Privately Insured In Hospital Medical Claim (IMC)

Requirements

Provider/Entity is registered with Medicare and Health Funds - Pre-requisites
Provider/Entity has confirmed if participating in No or Known Out-of-Pocket (OOP/GAP)
Provider/Entity has Insured Rate selected in Location rates for each Active Location in Utilities - Entities - Locations (Active)
Patient/Client has a current and verified Private Insurance Membership
If the Provider/Entity is an Allied Health Provider or a General Practitioner, a Referral is not required
If the Provider/Entity is a Specialist a current Referral is required unless an override is selected
Date of Service (DOS) is not older than two years
DCM will not process an IMC if any of the above is not correct
On transmitting the Claim, the Medicare Card is verified again based on the Date of Service (DOS)

On generating the Invoice with the Rate Insured, a button labelled IMC appears on the sidebar to select
- IMC (AG) informs that the Fund has an Agreement with the Provider
- IMC (SC) informs that the Fund pays their fee schedule to the Provider
- IMC (PC) will only appear if
  - The fund is not added to the Provider's Schemes and Agreements, or
  - The Provider is charging more than the Fund allows
The Fee equals the Benefit
Right-click on the Item Description to select any Qualifiers that Medicare requires

The timing of the In Hospital Medical Claims (IMC) varies per Fund
- AHSA - within 20 days depending on the fund
- BUPA - within 10 working days
- Medibank - within 5 working days
- Others vary
This process can be automated
Otherwise, go to Regular Tasks - Online Claiming and select the Get ECLIPSE button on the sidebar

On getting the ECLIPSE Payment details, and the Invoice is paid in full, the Invoice will be receipted, and the status of the Claim Status will change to Completed without staff involvement
Should there be a difference in what was paid to what was claimed, the Claim Status will be Reports Available.
Right-click on the Claim and select Get Report for detail. Options are:
- Accept what has been paid resulting in what was invoiced updating to what was paid
- Right-click and go to Invoice and Resolve the Issues. There would be a missing Qualifier, eg: Not Normal Aftercare
- Resubmit Later resulting in the Claim being moved to the Claims to Resubmit section
- Resubmit Now resulting in the Claim being Resubmitted with a new Claim ID