It is here that you add and maintain Health Funds, Workcover, TAC, Surgery Connect, Employers and other third-party payers.

Select Get Participant Services to view any missing Health Funds and to update the Services they provide
Right-click on a fund in the list to view fund members
On adding a new Health Fund that participates in ECLIPSE, ensure you go to Utilities - Entities - (select the Entity/Provider) - Schemes and Agreements and select ADD on the sidebar to add this new Health Fund. If you do not do this, it will result in your possibly transmitting an IMC(PC)

Should you have negotiated a fee above or below the fee schedule provided to DCM, you can manage this by entering an Agreed Uplift percentage in Utilities – Entities – Schemes and Agreements

Health Funds

There are close to 40 health funds that offer ECLIPSE. About 30 of these are members of https://www.ahsa.com.au/web/fundlist. 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 https://www.servicesaustralia.gov.au/organisations/health-professionals/services/medicare/simplified-billing-and-eclipse/resources/private-health-insurers-functions-and-contact-details

Fund Groups

It is the Fund Group that populates the correct Fee on the IFC and/or Invoice and details the maximum Out-Of-Pocket (OOP aka GAP). As updated Fee Schedules become available, these fees are pushed out to you. The updates do not replace existing fees, thus allowing for prior billing.

Go to Utilities - Lookups - Insurance - Insurer Group to maintain Fund Groups.

Group	About
ADF	Australian Defence Force managed by BUPA Bupa Health Services \| ADF HSC Provider Hub
AHSA	Maximum OOP of $500 effective 1 July 2020 Fund List - AHSA
AMA	Australian Medical Association Leading Australia's Doctors. Promoting Australia's Health. \| Australian Medical Association (ama.com.au)
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. Home - Australian Regional Health Group (arhg.com.au)
BUPA	There are two fee schedules. One for Providers who charge an OOP (Maximum $500) and one for those who do not. This is managed in Utilities - Entities - (select Entity/Provider) - Locations (Active) - Initial Setup Bupa \| Information for hospital, medical and ancillary providers
CTP	Compulsory Third Party
DVA	Department of Veteran Affairs Homepage \| Department of Veterans' Affairs (dva.gov.au)
GMHBA	Now with AHSA
GUH	Owned by NIB. Maximum OOP of $400 For Providers \| GU Health Insurance
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 Anaesthesist (WA Only) - allocated to the HBF Group HBF \| Health Insurance
HCF	There are two fee schedules. One for Providers who charge an OOP (Maximum $500) and one for those who do not. This is managed in Utilities - Entities - (select Entity/Provider) - Locations (Active) - Initial Setup Provider portals \| HCF
MBP	Medibank Private. Maximum OOP $500 Medibank GapCover scheme \| Medibank
Mildura	Allows an OOP but has No OOP/Gap agreements with a number of Providers Mildura Health Fund
NDIS	National Disability Insurance Scheme (NDIS)
NIB	No OOP allowed Information for Hospital, Medical and Extras providers \| nib
NIBGS	nib's GapSure Anaesthetists network guarantees a No Gap or Known Gap up to $500 for anaesthetic services No Gap & Known Gap specialist partners for hospital procedures \| nib
Other	Based on 100% of the Medicare Schedule MBS Online - MBS Online
St Lukes	Have a 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. For Providers \| Information, Forms and Links \| St Lukes
TAC	TAC - Transport Accident Commission - TAC - Transport Accident Commission
WorkCover	Government Gazette No 358 of Friday 4 December 2020 (nsw.gov.au) Service providers \| WorkSafe.qld.gov.au Fee schedules (rtwsa.com) Provider information \| WorkSafe Victoria WorkCover WA

Fund Categories

Go to Utilities - Lookups - Insurance - Insurer Fund Category to maintain Insurer/Company Categories

Levels of Cover

In Australia, all health funds have to fit their hospital cover into one of 4 tiers: Gold, Silver, Bronze and Basic. Gold gives you the highest coverage, and Basic gives you the lowest coverage. Health funds can also offer policies that cover more treatments than required by the standard health insurance tiers. These policies will include a ‘+’ or ‘plus’ in the name and fall under one of three subset health insurance tiers: Basic+, Bronze+ and Silver+.

The majority of funds participate in direct billing as stated above. This is known as ECLIPSE (Electronic Claim Lodgement and Information Processing Environment) being In Hospital Medical Claiming (IMC) for medical billing and In Hospital Claiming (IHC) for hospital stays.

Stay Up-To-Date

Health Funds are being taken over and merging.

On your 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 http://www.humanservices.gov.au/health-professionals/services/simplified-billing-and-eclipse/health-fund-functionality-and-contact-details

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:
http://www.privatehealth.gov.au/dynamic/healthfundlist.aspx

Participants IDs

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:

HCP for Hosptial Casemix Reporting
IHC for Hospital Medical Billing
IMC for Doctors Medical Billing

Insurers/Companies Participant/Fund Brand IDs and Services can be updated by selecting Get Participants on the side panel.

Insurers/Companies entered here can be selected in the Client Insurance section if generating IFC/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 up to you to add Workcover agent details and any other Third-Party Payers. You can also add Insurer/Company Contacts.

Steps 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.

Should an Insurer/Company be a new Insurer/Company, it can also be added from Client Insurance if your user role has permission to do so, by clicking on the [+]. Always search first so that you do not create a duplicate record.

An Insurer/Company's detail can be viewed by selecting the elipses button [...].

Search

Welcome to DCM Help Centre

Insurers/Companies