlined column heading. 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. 15

15 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. 16

16 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 17

17 A response code of; Eligibility Response Code A Accepted What it means The patient is eligible to claim for the presenting illness specified as at the admission date. What you need to do Check the product description for what is payable. W Warning R Rejected 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. The patient is not eligible to claim for the presenting illness specified as at the admission date. Check the response as conditions apply ie the member may not be financial, benefit limitations may apply or the presenting illness could possibly be preexisting. 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. 18

18 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 Table Description Detailed description of the table that the patient is covered by for the admission Table Scale The membership type ie Family, Family Plus, Single, Couple, Sole Parent, or sole Parent Plus etc. 6.3 Details applicable to admission Financial status as at admission date This indicates the eligibility check could result in a different response if the condition is deemed PEA 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. 19

19 Note: It is recommended that you advise the patient in ALL circumstances that the payment of the claim will be subject to financial status 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 preexisting) 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 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 copayment amount that will be payable. The estimated length of stay submitted in the request is NOT used to perform any copayment calculations 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 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 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 320 (medical admission) or 399 (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. 20

20 If an excess amount (= or > 0) is displayed this is the excess amount payable. Use all three co-payment fields to determine co-payment amount payable. Restricted benefits (generally basic benefits) will apply for anything shown here No benefits are payable for anything shown here 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. 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 spreadsheet 21

21 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 302 Assisted Reproductive services or infertility treatments 303 Pregnancy related services including Obstetrics 304 Eye - Laser Surgery / refractive 305 Eye - Cataracts 306 Eye - Glaucoma 309 Cardiac (heart and artery) 310 Psychiatric 311 Rehabilitation 313 Surgical Podiatry 314 Dialysis for chronic renal failure 315 Chemotherapy 318 Teeth/Dental 319 Palliative care 320 Medical admission 341 Joint replacement - Hip 342 Joint replacement - Knee 343 Joint replacement - Shoulder 344 Joint replacement - Other 350 Lithotripsy 370 Plastic and reconstructive surgery 375 Cosmetic 390 Sterilisation 399 Unknown or Other Surgery 22

22 8 Key Contacts Information Request or Response data Copy of user guide Copy of the error messages Obtain Registration Form Help data on eclipse.civica.com.au Help data on eclipse.civica.com.au Submit a Registration Form System Unavailable Medicare Help Desk Mon to Frid 8.30am pm After hours No support available Log On Issues

23 8.1 Processing error messages 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 1007 Account Reference Id or Hospital Admission number required 1100 Not eligible for service selected 1101 Eligible for service selected 1102 Eligible subject to conditions 1103 Resubmit for new assessment if presenting illness is shown 1104 Eligible for service selected at previous cover The facility Id supplied is; 1. Not registered at the Fund 2. Not current. The account reference or hospital admission id is missing. The Patient is not eligible to have 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 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 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 patients cover was returned in the response. 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. Check the Facility Id, if correct contact the Fund, if incorrect resubmit with corrected data. Add the account reference or hospital admission id and then resubmit. Inform the patient that they are not eligible for the service. Refer to OEC guide for assistance on what areas to check. Check the Eligibility response carefully and resubmit 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. 24

24 Code Message Reason Action Required 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 1106 Eligible for service selected at previous cover Wait period applied 1107 Not eligible for service selected Pre Existing Ailment 1108 Eligible at previous cover subject to conditions 1109 Eligible subject to approval of accident certificate 1110 Eligible subject to conditions and approval of accident certificate 1999 Contact Fund 3040 RHBO system unavailable or service problems 9663 Member Number not recognised by fund 9665 Patient not recognised on the membership their required waiting periods. 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 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 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. Fund will not guarantee payment of the service until an accident certificate has been supplied and approved. 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 RHBO system may be undergoing scheduled maintenance or experiencing service difficulties. (May be set by hub or 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 Either no patient is identified or multiple patients are identified. 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 as per the eligibility response. Try again later 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 have sent back a successful response). (Provide sufficient patient 25

25 Code Message Reason Action Required details to ensure unique match within membership Member to contact fund Possible fraud or accident claim Member to contact fund 9667 Cover is suspended or cancelled or membership issues Member Number is valid 9668 Inappropriate Cover Cover is either Ancillary or Ambulance only 9669 Patient is ceased or pending cessation 9671 Location/provider not authorised to use channel at fund Member Number is valid. Appropriate cover for membership number. Patient details matched. Location/Provider could be suspended or not registered for ECLIPSE 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. Cannot lodge a medical claim, as member is not covered for that service. Check with member. Cannot lodge a medical claim, as member is not covered for that service. Check with member. Member to contact fund. Patient may not have current student registration Provider to contact fund Member needs to register the baby at the fund. 26

26 Membership card samples Please use the logo on the card presented to determine the heath fund identifier to submit to. 27