HOW DO I PARTICIPATE IN ACCESS GAP COVER? HOW DO I CLAIM? Complete the Provider Details & Direct Credit Authority form.

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2 HOW DO I PARTICIPATE IN ACCESS GAP COVER? HOW DO I CLAIM? Complete the Provider Details & Direct Credit Authority form. (Attachments 3and 3A) Identify patient as a member of an AHSA Participating Fund (Refer to the Participating Funds Contact List) Establish patient eligibility (Refer page 9) Fax your completed form to AHSA on or post it using the Reply Paid address. If you are going to charge a co-payment you will need to provide written Informed Financial Consent to the patient. To do this simply complete the Estimate of Medical Fees form and give to the patient. (Attachment 4 Explanation on page 9) A letter of confirmation will be sent to you by AHSA. Complete AHSA Doctor Account form or equivalent (Attachment 2 Explanation on page 18) You can then start billing under Access Gap Cover. Batch your claims (Max of 20 per batch) Attach Account Summary Form (Attachment 1 Explanation on page 17) Send claims to the patient s Health Fund (Not AHSA) (Refer to the Participating Funds Contact List) Receive payment for services rendered within 21 days of billing the Fund (Including Medicare entitlement) 2

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4 CONTENTS How Do I Participate In Access Gap Cover? (step by step guide) 2 How Do I Claim? 2 Overview of Access Gap Cover 6 Who is AHSA? 6 AHSA Market Share 6 What is Access Gap Cover 6 What are the Advantages for Doctors? 6 How to Participate in Access Gap Cover 8 Overview of Claims Process 9 Step 1 Determine Private Patient Status and Fund Details 9 Step 2 Patient Eligibility 9 Eligible Services 9 Informed Financial Consent (IFC) 9 Financial Disclosure 9 Step 3 Patient Co-Payment Facility 10 Claims Submission Process 11 When the Fund Receives your Account 12 Step 4 Claims Payment 12 Membership Eligibility 13 Application to all Hospital Products 13 Application to Exclusion Products 13 Application to all Excess Products 13 Waiting Periods 13 Pre-Existing Ailment 13 Under what Circumstances are Benefits not Payable? 14 Calculating Benefit Payments 14 The Medicare Benefits Schedule Defines All Fee Arrangements 14 Access Gap Cover Schedule of Benefit for MBS items 14 Specific Billing Procedures Derived Fee Items, Multiple Operations, 15/16 Multiple Anaesthesia Services, Other Multiple Procedure Rules, Diagnostic Imaging Services, Assistance at Operations, Locums & Rounding Policy How to Use the Account Summary Form 17 Why is the Account Summary Form Required? 17 How is the Account Summary Form Used? 17 How to Use the Doctor Account Form 18 4

5 Claims and Payments Report 19 The Medical Claims Summary Report 19 Statement of Benefit for the Member 19 Claims Explanation Codes Reporting of Explanations 20 Table One Most Common HIC (Medicare) Explanation Codes ( H ) 21 HIC (Medicare) Claim Explanation/Rejection Procedures 22 Table Two Complete List of AHSA Member Fund Explanation Codes ( F ) 23 Fund Claim Explanation/Rejection Procedures 23 Other Business Guidelines 24 Will my patient relationship be affected? 24 What if I have more than one type of arrangement with AHSA? 24 Access Gap Cover Schedule Process 24 Salaried Doctors at Public Hospitals 24 Does the fund provide my name to its members? 24 Informed Financial Consent (IFC) 24 What is a valid claim? 24 Access Gap Cover Schedule Benefit 25 How will my benefits be paid? 25 Incorrect Charges 25 Who is eligible for Access Gap Cover? 25 When will my benefits be reviewed? 25 Hospital-Substitute Treatment (H-ST) 26 What if MBS items are introduced, deleted and/or changed? 26 Change of Address/Other Details 26 What if I no longer want to participate? 26 Attachments 27 Attachment 1 Access Gap Cover Account Summary Form 28 Attachment 2 Access Gap Cover Doctor Account Form 29 Attachment 3 Provider Details & Direct Credit Authority Form 30 Attachment 3A Additional Practice Locations Form 31 Attachment 4 Estimate of Medical Fees Form 32 Support for Providers 33 Now available on our website 34 Frequently Asked Questions 35 For further information please feel free to contact an AHSA office Freecall Phone Freecall Fax Website access@ahsa.com.au 979 Burke Road, Camberwell, Victoria

6 OVERVIEW OF ACCESS GAP COVER WHO IS AHSA? AHSA represents a number of Registered Private Health Funds across Australia and is responsible for facilitating payment arrangements between hospitals, doctors and health service providers on behalf of these funds. (See back cover for the list of Access Gap Cover Participating Funds.) AHSA MARKET SHARE The combined membership of AHSA Participating Funds purchase in excess of $1.2 billion worth of hospital and health care services on behalf of approximately 2.1 million Australians. WHAT IS ACCESS GAP COVER? Access Gap Cover is the AHSA Participating Fund Gap Cover arrangement. Access Gap Cover: Enables Health funds to cover the medical gap without the need for a contract with doctors. Facilitates payment of the medical gap above the schedule fee in a simple manner that benefits Patients, Doctors and Health Funds. WHAT ARE THE ADVANTAGES FOR DOCTORS? No Contract. Allows for a Known Gap (limits apply) where written informed financial consent has occurred. Schedule has been set to encourage no out of pocket costs for patients. Benefits include: One Fee Schedule per state for all participating AHSA Funds. One set of Billing and Business Guidelines. Simpler billing systems for Doctors. Doctors provide details once for all participating AHSA Funds. A comprehensive list of contact numbers, faxes & addresses for all participating AHSA Funds. Schedule will be indexed annually. Many Health Funds participate in Access Gap Cover. (See back cover). 6

7 Simplified Billing. Benefits include: Better service and a simple system for patients No bills or claiming procedures for the patient. Avoids patient confusion. Provides financial certainty. Improved cash flow for doctors 21 day turnaround. Reduces bad debts for doctors. Doctors do not have to deal with Medicare the Fund claims the Medicare benefit for the patient as well as dealing with any claiming issues. Patient management remains with the Doctor no interference in clinical practice. Participation on a patient by patient basis doctors have the ability to Opt In and Out. A detailed reference document for practice staff the Billing and Business Guidelines. Doctors may withdraw from Access Gap Cover at any time. Access Gap Cover stationery available on our website. Support from AHSA via phone for any queries or problems on our Freecall number Member Statement of Benefit. Funds provide a statement back to their member summarising the services the doctor has performed, highlighting the value of private health. Medical Claims Summary Report. This report is sent back to the doctor after a batch of claims has been paid by the Fund. Provides Direct Credit information and outlines claim approvals and rejections. Streamlines the reconciliation process for the doctor. 7

8 HOW TO PARTICIPATE IN ACCESS GAP COVER 1. Complete the Provider Details and Direct Credit Authority form (Attachment 3) before you send your first Access Gap Cover claim 2. If you have more than one practice location that you wish to register, also complete the Additional Practice Locations form (Attachment 3A) 3. Return by fax to AHSA on Your details will be sent to all our participating health funds, saving you from having to provide your details multiple times 5. AHSA will send a letter to you, confirming registration 6. You can start using Access Gap Cover after receiving this letter 7. Send claims to the individual funds, not AHSA (refer to the Participating Funds Contact List) CONTACT AHSA FOR THE FOLLOWING: Initial Access Gap Cover registration Additional Provider Numbers to be registered on Access Gap Cover Change of Billing Address, bank details and other contact details CONTACT THE RELEVANT INDIVIDUAL PARTICIPATING FUNDS FOR THE FOLLOWING: Submission of claims Claims follow up Eligibility of patients Claims and Payments Reports Important Notes: 1. AHSA acts on behalf of participating health funds and we need to advise all of these funds that when they receive a claim from your practice, the Access Gap Cover benefit levels apply. 2. As Access Gap Cover is administered by AHSA, all of its participating funds will be notified of your registration, even if you bill only some funds. 3. Unless you complete the Provider Details and Direct Credit Authority (Attachment 3) or inform us separately that you do not wish to be placed on our listing of doctors participating in the Access Gap Cover scheme, your name, practice location and/or billing contact details as well as specialty(s) will be made available on a public doctor listing, provided to GP s and/or given to health fund members over the phone. 4. AHSA collects, stores and passes on your bank details to participating funds for the purposes of allowing Access Gap Cover payments to be made to you. For more information about privacy of your personal information, go to our website to see the Privacy for Doctors section under Access Gap Cover. It can be found at the following link: 5. If you choose to send your Access Gap Cover claims to your patients rather than to their health fund, you MUST include on your account the details outlined in the section on billing the patient on page 12 of this document. Otherwise the claim may not be recognised as an Access Gap Cover claim. ACCESS GAP COVER MATERIALS ARE AVAILABLE ON OUR WEB SITE All Access Gap Cover materials are on our web site. Go to and click on DOCTORS to access the following: Gap Cover forms for claiming, i.e. the Account Summary form Participating Funds Contact List Schedule of Benefits Billing and Business Guidelines Participating Doctor Forms for new registrations and/or practice locations 8

9 OVERVIEW OF CLAIMS PROCESS A member of an Australian Health Service Alliance (AHSA) participating fund is referred to you for an illness or treatment requiring hospitalisation. STEP 1 DETERMINE PRIVATE PATIENT STATUS AND FUND DETAILS 1. Ask the patient whether they are being treated as a private patient. 2. If yes, ask the patient whether they will be using Private Health Insurance. 3. If so, obtain their Medicare number (including the 1-digit patient reference number). 4. Determine which AHSA Participating Fund the patient belongs to and obtain their membership number. STEP 2 PATIENT ELIGIBILITY To confirm patient eligibility and membership level of cover please contact the appropriate AHSA Participating Fund. AHSA acts as an agent to our Participating Private Health Insurance Funds for the purposes of the administration of gap cover arrangements with providers. The AHSA Participating Funds Contact List includes information such as the Fund name, address, telephone, fax, and contact details to enable eligibility and membership level of cover checks. For best efficiencies we suggest your office telephone the appropriate Fund to confirm the patients eligibility and table coverage. Details that require confirmation are as follows: The patient is a member of a fund that belongs to AHSA and the fund participates in Access Gap Cover. The product that the patient has purchased is eligible for medical insurance. The procedure is covered by the member s policy (ie. not an exclusion). The patient s membership is financial. Waiting periods and Benefit Limitation Periods have been served. ELIGIBLE SERVICES The following services are eligible for Access Gap Cover once eligibility has been confirmed: Services rendered to the patient during a period of hospitalisation or under an approved Hospital in the Home program. Services rendered to the patient where they fit the criteria for Hospital-Substitute Treatment (see page 26 for further explanation)*. Please note that unless services fall into this category, any consultations or treatments prior to or after hospitalisation do not form part of this process and need to be billed separately. Remember to inform the patient that these services are claimable through Medicare only. INFORMED FINANCIAL CONSENT (IFC) Written informed financial consent is required under Access Gap Cover if you are charging a gap to the patient. You can use the 'Estimate of Medical Fees' form (Attachment 4) for this purpose or you can use your own method of written IFC, providing patient and procedure details and details of any patient gaps are clearly indicated and the patient or guardian has indicated acceptance. The form or letter should be given to the patient prior to the procedure where practicable, before the time of admission to the hospital or day facility for the treatment in question, or otherwise, as soon as the circumstances reasonably permit. Although you are not required to send a copy to the Health Fund, you are required to indicate on the claim to the fund that this has been done. Please use the tick boxes as shown on the 'Account Summary Form' for this purpose. For more information, see page 24 under Other Business Guidelines. FINANCIAL DISCLOSURE Access Gap Cover also requires that you disclose any financial interests in products or services recommended or given to the patient. The services are not compensable. 9

10 Important Note: Indicate on the claim to the fund whether or not you have provided: Informed financial consent Financial disclosure As the benefits reduce according to whether the service is a multiple operation, so will the patient out-of-pocket (gap). The percentages to calculate the cap on the patient out-of-pocket (gap) will be: There are tick boxes on the Account Summary form for this purpose. STEP 3 PATIENT CO-PAYMENT FACILITY Multiple Operations First Service Second Service Third Service Service Thereafter 100% 50% 25% 25% Access Gap Cover enables you to charge your patients a co-payment if you wish to do so. If you have elected to charge a co-payment, you need to inform the patient in writing of the charge prior to treatment. This amount is to be billed direct to the patient by you. You still need to put the total charge on the account to the fund (inclusive of any patient co-payment). Remember to inform the patient that the co-payment is not claimable through any other source. The patient co-payment can be up to the difference between the AHSA benefit and the AMA fee but no more than $400 per item. If the procedure does not have an AMA Fee, a maximum up to $400 may be charged to the patient. For example: AGC Fee AMA Fee Max Gap MBS A $600 $700 $100 MBS B $800 $1,500 $400 MBS C $900 Not available $400 MBS D $300 $300 No gap to patients Obstetricians may charge a co-payment up to $800 per confinement for items that relate to Management of Labour and Delivery as defined in the Medicare Benefits Schedule. It would greatly assist Funds and your patients if you would provide details of the co-payment charged to the member on the Access Gap Cover Doctor Account Form (or by showing the total charge, including co-payment on your account) at the time of claiming the Access Gap Cover benefit. Multiple procedures and the cap on the patient out-of-pocket (gap) The cap on the gap will follow the guidelines already used by Medicare for multiple procedures. Examples of a Multiple Procedure claim under Access Gap Cover Item Number AHSA AGC Benefit Maximum AGC Patient Co-payment (Gap) Maximum Charge (shown on invoice) (100%) $1, $400 $1, (50%) $ $200 $ (25%) $87.65 $57.35 $145 Total $1, $ $2, Based on the AGC Queensland Schedule of Benefits dated 1 November In this example: If your total charge is above $2,418.65, AGC benefits would not be payable. The maximum AGC Patient Co-payment is $657.35, which means you can charge any amount to the patient up to a maximum of $ If you limit your charge to $1,761.30, your patient will not have a co-payment (gap) to pay. The co-payment amounts are required to be included in the itemised charges (as shown above). The item number, the individual charges as well as the total charge (inclusive of any patient co-payments) are required on your invoice. For multiple item procedures, the co-payments must reflect the percentage ranking of the item, as shown above (i.e. 100% of the allowable patient co-payment for the procedure with the highest MBS fee, 50% for the 2nd procedure and 25% for procedures thereafter). For any procedure or combination of procedures, if you decide to charge over and above the allowable AGC Patient Co-payment amounts, then AGC benefits will not be payable. 10

11 CLAIMS SUBMISSION PROCESS 1. Submit the claim to the appropriate FUND for payment. Refer to the AHSA Participating Funds Contact List for individual fund addresses. Do not send claims to AHSA. 1a. Complete the Access Gap Cover Account Summary Form (Attachment 1). This form acts as a batch header and should be completed each time you send a batch of claims to a fund. 1b. Complete the Access Gap Cover Doctor Account Form (Attachment 2). This form acts as a substitute account however, where your accounts include all details required on the Access Gap Cover Doctor Account Form, you can attach your accounts to the completed Access Gap Cover Account Summary Form rather than completing the Access Gap Cover Doctor Account Form. Refer to page 17 to see how to complete the Account Summary Form and page 18 for the Doctors Account Form. All Access Gap Cover forms may be downloaded from the AHSA website: Go to DOCTORS, then Forms in Access Gap Cover. 2. Please ensure that the following Fund and Medicare details are completed: Patient s name, address and date of birth. Medicare Card number as well as the Medicare 1-digit patient reference number. (SUPPLY OF MEDICARE CARD DETAILS IS VERY IMPORTANT AND WILL AVOID UNNECESSARY PAYMENT DELAYS). Fund name. Fund membership or card number. Name of the hospital where the service was performed. Name of the contracted facility where the service forms part of Hospital-Substitute Treatment. If the service forms part of Hospital- Substitute Treatment (H-ST), please write the words hospital-substitute treatment on the account (or if you use the Doctor Account Form, place a tick against the applicable services in the column called H-ST ). All service details ie. date of service, MBS item number, etc. Whether the claim was compensible. An itemized account including the total fee charged, inclusive of any patient co-payment. 3. Forward this account together with any other patient accounts to the fund in batches of up to 20 accounts either weekly or fortnightly. Note: There may only be one account to submit for a particular Fund. Please do not send more than 20 in one batch to a particular Fund. (DO NOT SEND CLAIMS TO AUSTRALIAN HEALTH SERVICE ALLIANCE). If you have chosen to opt a particular patient into the Access Gap Cover arrangement and you still wish to send the account to your patient, please ensure you are aware of the following: Important Note: If you decide to send your account directly to your patient, AHSA Participating Funds cannot guarantee payment within 21 days. Payment will be made within 21 days once the Fund receives the claim from your patient. If you are not satisfied with the payment turnaround time once you have sent your account to your patient, you cannot re-submit the account directly to the Health Fund. If your patient claims through Medicare before forwarding to the Fund, the Fund cannot pay above the standard 25% of the schedule fee. We strongly recommend you bill the Fund direct. This will improve the claim turnaround time and simplify the process for your patients. Where your patient has elected to use their private health insurance and you bill your patient directly for Hospital-Substitute Treatment, please ensure your patient is aware that they must send the claim to their private health fund and not Medicare. If your patient takes their claim to Medicare, Medicare will return the claim to them requesting that they take the account to their private health fund. 11

12 Process: 1. If you decide to send your accounts to your patients, the fund will need certain information before they are able to process the claim. We therefore ask that you ensure the following information is included on your Access Gap Cover accounts to facilitate the claims process and avoid payment delays. Health Fund TO THE PATIENT Send this form with the attached account to your private health fund DONOT SEND TO MEDICARE Membership No. Medicare No. (Including 1-digit patient reference no.) Patient Co-Payment (Optional) $ Facility where services provided 2. The Fund will raise a payment for you that covers the Medicare benefit (75% of the MBS fee) and the remainder of the charge up to the Access Gap Cover Schedule Benefit. 3. You will be notified of all approvals and rejections. This notification will be made at the time of receiving payment. As there are four unique computer systems across the participating AHSA member funds, there will be four different versions of the Medical Claims Summary Report, however, the information contained in each will be the same. This document outlines the information contained on the Medical Claims Summary Report (page 19). 4. Any Fund/Medicare explanations (depending on explanation code) need to be either re-submitted to the appropriate Fund for processing or sent to the member for payment. This document includes information regarding the list of explanation codes and handling procedures (pages 20 23). STEP 4 CLAIMS PAYMENT Payments will be made via Electronic Funds Transfer (EFT) directly into your bank account where requested by you. I have provided this patient with an Estimate of Medical Fees form I have disclosed any financial interests in the management of this patient. Yes Yes No N/A Payments will be released by the fund to you within twenty-one (21) days of receipt of the claim by the fund. This is subject to funds receiving payment from Medicare within the appropriate time frames. This information is ESSENTIAL as it: Ensures your patient has clear instructions to forward the account directly to the Fund. Will enable the Fund to identify that the claim must be paid according to Access Gap Cover. 2. Send the account to your patient. 3. Your patient should forward the account directly to their Health Fund. WHEN THE FUND RECEIVES YOUR ACCOUNT 1. Each Fund will validate this data and forward it to Medicare for processing. Medicare will process the claims and pay 75% of the MBS fee to the fund. Or for faster payments, use the ECLIPSE electronic payment system and receive your Access Gap Cover benefits within days. See inside front cover of the Access Gap Cover Schedule of Benefits for more information about ECLIPSE or visit the Medicare Australia website: business/online/eclipse/index.jsp or; Phone Medicare Australia ebusiness Service Centre or; Patients will receive a Statement of Benefit verifying that the service was performed and that a benefit payment has been made. 12

13 MEMBERSHIP ELIGIBILITY To confirm patient eligibility and membership level of cover please contact the appropriate AHSA Participating Fund (Refer to the Participating Funds Contact List). APPLICATION TO ALL HOSPITAL PRODUCTS All Funds of AHSA that have elected to participate in Access Gap Cover shall apply the arrangement to hospital table products offered by the Fund. As exclusions may apply to some Fund products (refer below) and/or some Funds have elected to restrict benefits on their public (basic) hospital table, you are encouraged to contact Funds to confirm eligibility. APPLICATION TO EXCLUSION PRODUCTS Where a Health Fund product has an exclusion clause(s), the relevant procedure may be excluded from benefits. In these circumstances you will need to determine the eligibility of the patient for benefits. APPLICATION TO ALL EXCESS PRODUCTS Where a Health Fund product includes a front-end deductible or excess, the relevant amount will not apply to the medical gap benefits that would be payable under the Access Gap Cover arrangement. WAITING PERIODS The following waiting periods apply to all new members (if they were previously uninsured). These waiting periods may also apply when a member changes their level of cover or transfers their membership from one Fund to another. A waiting period of up to 12 months exists for all obstetric related services; (dependent upon the particular Fund) and A twelve month waiting period on all Pre-Existing Ailments. PRE-EXISTING AILMENT A Pre-Existing Ailment is defined in the private Health Insurance Act 2007 Sect as: 1. A person insured under an insurance policy has a pre-existing condition if: 1a. the person has an ailment, illness or condition; and 1b. in the opinion of a medical practitioner appointed by the insurer that issued the policy, the signs or symptoms of that ailment, illness or condition existed at any time in the period of 6 months ending on the day on which the person became insured under the policy. 2. In forming an opinion for the purposes of paragraph 1b, the medical practitioner must have regard to any information in relation to the ailment, illness or condition that the medical practitioner who treated the ailment, illness or condition gives him or her. 3. If: 3a. a private health insurer replaces a complying health insurance product with another complying health insurance product; and 3b. a person who was insured under a policy that was in the replaced product is transferred by the insurer to a policy that is in the replacement; the reference in paragraph 1b to the day on which the person became insured under the policy is taken to be a reference to the day on which the person became insured under the replaced policy. Please Note: Funds will only pay a benefit if the member is financial at the time of treatment or service. Funds will only pay a benefit after the member has served all Waiting Periods. Some tables with some Funds have other restrictions such as Exclusion Tables. Some Funds will not provide a benefit for cosmetic surgery. Some Funds will not pay a benefit for surgery performed by a surgical podiatrist. The best way to be sure that your patient is eligible for benefits under Access Gap Cover is to contact the relevant Fund and check their eligibility. Refer to the Participating Funds Contact List to enable eligibility and membership level of cover checks. 13

14 UNDER WHAT CIRCUMSTANCES ARE BENEFITS NOT PAYABLE? Funds will not pay an Access Gap Cover medical benefit: If the service was not performed whilst a patient of a recognised hospital or day facility (unless the service forms part of an approved Hospital in the Home Program or a Hospital- Substitute Treatment approved by AHSA); If the membership was unfinancial at the time of treatment or service; If the claim was covered by Workers Compensation, Third Party or is compensable from elsewhere; Where waiting periods have not been served; Where the Fund product excludes benefits for specific treatments and procedures; Where a Medicare benefit is not payable or where Medicare has rejected the claim; Where the claim has not been lodged within two years of the date of service; If the Hospital-Substitute Treatment is provided outside an AHSA contractual arrangement; Where Medicare has already paid 85% of MBS for an out-of-hospital treatment that should have been claimed as a Hospital-Substitute Treatment; Where the member is not on a table eligible for medical insurance benefits, e.g. Ancillary cover only; Where no other benefits will be paid to the cost of hospitalisation; If the MBS item is an uncertified Type C procedure and therefore does not form part of Hospital Treatment. E.g. Sometimes items 13939, & fall into this category and if they do, Access Gap Cover benefits will not be payable. Hospital Treatment, specifically excluded treatment is defined in rule 5 of the Private Health Insurance (Health Insurance Business) Rules The excluded treatments outlined in rule 5 (a) are those treatments listed in clause 8 of schedule 3 of the Private Health Insurance (Complying Product) Rules, namely the Type C procedures; and Where you have billed the member directly and the member has collected their Medicare entitlement.* * NB: funds will not pay the Access Gap Cover benefit under this situation. The maximum a Fund can pay is the standard 25% of the MBS Fee. In these circumstances you may wish to come to an arrangement with the patient. For example: if the MBS fee for a given item was $100, then schedule of benefits may list a total benefit amount of $110. CALCULATING BENEFIT PAYMENTS THE MEDICARE BENEFITS SCHEDULE DEFINES ALL FEE ARRANGEMENTS As Access Gap Cover is based on the Medicare Benefits Schedule (MBS), it will apply at all times. If changes are made to the items included in the MBS during the term of the Access Gap Cover arrangement, the items will take effect in the arrangement from the date of inclusion or exclusion from the MBS. ACCESS GAP COVER SCHEDULE OF BENEFIT FOR MBS ITEMS This schedule will provide either: 1. A dollar benefit against each MBS item number covered under the agreement. This Or dollar amount will include the total of the MBS fee and the Fund benefit payment. 2. A percentage benefit amount that applies to the MBS fees of the items listed in the agreement. This percentage figure includes both the Medicare and Fund percentage benefit. For example: if the quoted benefit was 110% of the MBS fee, this is made up of the standard 75% Medicare contribution, the standard 25% Fund contribution and an additional Fund contribution of 10%. If a percentage is listed, it is up to the provider to calculate the relevant dollar benefit amount. 14

15 SPECIFIC BILLING PROCEDURES As Access Gap Cover is based on the MBS, the normal Medicare claims assessing rules prevail, prior to the determination of any benefits that the Fund will pay that exceed the MBS. The assessment of the Medicare benefit will continue to be conducted by Medicare and the Fund will rely on that assessment to determine the level of Fund benefits that are payable under Access Gap Cover. Derived Fee Items All derived fee items will be displayed as a percentage. The Access Gap Cover benefit payable (including the Medicare component) will be determined by using the appropriate MBS fee (indicated on the Medicare Statement of Benefit) multiplied by the AHSA quoted percentage. (The percentage as quoted for [Group T9 Assistance at Operations] will be applied to the MBS fee for the associated operation). For example: Where the assistant surgeon uses item apply the AHSA quoted percentage for item to the MBS fee for the applicable operation and divide by five. Multiple Operations Multiple operations will be calculated using Medicare Rules. Use the MBS fee to determine the order for Multiple Operations (do not use AHSA benefit to order your items). Benefits however will be calculated by applying the appropriate percentages to the AHSA benefit payable (including the Medicare component) ie. 100%, 50% and 25% thereafter. Multiple Anaesthesia Services Where anaesthesia is provided for services covered by multiple items in the Relative Value Guide (RVG), Medicare benefit is only payable for the RVG item with the highest basic unit value. However, the time component should include the total anaesthesia time taken for all services. Note: An overview of the Relative Value Guide (RVG) for Anaesthesia can be found in section T10 of MBS book. Multiple Anaesthesia Services (Section T10.4.4). Other Multiple Procedure Rules From time to time Medicare may introduce further multiple procedure rules ie. Multiple Vascular Ultrasound Services Site Rule DIK.6.1. Medicare rules prevail in all instances. Diagnostic Imaging Services All diagnostic imaging services will be displayed as a percentage. The AHSA benefit payable is calculated (including the Medicare component) as follows: Under normal conditions (When Rule A, B or C do not apply) multiply the AHSA quoted percentage by the MBS fee. When any combination of Rule A, B and C apply, multiply the AHSA quoted percentage by the adjusted MBS fee. Note: A comprehensive explanation of multiple procedure rules A, B and C can be found in section DIJ of the MBS book. Note: A comprehensive explanation of Multiple Operations can be found in section T8.5 of the MBS book. 15

16 Assistance at Operations Assistance at Operations Access Gap Cover arrangement (Where the surgeon is participating under the Access Gap Cover arrangement and the assistant is not). Where the assistant s services appear on the same account as the surgeons, the assistant will be paid the Access Gap Cover benefit even if they are not participating in the Access Gap Cover arrangement. Medicare should not reject the claim. The total amount will be made payable to the surgeon under his/her provider number. The allocation of the total payment is a matter to be resolved between the surgeon and the assistant. Where the assistant bills separately he/she will be required to participate in the Access Gap Cover arrangement in his/her own right to receive the Access Gap Cover benefit. Where the assistant does not wish to participate, the claim should not be processed according to Access Gap Cover. Locums Rounding Policy NO rounding is required under Access Gap Cover. The charge per MBS should be the Access Gap Cover fee. For calculations involving derived fees, multiple procedures and/or diagnostics, it may be necessary to round the TOTAL to the nearest cent. To be specific, rounding to the nearest cent will involve rounding to two decimal places. Where the third decimal value is 5 or greater: round UP to the nearest cent. Where the third decimal place is less than 5: round DOWN to the nearest cent. For example: $ will round UP to $ $ will round DOWN to $ Where a locum carries out a service for a doctor who is a registered under Access Gap Cover, and the locum uses the same practice provider number as the usual doctor the fund will pay the Access Gap Cover fees for the locum services. If the locum uses their own provider number and has not registered with Access Gap Cover, payment will be made up to MBS fee only. The latter should not be processed according to Access Gap Cover. 16

17 HOW TO USE THE ACCOUNT SUMMARY FORM An Access Gap Cover Account Summary Form (Attachment 1) must accompany all medical claims that are sent by you directly to the Health Fund. WHY IS THE ACCOUNT SUMMARY FORM REQUIRED? 1. It allows the fund to recognise the claim as an Access Gap Cover Claim. 2. It will summarise the number and amount of accounts you submit. 3. The Account Summary Form number will assist you to track and reconcile the weekly or fortnightly submission of claims. 4. It provides a comment field for your administration staff to note any general information pertaining to the accounts. 5. It also includes your declaration that these services were provided to a patient receiving hospital treatment either accommodated within a hospital or under an approved Hospital in the Home Program or the services form part of Hospital-Substitute Treatment approved by AHSA. HOW IS THE ACCOUNT SUMMARY FORM USED? The Account Summary Form is to be completed in duplicate. The original is stapled to the accounts submitted in that batch while your accounting staff retains the duplicate. All fields on the form must be completed with the exception of the comments. The majority of the fields are self-explanatory; however, the following may assist: Account Summary Number This is the date the batch of accounts leaves the provider s rooms, with an alpha character signifying the order of bundles for that day. For example: if multiple batches were sent on 7th of August 2007 Batch 1 = A Batch 2 = B Batch 3 = C It is important that this number is unique per batch, as this number combined with your provider number will enable the fund to identify your batches. If you have a query with one of your batches, you need to quote the Account Summary Number together with your provider number, to enable the fund to locate it quickly. Total Fee Charged This is the total fee charged for all claims submitted in the batch. The fund will use this figure to reconcile that the assessor has entered all claims for that batch. Total Number of Accounts This is the total number of accounts submitted in the batch. Please remember that the number of accounts submitted per batch cannot exceed 20. Total Amount Claimable This is the total amount you are expecting to claim back from the fund once the claims have been assessed. The Fund will provide you with a Medical Claims Summary Report, which will total both the amounts of claims approved for payment and the rejections. This total should equal your total amount claimable and will assist you in reconciling claims payments. Comments Your administration staff can note general comments pertaining to the batch, in this field. The Fund assessors may also do the same. Any comments entered by Fund staff will be for internal purposes only. Your copy of the Account Summary Form should be used when reconciling the payment summary report that you receive from the Fund. 17

18 HOW TO USE THE DOCTOR ACCOUNT FORM All fields on the Doctor Account Form (Attachment 2) need to be completed. Both Medicare and the Fund use the information on this form to assess medical claims. Completed account forms are collated into batches (20 max) and forwarded to the appropriate fund with an Account Summary Form. The majority of fields on this form are self explanatory, however the following may assist: Health Fund Name Please indicate which participating Health Fund the patient belongs to. Membership Number The AHSA Participating Fund membership number MUST be provided. This information can be obtained from the patient or by contacting the appropriate Participating Fund directly. Dependant Suffix The dependant suffix is used by the Fund to identify which dependant on the membership the claim is for. Only enter this information if known. Patient Account Reference (Invoice or Account number) The patient reference is assigned by you and should match your patients accounting record. The Fund records this information as part of the claim. This will enable the Fund to quote your patient account (claim) reference on the payment summary report for reconciliation. Facility at which the Service was Provided The name and provider number of the hospital or approved day care facility MUST be entered in this field. Any claims submitted without this information will be rejected. Patient Reference Number The Patient Reference Number is a single character number found alongside a dependant on the Medicare card. This number is used to identify the person the claim is for. The Medicare reference number must be supplied wherever possible; otherwise Medicare may not be able to process the claim or the claim may be delayed. H-ST Hospital-Substitute Treatment Please indicate by placing a tick against the appropriate services if they form part of H-ST. Please refer to page 26 for further information about H-ST. Applicable Service Conditions Applicable Service Conditions are special Medicare requirements. Medicare requires certain information relating to these specific situations. Please ensure the information submitted on your account meets all Medicare requirements. Some of these conditions may not relate to your area of specialty. Please refer to the Medicare Benefits Schedule for further information. Comments The comments section is supplied to enable you to add or supply any supporting information you feel is necessary regarding that claim. Please Note: Where your accounts include all details required on the Access Gap Cover Doctor Account Form, you can attach your accounts to the completed Access Gap Cover Account Summary Form rather than completing the Access Gap Cover Doctor Account Form. All Access Gap Cover forms may be downloaded from the AHSA website, which is: Go to Doctors, then Forms in Access Gap Cover. If the services were performed as part of Hospital- Substitute Treatment, the name of the substitute care service provider under contract to AHSA funds MUST be entered in this field. Any claims submitted without this information will be rejected. 18

19 CLAIMS AND PAYMENT REPORT Your Medical Practice will receive the following report from the Fund, which will assist with the reconciliation of submitted batches of claims. Please note that Australian Unity will only provide electronic remittance advice, either via the Eclipse system or the Australian Unity Self Service Portal. Please contact Australian Unity on or if you require further information. THE MEDICAL CLAIMS SUMMARY REPORT This report will be sent to your practice after a claim or batch of claims has been lodged with Medicare for assessment and payment. The report outlines whether a claim or batch of claims have been approved or rejected. The total benefit paid will be forwarded to the practice via direct credit, in conjunction with this report. Fields on this report include: Practice Reference This is the Account Summary Number under which the claims were submitted. (Not applicable if you send your Access Gap Cover account to your patient). Provider Number The number of the provider who performed the service. Patient Reference Your patient account reference. Item Number MBS item number of the service performed. Service Date Date the service was performed. Description This field includes the Fund's reference and the Account Summary Number (not applicable if you send your Access Gap Cover account to your patient). Amount Payment amount or total payment amount per batch. Direct Credit Details If the payment was made by Direct Credit, the transaction number and the date will be indicated here. STATEMENT OF BENEFIT FOR THE MEMBER The fund will also provide the member with a Statement of Benefit outlining the payment made as well as any rejections. The Statement of Benefit for the member is an important part of the Access Gap Cover process as it outlines the amount of money Funds have paid on their behalf and therefore reinforces the value of Private Health Insurance to Fund members. The following standard explanation will be included on all Statements of Benefit that are sent to members to clarify that it is for their information only and no further action is required. THIS IS NOT A BILL This statement is for your records only and outlines benefits paid on your behalf. If there is any additional co-payment your doctor should have already advised you and will bill you separately. Amount Charged Amount charged per item. Benefit Paid Benefit amount paid. Explanation Flag Identifies who rejected the claim H means HIC, F means Fund. Explanation Code 3 digit explanation code. 19

20 CLAIMS EXPLANATION CODES REPORTING OF EXPLANATIONS The Fund will provide you with a report that includes the total payment. Table One (page 21) outlines the HIC (Medicare) Explanation Codes and Table Two (page 23) outlines the AHSA Participating Fund Explanation Codes. These tables provide a listing of explanation codes, a description of each code and procedure number. The procedure number or code corresponds to a recommended action. Table 2: Fund Codes (F) A list of recommended actions that correspond with the Fund procedure codes appears below the table on page 23. Where the rejection is flagged as H it indicates that it is a HIC (Medicare) generated rejection whereas if it has code F it will indicate that it is a Fund specific rejection. All rejections will be advised on the Medical Claims Summary Report. Claims systems produce this report. Table 1: HIC Codes (H) A list of recommended actions that correspond with the HIC procedure numbers appears on page

21 TABLE ONE MOST COMMON HIC (MEDICARE) EXPLANATION CODES ( H ) (Recommended actions that correspond to procedure numbers are on page 22) CODE DESCRIPTION PROCEDURE 400 Equipment number missing or invalid Benefit not payable charge amount missing or invalid Benefit not payable number of patients attended required Subsequent consultation referral details required Benefit not payable referral/request details required Equipment number invalid for servicing provider Unable to assess claim please forward documents Benefit not payable overseas student Date of service prior to 29 may Card number for this enrolment needs to be verified Age restriction applies for this item verify details MBAC determination/precedent number not supplied or invalid Benefit not payable provider unable to claim this service Benefit not payable date of service prior to date of request Provider practice location is closed at date of service Referral details same as rendering provider self deemed? Services form a composite item composite item required Referral needed if no referral, nr item to be transmitted Item cannot be claimed more than once in one attendance Benefit already paid on item verify if multiple pregnancy Operation/s schedule fee does not meet item description Wrong assistant item used for the operation/s performed Benefit paid has been reduced (benefit = charge) Optical condition not specified contact provider More information required which eye was treated Benefit not payable individual charges required Indicate whether new treatment or continuing management Compensation related services please forward documents DOS greater than 2 years please forward documents Patient cannot be identified from information supplied Conflicting referral details please clarify Initial consultation previously paid query subsequent con Item indicated as not part of multi-op no explanation? Associated referral/request line not required 434 Expired or invalid card benefit not payable Service for nursing home care recipient/benefit not paid 436 Non in-patient service not claimable under simplified bill EFT details invalid cheque issued for benefit 461 Adjustment to benefit previously paid Patient/service details invalid or missing 1 This limited but common list of HIC (Medicare) Explanation Codes is current and correct at the time of publishing. For a comprehensive list of HIC (Medicare) Explanation Codes please contact Medicare Australia. 21

22 HIC (MEDICARE) CLAIM EXPLANATION/ REJECTION PROCEDURES 1. Amend the account as necessary and re-submit with your next batch of claims. 2. Check account details in accordance with the rejection message and do the following: If correct, nothing will be payable for this service and you must claim directly from your patient. Please remember to mark the claim The amount on this account is NOT claimable through the Fund or Medicare. If incorrect, amend the claim and re-submit to the Fund. 3. Check rejection message details with your records and the patient: If correct, nothing will be payable for this service and you MUST claim direct from your patient. Please remember to mark claim The amount on this account is NOT claimable through the Fund or Medicare. 4. More information is required before re-submission of the claim to the Fund. 5. Benefit has been adjusted (due to rejection code) no further benefits payable. Check rejection message details with your records and do the following: If incorrect, contact the appropriate Fund, and they will advise you of the manual review procedures. If correct, nothing will be payable for this service. The difference between your fee charged and the benefit payable is not claimable from the member. 6. The Fund has contacted the member. Please re-submit the claim when either the Fund or the member has advised you. 7. No Fund benefit is payable for this account. 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 incorrect, amend the claim and re-submit to the Fund. 22

23 TABLE TWO COMPLETE LIST OF AHSA PARTICIPATING FUND EXPLAINATION CODES ( F ) (Recommended actions that correspond to procedure codes appear below table) CODE DESCRIPTION PROCEDURE 006 MBS number required A 007 Signature of the member or POA required A 009 No benefits are payable for this item B 012 The service is included with another item F 018 Accident questionnaire has been requested C 019 Item may be claimable from another source C 020 Student dependant age query C 022 DOS is within 2 months of joining B 023 DOS is within 12 months of joining B 024 Query pre-existing C 025 Item previously paid F 028 Membership unfinancial as at the DOS C 051 The patient is not a member with this Fund B 052 The item is claimable from another source B 053 Awaiting clearance details from previous Fund C 054 Claim deemed pre-existing D 060 Patient not registered under this membership C 195 Arrangement withdrawn. Benefits > schedule fee not payable E 196 Table coverage excludes this item D 197 DOS is prior to commencement date of arrangement E 198 Item charge not in line with current arrangement A 199 Charge exceeds current arrangement. Paid as current arrangement F This list of explanation codes will be used by AHSA Funds participating in Access Gap Cover. FUND CLAIM EXPLANATION/REJECTION PROCEDURES A. Amend the claim as necessary and re-submit to the Fund. B. No Fund benefit is payable for this account. Please bill the member directly in your normal manner. C. Claim is being held by the Fund. Once the situation has been clarified we will reconcile with your next claim submission. (Claims will either be paid or new rejection codes will be issued.) D. No Fund benefit is payable for this account. Please bill the member directly in your normal manner. Remember to mark the account The amount on this account is claimable through Medicare only. E. Please bill the member directly in your normal manner. The member may then claim from Medicare and then 25% of the Schedule fee from the Fund in the usual manner. F. No further action required. The patient must not be billed for this service. 23