It is here that you add and maintain Health Funds, WorkCover, TAC, Surgery Connect, Employers and other third-party payers.
If your provider has registered with a fund to transmit claims, ensure you then go to Utilities - Entities - (Provider) - Schemes and Agreements and ensure the Fund is listed. If not, select ADD on the sidebar.
There are close to 40 health funds that offer ECLIPSE. About 30 of these are members of Fund List - AHSA There are other corporate funds.
If you need to contact a fund or to register with a fund, you can find a list of them here Private Health Insurers’ functions and contact details - Simplified Billing and ECLIPSE - Services Australia
It is the Fund Group that references the Doctor Fee Schedules and detail the maximum Out-Of-Pocket (OOP aka GAP). Fund Groups in DC are:
- AHSA - maximum OOP of $500 effective 1 July 2020. Prior to this they allowed a maximum OOP per line item being the difference between the AHSA fee and the AMA fee but not more than $400
- ARHG - The Australian Regional Health Group (ARHG) have a number of regional funds as members. This group does not have a fee schedule for medical billing. They do, however, enter into contract fees for hospital billing.
- BUPA - maximum OOP of $500
- GMHBA - Under the AHSA Group
- HBF - The HBF Health Fund may need to be entered in three times
- HBF (WA Only) - allocated to the HBF Group
- HBF (all other States) - allocated to the AHSA Group
- HBF Specialist Anaesthetist (WA Only) - allocated to the HBF Group
- HCF - They have two fee schedules.
- No OOP allowed (No Gap) where they pay more, and
- OOP allowed (Known Gap) where they pay less. It was originally understood that a Provider could only register with one. However, it appears they can use either. This is managed in Utilities - Entities - (Provider) - Location. Select HCF Known Gap Provider if charging an OOP at that location.
- MBP - Medibank Private - maximum OOP of $500
- NIB - No OOP allowed. NIB GapSure for Anaesthetics Network has the ability to charge a known gap up to $500, rules apply see link Honeysuckle Health | Home
- Other - this is based on the Medicare schedule
- St. Lukes - They use Medical Gap Scheme; Providers need to fill in their SLH Medical Gap Opt Out form if they do not wish to be part of the Medical Gap Scheme. Maximum OOP of $500 per Provider, per episode.
Go to Utilities - Lookups - Insurance - Insurer Group to maintain Fund Groups.
Go to Utilities - Lookups - Insurance - Insurer Category to maintain Fund Categories
The majority of funds participate in direct billing as stated above. This is known as ECLIPSE being In hospital Medical Claiming (IMC) for medical billing and In Hospital Claiming (IHC) for hospital stays.
Health Funds are being taken over and merging and it is hard to keep up.
On your first installation of DCM the Insurers/Companies table contains health fund details for you to maintain and ensure the detail is relevant to you. DCM software updates do not change this table. Go to Private Health Insurers’ functions and contact details - Simplified Billing and ECLIPSE - Services Australia
You also need to know that GU Corporate (ex Grand United) only looks after corporate health funds and they do not ECLIPSE. There are over 300 of these funds and include Boeing Australia, Cadbury Schweppes, Caltex, Caterpillar, FAI, Kraft, Motorola and Rockwell to name a few). Grand United non-corporate funds are now Australian Unity.
- Better Health no longer exists. Use AHM
- Goldfields Medical Fund (GMF) was taken over by HBF WA
Not all Health Funds have agreements with hospitals. You will find hospital agreement details here: Health Insurers (privatehealth.gov.au)
Also known as Fund Brand IDs and on the link above they reference ATO IDs that may differ from the Participant ID.
It can all be very confusing and sometimes there is a typo in the documentation provided!
Some funds actually have one ID for ECLIPSE and another Statutory Reporting ... just to keep us on our toes!
As a result, DCM allows for three fields to store these IDs being:
- MED for Doctors Medical Billing
- IHC for Hospital Medical Billing
- HCP for Hosptial Casemix Reporting
Insurers/Companies entered here are added in the Client Record - Insurance section if generating invoices for the Insured Rate.
They can also be selected as a Client Contact and flagged as a Payer. This is ideal if you are invoicing Employers.
If generating ECLIPSE Claims (Medical and In Hospital Claims), the detail entered here must be correct.
It is here that you add and maintain Third Party Payers to include WorkCover (per State) and Victoria's Traffic and Accident Commission (TAC).
It is up to you to add WorkCover agent details and any other Third-Party Payers. You can also add Insurer/Company Contacts.
Each Insurer or Company is allocated a Group. It is the Group that decides the fee to be charged.
DCM updates fee schedules as they become available for the In hospital Medical Claims (IMC).
Should you have negotiated a fee above or below the fee schedule provided to DCM, you can accommodate this by entering your Contracted Rates in Utilities – Entities – Schemes and Agreements if ECLIPSING or Utilities – Entities – (select entitiy) Locations (Active) - Location Rate - Insured Rate – Edit
To add an Insurer/Company
- Select Contact Management - Insurers/Companies
- Select Add or press [ALT+A] to add an Insurer/Company
- Select Delete to delete an Insurer/Company noting that if they have been referenced in DCM, you cannot delete
An Insurer/Company can also be added from Client - Contacts and Client - Insurance if your user role has permission to do so