Privately Insured in hospital Medical Claim (IMC)

Requirements

Provider/Entity is registered with Medicare and Health Funds - Pre-requisites – Direct CONTROL Medical (DCM)
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 a Specialist a current Referral is required unless an override is selected
Date of Service (DOS) is not older than 6 months
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
Select Charge OOP if fund allows

One invoice equals one claim
Should the Claim not be transmitted from the invoice, as will be the case if feeding in from an upstream application, go to Regular Tasks - Online Claiming - Invoices not Claimed (x) and transmit/process from there

The timing of the receipting of the In Hospital Medical Claims (IMC) varies per Fund. At time of writing
- 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 by selecting options in Utilities - Configure - Medicare / IHC
Otherwise, go to Regular Tasks - Online Claiming and select the Get ECLIPSE Payments 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 Payment
- Resubmit Later
- Resubmit Now resulting in a new Claim ID
You can either use the toggle buttons at the top of the form or select from the drop down

The reason for no payment above is due to the Service being previously paid (162 Reason Code)
Accepting Payment and then selecting Complete on the sidebar will change the invoiced amount to what has been paid.
In the example above, the invoiced amount will change to $0.00
If monies have been paid, you need to Accept Payment and Complete to receipt the invoice

Right-click and Go to Client or Go to Invoice and Resolve the Issues.
- There could be a missing Qualifier, eg: Not Normal Aftercare, or
- The Referrer's Provider number is not valid. This should be highlighted on entering the Referrer details and resolved then. Know that the Provider Number must be 8 characters in length. Should it be 7, try entering a 0 at the start
The above issue is Referral/Request details not supplied
Resolve the issue and then either ...
- Resubmit Now resulting in the Claim being Resubmitted with a new Claim ID
- Resubmit Later resulting in the Claim being moved to the Claims to Resubmit section

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