Simplified Billing ECLIPSE An overview medicareaustralia gov au

Simplified Billing/ECLIPSE An overview medicareaustralia. gov. au

Simplified Billing • • Reduces the number of accounts a private patient receives after being in hospital by streamlining the claims procedures by removing the need for patients to submit claims to Medicare and their private health fund themselves. • Allows un-paid in-hospital services to be submitted to Medicare Australia and a private health fund. • Provides for informed financial consent to ensure the patient is aware of any out-of-pocket expenses. • These claims can be submitted manually or electronically. • medicareaustralia. gov. au First introduced in May 1995 as part of the Private Health Insurance Reforms. Electronic claims can be transmitted either via the ECLIPSE or SMTP (ED) channels.

Claiming Arrangements There are four options available to use Simplified Billing: • Approved Billing Agents • Medical Purchaser Provider Agreement (MPPA) • Hospital Purchaser Provider Agreement/Practitioner Agreement (HPPA/PA) • Gap Cover Scheme medicareaustralia. gov. au

Approved Billing Agents • • Billing agents can be a private health fund, hospital, an individual or an organisation. • Billing agents act on behalf of the patient to claim Medicare benefits and private health fund medical benefits. • medicareaustralia. gov. au Allows Simplified Billing claiming to occur without the need for any form of agreement. Billing agent must obtain a patient signature for the assignment of benefit.

Medical Purchaser Provider Agreement (MPPA) • • The private health fund can make an agreement with the medical provider to pay benefits above the Medical Benefits Schedule Fee. • medicareaustralia. gov. au Allows a private health fund to claim Medicare benefits on behalf of their members when they have a MPPA in place with the medical provider. Agreements between the private health fund and the medical provider may be expressed orally or in writing.

Hospital Purchaser Provider Agreement/Practitioner Agreement (HPPA/PA) • • This agreement is a combination of agreements between the medical practitioner and the hospital, and between the hospital and a private health fund. • medicareaustralia. gov. au A medical provider does not need to deal with a private health fund directly when submitting claims. Agreements between the private health fund and the medical provider may be expressed orally or in writing.

Gap Cover Scheme • • The medical provider must not have a medical purchaserprovider agreement or a practitioner agreement or a hospital purchaser-provider agreement in place with the private health fund. • The insured person pays a specified amount or percentage under a known gap policy or the full cost of the treatment is covered under a no gap policy. • medicareaustralia. gov. au Private health funds can offer insurance for the cost of a particular hospital treatment for a person where the cost of the treatment is greater than the schedule fee. The scheme must provide for the insured person to be informed in writing, where circumstances make it appropriate, of any amounts that the person can reasonable be expected to pay for treatment and the insured person acknowledges receipt of this advice.

Introduction ECLIPSE is one of a number of electronic claiming solutions offered by Medicare Australia Today’s presentation will cover: • What ECLIPSE is and how it works • Features of ECLIPSE • The ECLIPSE Network • Online security • Connecting to ECLIPSE • Where to find out more medicareaustralia. gov. au

Electronic claiming solutions Medicare Australia offers a range of electronic claiming solutions: • Medicare Easyclaim: Standalone and Integrated • Medicare Online • ECLIPSE medicareaustralia. gov. au

What is ECLIPSE? ECLIPSE - Electronic Claim Lodgement and Information Processing Service Environment Enables private patients seeking treatment in hospital to claim rebates from Medicare, their private health fund and the Department of Veterans’ Affairs, (DVA) in one online transaction. medicareaustralia. gov. au

Benefits of ECLIPSE Benefits: • Paperless business transactions between Medicare Australia, private health funds and DVA in one software product • Patients pay only the gap • Quicker processing times • Faster resolution of complex claims • Improved data quality • Electronic remittance advice • Informed financial consent medicareaustralia. gov. au

How does ECLIPSE work? ECLIPSE is an extension of Medicare Online which connects medical practitioners, hospitals, billing agents, private health funds, DVA and Medicare Australia via a secure internet connection. medicareaustralia. gov. au

The ECLIPSE Network 2 Medicare 1 Site The ECLIPSE Network ECLIPSE HUB 4 medicareaustralia. gov. au 3 Private Health Fund

Features of ECLIPSE Features • In-patient Medical Claims • In-hospital Claims • Online Patient Verification • Online Eligibility Check • Status requests • Retrieve reports • Overseas Claims • Online security medicareaustralia. gov. au

Online Patient Verification (OPV) • Medicare Australia (PVM) • Private Health Fund (PVF) Enterprise Patient Verification (EPV) • Multiple patient verifications per transmission medicareaustralia. gov. au

Online Patient Verification (OPV) Medicare 2 1 ECLIPSE Site 4 HUB 3 Private Health Fund 1 - Patient Verification is submitted from the site. 2 - The ECLIPSE HUB submits the Medicare patient information to Medicare for assessment, Medicare passes the assessment information back to the ECLIPSE HUB (PVM). 3 - If successful, the private health fund patient information is submitted to the private health fund for assessment, the private health fund passes the assessment information back to the ECLIPSE HUB (PVF). 4 - The ECLIPSE HUB submits both the Medicare and private health fund assessments back to the transmitting site. medicareaustralia. gov. au

Inpatient Medical Claims (IMC) are submitted to Medicare Australia and private health funds: • IMC Schemes (SC) – Un-paid claims that are submitted where a private health fund offers does not have a medical purchaser-provider agreement or a practitioner agreement or a hospital purchaser-provider agreement in place and the insured person pays a specified amount or percentage under a known gap policy or the full cost of the treatment is covered under a no gap policy • IMC Agreements (AG) – Un-paid claims that are submitted where a provider or hospital have an agreement with the specified private health fund. The private health fund can make an agreement to pay the provider benefits above the Medical Benefits Schedule Fee • IMC Medical Benefits (MB) – Un-paid claims that are submitted from a Billing Agent (contains a ‘Billing Agent ID’) to Medicare and a specified private health fund • IMC Medicare Only (MO) – Un-paid claims that are submitted from a Billing Agent (contains a ‘Billing Agent ID’) but only invokes Medicare Australia • IMC Two-Way (TW) – Paid or Un-paid claims that are submitted from a Medicare Branch to a specified private health fund • IMC Patient Claims (PC) – Claims that are submitted where a patient has the option of having paid, part-paid or not-paid claims, to a specified private health fund medicareaustralia. gov. au

In-Patient Medical Claim (IMC) 2 Medicare 3 1 ECLIPSE HUB 4 5 Private Health Fund Site 1 - In-Patient Medical Claim is submitted from the site, an acknowledgement from the ECLIPSE HUB is sent to the site (IMC). 2 - The ECLIPSE HUB initiates a patient verification at Medicare (PVM) and, if successful, a patient verification at the private health fund (PVF). All assessment information is passed back to the ECLIPSE HUB. 3 - If successful, the ECLIPSE HUB submits the claim information to Medicare for assessment, the assessment can be returned in real-time or pended for further assessment. The information is then sent back to the ECLIPSE HUB. 4 - The ECLIPSE HUB submits the claim information, along with the Medicare assessment, to the private health fund for assessment (IMH). The private health fund will acknowledge that they have received the claim. 5 - The private health fund will send their assessment details back to the ECLIPSE HUB (IMX), the ECLIPSE HUB will acknowledge their assessment. The completed claim information is ready for retrieval by the transmitting site. medicareaustralia. gov. au

In-Patient Medical Claim (IMC) payments 2 Medicare Provider 1 2 ECLIPSE Site HUB 4 Private Health Fund 1 - Medicare sends the Medicare benefit to the private health fund 2 - The private health fund passes the Medicare benefit and the private health fund benefit to the provider or billing agent. medicareaustralia. gov. au

Online Eligibility Checking (OEC) • Checks eligibility for both Medicare and private health fund benefits • Estimates out-of-pocket expenses • Enables informed financial consent before the episode of care medicareaustralia. gov. au

In –Hospital Claims In-Hospital Claims (IHC) • Lodgement of claims for a hospital stay directly with private health fund or DVA • Processing reports • Electronic remittance advice medicareaustralia. gov. au

In-Hospital Claim (IHC) 2 Medicare 2 1 Hospital ECLIPSE HUB 3 4 Private Health Fund 1 - In-Hospital Claim is submitted from the hospital, an acknowledgement from the ECLIPSE HUB is sent to the hospital (IHC). 2 - The ECLIPSE HUB initiates a patient verification at the private health fund (PVF). All assessment information is passed back to the ECLIPSE HUB. 3 - The ECLIPSE HUB submits the claim information to the private health fund for assessment (IHH). The private health fund will knowledge that they have received the claim. 4 - The private health fund will send their assessment details back to the ECLIPSE HUB (IHX), ready for retrieval by the transmitting hospital. medicareaustralia. gov. au

Status Requests (STS) • Checks the status of an in-patient medical claim at any time Retrieve Reports (RTV) • Checks the processing report for up to 50 In-patient Medical Claims at a time • Provides assessment of claims details including Medicare and private health fund status • Provides assessment codes for each service within a claim medicareaustralia. gov. au

Overseas Claims (OVS) • OVS Agreement (AG) • OVS Scheme (SC) • OVS Patient Claims (PC) • OVS Medical Benefits (MB) For definitions please see the ‘Inpatient Medical Claims (IMC)’ section. medicareaustralia. gov. au

Online security • Public Key Infrastructure (PKI) used to encrypt and secure all information electronically transmitted to and from Medicare Australia and private health funds. • PKI provides the highest level of confidentiality, privacy and authentication available for transmitting medical data. www. medicareaustralia. gov. au e. Business Service Centre 1800 700 199 medicareaustralia. gov. au

Connecting to ECLIPSE The site must: • contact their software vendor to see if they offer ECLIPSE • register for, and receive a digital certificate • liaise with private health funds where they may have agreements or schemes in place • contact the Medicare Australia e. Business Service Centre or request a visit from a Business Development Officer medicareaustralia. gov. au

More information www. medicareaustralia. gov. au For health professionals e. Business Service Centre 1800 700 199 medicareaustralia. gov. au

Questions? ? medicareaustralia. gov. au