st.lukes GAP cover Billing and Claiming Guidelines

Transcription

1 st.lukes GAP cover Billing and Claiming Guidelines Closing the gap in private health care. r health your health fund your health your health fund your health your health fund your health your health fund your health January 2008

2 INTRODUCTION BILLING AND CLAIMING GUIDELINES Who is eligible for St. Luke s Gap Cover? What waiting periods apply to St. Luke s Gap Cover? When are St. Luke s Gap Cover benefits not payable? Charging No Gap Charging a Known Gap How are claims paid through the St. Luke s Gap Cover arrangement? Payment of benefits Statement of Benefit Claim rejection procedures How to use the Batch Summary? Enquiry Support and Stationery Supplies Page APPENDICES Stationery Order Form Batch Summary (Sample) Estimate of Medical Fees (Sample)

3 Introduction St. Luke s Gap Cover is a medical gap cover arrangement that is designed to provide Medical Practitioners with the option of eliminating or reducing the medical gap for eligible St.LukesHealth members requiring hospital in-patient medical services. These Billing and Claiming Guidelines provide information to participating practitioners on the claiming process associated with St. Luke s Gap Cover. The guidelines should be read in conjunction with the Operating Guidelines contained within the St. Luke s Gap Cover Information for Medical Practitioners booklet. 1

4 Billing and claiming guidelines WHO IS ELIGIBILE FOR ST. LUKE S GAP COVER? Eligible Services An eligible service is a service: which has been rendered to an eligible St.LukesHealth member who has been admitted as a private patient to an approved hospital or day hospital facility; where informed financial consent has been obtained from the patient where a known gap has been charged and financial disclosure has been provided to the patient; where the fee charged for the service is in accordance with the No Gap or Known Gap levels provided for within St. Luke s Gap Cover; which has been submitted to the Fund prior to being submitted to Medicare. Services provided to out-patients or patients using facilities of the hospital but who are not formally admitted as a day patient or overnight patient do not qualify for St. Luke s Gap Cover benefit. Any consultations or treatments before or after hospitalisation need to be billed separately. The patient should also be advised that these services are only claimable through Medicare. Eligible St.LukesHealth members St.LukesHealth members who are covered on the following hospital products are eligible for St. Luke s Gap Cover: Product Name Hospital Platinum Hospital 100 to Hospital 1000 Limited Excess Top Private Hospital Pasplan & Status 85 Packaged Basic Packaged 300 & 500 Packaged Platinum Plus Plan Code J J1 to J5 & JT K P1 to P4 EP Z3 & Z5 ZP In addition, an eligible St.LukesHealth member means a person: 1. Who during an episode of hospital care: a) is a financial member of St.LukesHealth and holds an appropriate level of health insurance cover; b) is not subject to a Waiting Period; c) is registered for and entitled to receive Medicare rebates for the services performed; d) is a patient as defined in Section 3(1) of the Health Insurance Act 1973; and 2. Who during an episode of hospital care, received services: a) which are not eligible for compensation, damages or any other indemnification; b) which do not relate to a Pre-Existing Ailment where such services are provided within the first 12 months of commencing a membership with a registered private health insurer; c) which are not excluded from attracting a Medicare rebate, such as cosmetic surgery. Where the member s level of hospital cover carries an excess, this excess does not apply to the St. Luke s Gap Cover benefit. Confirmation of patient eligibility You should confirm with the patient whether they have private health insurance and obtain both their current Medicare number including their Medicare card reference number and their St.LukesHealth membership number. On confirmation of the above, the following six points should be checked: 1. Is the patient a St.LukesHealth member? 2. Is the service eligible for Medicare rebates? 3. Does the member hold appropriate cover? 4. Is the member up to date with payments? 5. Have waiting periods been served? 6. Are the services eligible for compensation? (Benefits are not payable where compensation or damages may be claimed from another source.) 2

5 We recommend your administration staff contact St.LukesHealth Customer Service on to confirm the patient s eligibility. WHAT WAITING PERIODS APPLY TO ST. LUKE S GAP COVER? The following Waiting Periods apply to all new members who were previously uninsured. These waiting periods may also apply when an existing member increases their level of cover or when a member transfers to St.LukesHealth from another Fund where the previous Fund did not offer an equivalent Gap Cover arrangement. A two (2) month waiting period applies to all benefits except as further specified below. A twelve (12) month waiting period applies to all obstetric related services whether or not the member was pregnant at the time of joining or changing cover. This includes miscarriage, threatened miscarriage, termination and treatment for other obstetric conditions. A twelve (12) month waiting period applies to pre-existing ailments. A pre-existing ailment is an ailment, illness or condition the signs or symptoms of which, in the opinion of a Medical Practitioner appointed by St.LukesHealth existed at any time in the period of 6 months ending on the day on which the member became insured under the policy. Waiting periods commence from the date of joining a private health insurer or from the date of changing cover. For previously uninsured members, no benefit is payable during the application of a waiting period. Members who have transferred from another registered private health insurer receive continuity of membership for benefit entitlements for which they were previously covered, provided the St.LukesHealth cover includes those equivalent benefits and the member has served the required waiting periods with their previous insurer. Where the St.LukesHealth cover or benefit is higher than that of the previous insurer s membership entitlements, then benefits will be payable at the previous (lower) level of benefits during the application of a waiting period. When a waiting period is applied to a member changing their level of cover, benefits will be paid at either the previous level of cover or the new level of cover, whichever is the lesser. WHEN ARE ST. LUKE S GAP COVER BENEFITS NOT PAYABLE? St. Luke s Gap Cover benefit will not be paid: if the member was charged a known gap and informed financial consent was not obtained from the patient or if financial disclosure was not given to the patient. if the fee charged is in excess of the known gap limits applicable to St. Luke s Gap Cover. if the service was not an eligible service as described on page 2. if the member was not an eligible member as described on page 2. where the Medicare rebate is not payable, or where Medicare has rejected the claim. if the claim was lodged more than two years after the date of service. if the member has received their Medicare rebate prior to the account being submitted to St.LukesHealth. Note: Where St.LukesHealth does not pay a St. Luke s Gap Cover benefit, the maximum payable is the difference (25% medical gap) between the Medicare rebate and the Commonwealth Medicare Benefits Schedule Fee. In these circumstances you may wish to come to an arrangement with the member. 3

6 Billing and claiming guidelines (cont d) CHARGING NO GAP If you wish your patient to be fully covered for the service you are providing, your fee should not exceed the level shown in the St. Luke s Gap Cover Schedule of Fees. Where your fee is equal to or less than the St. Luke s Gap Cover Schedule Fee, an eligible member will be fully covered under St. Luke s Gap Cover providing all other eligibility requirements have been met. In all aspects, St.LukesHealth benefit assessment will be based on Medicare assessment rules. Billing Multiple Procedures with No Gap In arriving at the charge for a multiple procedure under St. Luke s Gap Cover, the same multiple procedure rule or formula is to be used as contained in the Commonwealth Medicare Benefits Schedule. In all cases, the MBS fee level should be used to determine the order in which the multiple procedure is to be calculated. Once the order is determined, the appropriate percentages should be applied to the St. Luke s Gap Cover Schedule Fee for each item. Example of a multiple procedure Procedure 1 Procedure 2 Procedure 3 MBS item MBS Fee St. Luke s Fee 100% Fee 50% Fee 25% Fee $500 $600 $600 $400 $650 $325 $300 $500 $125 The total no gap fee for this multiple procedure is $1050 In the above example the 100% fee was applied to Procedure 1 even though the St. Luke s Gap Cover Schedule Fee for Procedure 2 was higher. This is because the MBS Fee for Procedure 1 was higher than for Procedure 2. Under Medicare assessing rules, the MBS Fee is used to determine the order in which the multiple procedure is to be calculated. Billing Multiple Anaesthetics with No Gap Where a multiple anaesthesia is provided the Medicare rules under the Relative Value Guide for Anaesthesia apply. That is, the RVG item with the highest basic unit value should be charged. However, the time component should include the total anaesthesia time taken for all services. Derived Fees When calculating a derived fee through the gap cover scheme, the MBS Schedule Fee should first be calculated using the formula stated in the Medicare Benefits Schedule for the relevant item. The derived MBS schedule fee should then be multiplied by the percentage shown in the St. Luke s Gap Cover Schedule of Fees. CHARGING A KNOWN GAP If you elect to charge your patients a known gap, you need to obtain written informed financial consent from the patient prior to treatment, or in the case of an emergency, as soon after treatment as practical. If you charge a known gap to eligible St.LukesHealth members, St. Luke s Gap Cover benefit will only apply if the known gap for each service is within 10% of the St. Luke s Gap Cover Schedule of Fees. Billing Multiple Procedures with a Known Gap The rules to apply when billing a multiple procedure or multiple anaesthetic with a known gap are the same as shown on page 4. For example: Procedure 1 Procedure 2 Procedure 3 MBS item MBS Fee St. Luke s Fee Max. Known Gap Fee 100% Fee 50% Fee 25% Fee $500 $600 $660 $660 $400 $650 $715 $ $300 $500 $550 $ The total known gap fee for this multiple procedure is $1155 4

7 HOW ARE CLAIMS PAID THROUGH THE ST. LUKE S GAP COVER ARRANGEMENT? The following special claiming facilities are provided as part of the St. Luke s Gap Cover arrangement. Billing the fund direct To bill the fund directly, follow these steps: 1. Confirm that the patient is a member of St.LukesHealth. 2. Obtain the patient s St.LukesHealth membership number, Medicare Card number and Medicare Card reference number. 3. Obtain informed financial consent in writing from the patient if a patient contribution or known gap is being charged and provide financial disclosure by using the Estimate of Medical Fees form or similar. A sample of an appropriate Estimate of Medical Fees form is included in the Appendices. 4. Ensure your fee charged is within the allowable limits of St. Luke s Gap Cover. 5. Ensure the following details are provided on your account: Patient s name, address and date of birth. Patient s Account Reference. Medicare card number, including the patient s Medicare card reference number. St.LukesHealth membership number. Name and provider number of the hospital where the service was performed. All service details ie. Date of service, MBS item number, special exemptions, etc. Whether the claim was eligible for compensation. Fees charged for each MBS item, including any patient contribution. (Do not use a notional fee). Note: The St.LukesHealth membership number, the hospital detail, Medicare Card number and patient Medicare Care reference number can be included on the Batch Summary if this information is not provided on your account. 6. Forward all accounts for eligible services to St.LukesHealth as they are raised individually or in batches. 7. Complete, and attach, a Batch Summary to each batch of accounts submitted. If only one account is to be submitted, a Batch Summary still needs to be completed. A sample of the Batch Summary is included in the Appendices. Online claiming using ECLIPSE As an alternative to issuing paper based accounts, you can also claim electronically through your practice management software by using the ECLIPSE functionality. ECLIPSE stands for Electronic Claim Lodgement and Information Processing Service Environment. You may already use online claiming to lodge claims directly to Medicare. ECLIPSE is an extension of Medicare Australia s online claiming system that incorporates direct communication and claiming for providers with Medicare and private health insurers, all in the one transaction. If you wish to connect to ECLIPSE you should contact your software vendor to ask whether they currently offer ECLIPSE functionality. You can obtain more information about ECLIPSE from the following sources: call Medicare Australia s ebusiness Service Centre on co.eclipse@medicareaustralia.gov.au Referral details. Hospital Collection Point (HCP) code (if the account includes pathology services). Location Specific Practice Number (LSPN) (if the account includes radiology services) Any other information relevant to assessment of the service. Australian Business Number (ABN) 5

8 Billing and claiming guidelines (cont d) Claims processing When a batch of accounts is received, St.LukesHealth will confirm the member s eligibility for the Gap Cover benefit, including whether the requirements for Informed Financial Consent and Financial Disclosure have been met. St.LukesHealth will then validate the account data and forward it electronically to Medicare for processing. Medicare will process the accounts and pay the Medicare rebate to St.LukesHealth. If claims are processed electronically through ECLIPSE, the claim will go to Medicare first and then to the Fund by way of an automated service. St.LukesHealth will raise a payment for the Provider that covers the Medicare rebate, the 25% medical gap and the additional St. Luke s Gap Cover benefit. You will receive a Statement of Benefit listing payments and rejections. This statement will be mailed to you at the time of payment. Any St.LukesHealth/Medicare rejection will (depending on the reason for the rejection) need to be either resubmitted to St.LukesHealth for processing or sent to the patient for payment. Late lodgement of a claim Subsection 20B(2)(b) of the Health Insurance Act 1973 provides that a claim for assigned Medicare benefits must be lodged with Medicare Australia within 2 years of the date of a professional service. As a claimant, you may make an application to extend the 2 year time limit for lodging a claim for an assigned Medicare benefit. Claims submitted over 2 years from the date of service are not eligible for St.LukesHealth benefit even if late lodgement approval has been obtained from Medicare Australia. PAYMENT OF BENEFITS Payments will be made by Electronic Funds Transfer (EFT) direct to your nominated bank account usually within 21 calendar days of receipt of your patient s claim, providing Medicare payment has been received by the insurer. You will need to supply St.LukesHealth with your banking details on the EFT Payment Form included in the Appendices. If bank account details are not provided payment will be made by cheque. St.LukesHealth will forward payment for each account as soon as assessment is complete regardless of the processing status of the other accounts submitted within the same batch. STATEMENT OF BENEFIT A Statement of Benefit will be posted to you at the time payment is made by EFT (in the case of cheque payment, the statement will accompany the cheque). Please allow approximately 3 working days for receipt of the statement after payment by EFT. The Statement of Benefit will detail payments and rejections together with assessment/rejection explanations. St.LukesHealth will pay accounts (and forward payment for each account) as soon as assessment is complete regardless of the processing status of other accounts submitted by you in a particular batch. A Statement of Benefit may contain payment details relating to accounts from more than one batch. A Statement of Benefit will also be sent to the member detailing the benefit payment. 6

9 CLAIM REJECTION PROCEDURES As mentioned previously the Statement of Benefit will contain assessment/rejection explanations. These can relate to either Medicare and/or St.LukesHealth assessment. Medicare Assessment/ Rejection Explanation Codes Medicare assessment/rejection codes will appear on the St.LukesHealth Statement of Benefit. A full list of the Medicare assessment/rejection codes can be found on the Medicare Australia web site at reason-codes/medicare.shtml St.LukesHealth Assessment/ Rejection Letter If an account cannot be processed by St.LukesHealth the account will be returned to you along with a letter of explanation. The following list provides examples of reasons which may result in an account being returned: Membership is unfinancial No cover held with St.LukesHealth Not a private in-patient when the service was rendered Waiting Periods not served Insufficient detail supplied on account Claim previously paid Claim is over 2 years old and is therefore not eligible for insurer benefit Depending on the reason for rejection you may need to: Amend the account as necessary and resubmit with your next batch. Check account details in accordance with the rejection message. If correct and if Medicare and St.LukesHealth benefits are not payable, bill your patient direct. Please remember to mark your account The amount on this account is NOT claimable through Medicare or St.LukesHealth. If St.LukesHealth benefits are not payable, please bill the member direct in your normal manner. Remember to mark the account The amount on this account is claimable through Medicare only. If you have a query about an adjusted benefit please contact St.LukesHealth. If the adjustment is correct, nothing further will be payable for this service. If you require any assistance please contact St.LukesHealth. Detail on enquiry support is provided on page 8 of this document. HOW TO USE THE BATCH SUMMARY A Batch Summary must accompany any patient accounts sent direct to the insurer for processing through the St. Luke s Gap Cover scheme. A sample of the Batch summary is included in the Appendices. Why is the Batch Summary required? It will summarise the number of accounts submitted for reconciliation. The batch lodgment date will assist in tracking accounts prior to processing and in payment reconciliation. It includes your declaration that these services were provided to a patient of a recognized hospital and that the requirements of informed financial consent and financial disclosure have been met. 7

10 Billing and claiming guidelines (cont d) It signifies your request for the accounts to be processed under the St. Luke s Gap Cover Scheme in accordance with the operating and billing guidelines supplied by St.LukesHealth. How is the Batch Summary used? The Batch Summary is to be completed and stapled to the accounts submitted in that batch. If only one account is being submitted, a Batch Summary still needs to be completed. The following guidelines should be followed when completing the Batch Summary: SECTION 1 Provider details All fields in this section should be completed. The contact name should be the name of the person to be contacted in the event of an account enquiry. SECTION 2 Batch details Lodgment date: This is the date on which you forward the batch of accounts for processing. Account Reference / Surname: This is the account reference assigned by you to each account attached to the batch. This will assist St.LukesHealth to identify the accounts included in the batch. If you do not use an account reference, please show the patients surname in this field. St.LukesHealth Member Number: This is the patient s insurer membership number. Card Reference: This is the patient s reference number shown on the Medicare card. It is used by Medicare to identify which patient on the Medicare card received the treatment. Hospital Name: This is the name of the hospital where the service took place. SECTION 3 - Comments Comments: The comment section is supplied to enable you to add or supply any supporting information you feel is necessary regarding the batch of accounts. ENQUIRY SUPPORT For all enquiries please call When making an enquiry please request one of the following services: Member eligibility check: We will require you to identify your practice and we will also request the patient s name and date of birth. Claim enquiry: We will require you to identify your practice and we will also request the patient s name and date of birth. Details of the patient account may also be requested. St. Luke s Gap Cover arrangement enquiry: You will be transferred to the appropriate person dependent on the nature of your enquiry. STATIONERY SUPPLIES Supplies of the following can be obtained from St.LukesHealth. Batch Summary forms Stationery Order forms Estimate of Medical Fees pro forma Envelopes St. Luke s Gap Cover Brochures St.LukesHealth Product Brochures St. Luke s Gap Cover Posters Simply complete the stationery order form (a copy is included in the Appendices) and forward it to St.LukesHealth in one of the following ways: Fax: (03) Post: PO Box 915, Launceston, TAS, or Send your order by @stlukes.com.au The St.LukesHealth member number, Medicare number, Medicare card reference and Hospital name only need to be completed if this information is not shown on the individual patient accounts. 8

11 Stationery order form Provider details for delivery purposes Provider Name Address Date / / Contact Name Postcode Contact Telephone Number Stationery order ITEM NUMBER REQUIRED Batch Summary Forms Stationery Order Forms Envelopes St. Luke s Gap Cover Brochures St.LukesHealth Product Brochures St. Luke s Gap Cover Posters Estimate of Medical Fees Pro Forma Electronic copy Paper copy If electronic copy requested, please supply address below. Any special delivery instructions Please return this form to St.LukesHealth, PO Box 915, Launceston, Tasmania, 7250 or fax to (03)

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13 Batch summary SECTION 1 Provider Details Provider Name Practice Address Provider Number Contact Name Phone No. Fax No. SECTION 2 Batch Details Lodgment Date / / Batch $ Total Account Ref / Surname SECTION 3 Comments: Declaration: 1. Have the patients included in this batch been provided with an Estimate of Medical Fees and has informed financial consent been obtained? YES NO Not Applicable as No Gap applies. 2. Have you disclosed to all patients any financial interests you have in any product or service recommended or given to the patient? YES NO N/A The Account Reference column must be completed. The other columns need to be completed if the requested information is not shown on the patient account. St.LukesHealth Member Number Medicare Number Medicare Card Ref. Hospital Name SAMPLE ONLY I declare that the services listed on the attached account(s) were provided by me or on my behalf and that the services were rendered to the patient(s) whilst admitted as a private patient of a recognised hospital. This medical practice agrees to bill St.LukesHealth directly for the services listed on the attached account(s) and for these accounts accepts the operating, billing and claiming guidelines of the St. Luke s Gap Cover scheme as advised by St.LukesHealth. Signature of authorised person Name of authorised person

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15 SAMPLE ONLY

16 Health insurer SAMPLE ONLY private health insurer

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18 abn w stlukes.com.au e @stlukes.com.au Head Office 17 The Quadrant Mall Launceston 7250 t f Branch Offices 50a Murray Street Hobart 7000 t f Rooke Street Devonport 7310 t f Cattley Street Burnie 7320 t f Smith Street Smithton 7330 t f Orr Street Queenstown 7467 t f Emu Bay Road Deloraine 7304 t f A Registered Health Benefits Organisation 5132