Requirements
- Hospital/Entity is registered with Health Funds
- Hospital Contracts are setup
- Hospital/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
- Patient/Client has a current the Referrer/Surgeon in Referrals
- Date of Service (DOS) is within that agreed by the Health Fund
- DCM will not process an IHC if any of the above is not correct
- On transmitting the Claim, the Health Fund membership is verified again based on the Date of Service (DOS)
Invoicing/Claiming
- Unlike Patient Claiming, Bulk Billing, DVA Billing or ECLIPSE for the Medical Service, you cannot transmit the IHC from the invoice
- The IHC is transmitted from the Admission form
- This IHC option is ONLY available when the Health Fund Contract is met
- This allows for improved cash flow prior to finalising Clinical Coding for HCP and PHDB reporting
- One invoice equals one claim
The In Hospital Claim (IHC)
- Select IHC on the sidebar of the Admission. Should there be errors, they will be listed for you to resolve prior to transmitting
- Relevant detail populates from the Client Record, Invoice and Admission
Claim Segments
Mandatory (CID/PAT)
- Claim Identification (CID) - The CID holds details of the claim. The claim can be for a completed episode of care, a contiguous claim or an interim claim. All other segment groups are nested within
the CID segment. It also contains the total charge for the claim (sum of the SVB, ACS, PSG and MIG but only where those segments have a charge code = C) - Patient Data (PAT) - The PAT segment is used to define the patient information. Patient Identification (PID)
Episode (EPD)
- Episode Data (EPD) - The EPD segment is used for giving summary information regarding the patient's hospitalisation
SV Benefits (SVB)
- Single Value Benefit (SVB) - The SVB segment is used for bundled inpatient accommodation only. It is used for single value benefit (casemix) arrangements and fully or partially bundled episodic billing
Baby (ANB)
- Add New Baby (ANB) - The ANB segment is used to notify the private health insurer of a newborn baby that may or may not be on a membership. Note: Private health insurers cannot load newborn
information directly onto a membership without contact with the policy owner
Transfers (TFR)
- Transfer (TFR) - The TFR segment is used to report the transfer of a patient between hospitals. Separate segments are required for each transfer in and out.
- Select Add on the sidebar to add Transfers
- The Facility ID is the Hospital's Provider Number and not its Facility Code
Accom (ACS/ACD)
- Accommodation Summary (ACS) - The ACS segment provides a summary of accommodation and critical care details. If accommodation is included in the SVB, then total accommodation charges under ACS should be set to zero dollars. ACD and CCG, LPD segments are nested within the ACS segment.
- Accommodation Details (ACD) - The ACD segment is used for the detailed reporting of differing periods of accommodation.
- Critical Care (CCG) - The CCG segment is used for the detailed reporting of critical care where used by private hospitals and charged
for by public hospitals. - Leave Period (LPD) - The LPD segment is used for the reporting of up to nine leave periods that may have occurred within the total period of hospitalisation.
Services (PSG/MSG)
- Principal Services (PSG) - The PSG segment is used for the reporting and charging of all instances where a principal service or procedure is carried out during a single theatre visit. The repetitions allow for the inclusion of more than one visit during a claim period. Secondary services can be reported using the MSG segment nested within this group.
- Multiple Services Group (MSG) - The MSG segment is used for the reporting of multiple or secondary services for each of the principal services reported in the PSG segment.
Transport (TRG)
- Transport Group (TRG) - Not currently used
Misc (MIG)
- Miscellaneous Services (MIG) - The MIG segment is used for the reporting and charging of miscellaneous items not covered elsewhere in the claim, i.e. prosthesis
DRG (DMG)
- DRG Morbidity Group (DMG) - The DMG segment is required for the collection of diagnosis and ICD codes. It is essential for episodic billing
Non-DRG (MOR)
- Non-DRG Morbidity (MOR) - The MOR segment is for the collection of non-DRG
classifications. AN-SNAP (Australian National Subacute and Non Acute, Patient classification)
Certificate (CER)
- Certificate (CER) - The CER segment is used to notify the collection of relevant certificate information needed to support the claim.
- IHC Certificates can be added in Utilities - Configure - Medicare/IHC. Multiple Certificates can be added by selecting the ellipses [...] or going to Utilities - Lookups - In Hospital Claim - Certificate Text
Medical (MED)
- Medical Services (MED) - Not currently used
Remarks (REM)
- Remarks (REM) - The REM segment allows for the collection of free format
text that may be needed for the processing of a claim
Receipting
- The timing of the receipting for an In Hospital Claim (IHC) varies per Fund
- 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
- Select Edit Admission on the sidebar
- Select IHC on the sidebar
- Check detail and transmit the IHC
- On transmitting, this will result in a new Claim
- There may be reason to delete the invoice and create new. If so, the deleted invoice needs to be unassociated from the Admission and the new invoice associated
ECLIPSE Error Codes
Look up Medicare Online and ECLIPSE return codes - Health professionals - Services Australia