IMC Glossary of Terms

Description

Whether you’re new to the Medicare and Medicare ECLIPSE billing space, there’s a number of abbreviations and definitions you may like to familiarise yourself with.

For a complete list of abbreviations and definitions, follow the below link to the department of human services help guide below:

https://www.humanservices.gov.au/sites/default/files/eclipse-hospital-claiming-user-guide.docx

Commonwealth hospital facility provider number; The facility ID or hospital provider number is a unique and, usually, a seven digit number followed by a letter (i.e. 0012765A) that is used to identify the site this service was performed.

The Fund Payee ID is a number issued by the fund to the doctor working out of a specific location.

It is normally allocated to the doctor  when the doctor registers with the Health Fund and is available in the paperwork or email correspondence from the fund.

Only if your organisations has signed a Medical Purchaser Provider Agreement (MPPA), a Hospital Purchaser Provider Agreement (HPPA) or Provider Agreement (PA) with AHSA, can you set your claim type as Agreement for an AHSA Health Fund.

Agreement type claims are 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

There are two types of agreements:

• HPPA/ PA  is the combination of agreements between the practitioner and the hospital and a Private Health Fund

• MPPA is an agreement between the practitioner and the Private Health Fund

Source: AHSA website: https://www.ahsa.com.au/web/doctors/information/eclipse

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

There are two types of Gap Cover Schemes:

• No Gap Cover - Patient has no out of pocket expense

• Known Gap Cover - Patient does have out of pocket expenses and the provider must provide written informed Financial Consent

Source: AHSA website: https://www.ahsa.com.au/web/doctors/information/eclipse

Australian Government Medicare Australia: https://www.privatehealthcareaustralia.org.au/.../03a%20-%20Simplified%20Billing%...

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

A 'gap' is the amount you pay either for medical or hospital charges, over and above what you get back from Medicare or your private health insurer.  A ‘Known Gap’ is the maximum gap difference that an invoice or item can be charged for

A provider number is issued and used by Medicare and Department of Veterans’ Affairs (DVA) claims for processing.

A provider number consists of:

• a 3 to 6 digit number that identifies you, such as 123456, and

• 2 additional characters that identify your practice location, such as 1A or AA

In this example, the Medicare provider number would be 1234561A.

A Medicare provider number lets you:

• claim Medicare benefits for services you provide at a particular practice location

• refer patients to another practice where they can claim a Medicare benefit, such as:

• to another health professional

• for diagnostic imaging, or

• for pathology services

If you’re registered in multiple health professions, we usually issue a separate number for each profession.

In order to process claims with with Medicare and the DVA, the provider number must be associated with a Minor ID issued by MediRecords. A Minor ID looks like AST00011.

For more information click here

https://www.humanservices.gov.au/health-professionals/services/medicare/medicare-provider-number-health-professionals

AHSA or Australian Health Services Alliance is  Australian Health Service Alliance Ltd (AHSA) is a service company representing a number of small to medium sized private health insurance funds.

The company was formed in 1994 to provide management services to these Funds throughout Australia. By pooling their resources and creating AHSA, participating Funds are able to respond more effectively to the numerous changes occurring in the private health industry.

AHSA provides a range of services including management of:

• provider relationships

• Negotiation of contracts

• the collection, dissemination and analysis of data

• Access Gap Cover and other medical gap initiatives

• Broader Health Cover Management services

• prostheses and claims support

• educational services and training

• Claims Management and verification services

• Support of industry and fund initiatives

• Strategic advice with regard to healthcare services

• Further information is available in our Corporate Profile.

Un-paid claims that are submitted from a Billing Agent (contains ‘Billing Agent ID’) to Medicare and a Private Health Fund.

Un-paid claims that are submitted from a Billing Agent (contains ‘Billing Agent ID’) submitted to Medicare only.

There are three types of eligibility checks available in ECLIPSE to determine if a patient is eligible to claim against an illness/ condition or if  Medicare covers the patient and which Medicare benefits are payable.

For more information head to:

https://www.humanservices.gov.au/health-professionals/services/medicare/simplified-billing-and-eclipse

Hospitals and day surgeries use this check to determine if a patient is eligible for a selected, presenting, illness/ condition on the admission date. This check provides out-of-pocket expenses for excess, exclusions and co-payments associated with the patient’s hospital product

Hospitals and day surgeries and medical providers use this to check to determine if Medicare covers the patient, and which Medicare benefits may be payable for inpatient medical services

Hospitals and day surgeries and medical providers use this to check to determine if patient is eligible for a selected presenting illness/ condition on the admission date. It provides out-of-pocket expenses for excess, exclusions and co-payments associated with patient’s hospital product, and the Medicare and private health insurer benefits payable for the medical services.