Preferred providers

JS library only.

Preferred provider programs can reduce or eliminate out-of-pocket gap payments when ICD codes are provided as part of the health claim. The PMS must handle the ICD code in the HealthPoint request and response. The HCF "More for" program is an example of a claim that requires an ICD code, and other funds may be added.

Tyro strongly suggests PMS partners implement preferred provider functionality to support providers enrolled in these health fund programs. If an enrolled provider submits a claim without the required details, the claim may be declined or may not receive the "No-Gap" assessment. HCF approved providers can be from these modalities: chiropractors, osteopaths, podiatrists, physiotherapists, optometrists and dental.

To certify your PMS for preferred providers, contact the partner managers at partner-managers@tyro.com.

Implementation

Build the claim as for a standard claim, with one additional claim item that carries the details to trigger the preferred provider assessment.

A preferred provider claim always has at least two claim items. You can add more, but you can submit only one preferred provider claim item per claim.

Set the additional item as follows:

Field	Value
`serviceReference`	`ZZZ`
`claimAmount`	$0
`serviceDate`	The same as in the other claim items
`description`	The ICD-10 code or code description
`serviceCode`	The appropriate ICD-10 code
`patientId`	The same as in the other claim items

Set claimItemsCount to at least 2. Field padding isn't required, but if you want to pad, use a space on the right.

Example request

Tyro.iclientWithUI.initiateHealthPointClaim({
    providerId: "2147661H",
    serviceType: "P",
    claimItemsCount: "2",
    totalClaimAmount: "10000",
    claimItems: [
        {
            "claimAmount": "10000",
            "serviceCode": "560",
            "description": "Assessment Consult",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20190903"
        },
        {
            "claimAmount": "00000",
            "serviceCode": "G560",
            "description": "More For ICD code",
            "serviceReference": "ZZZ",
            "patientId": "02",
            "serviceDate": "20190903"
        }
    ]}, {
    transactionCompleteCallback: yourPosCode.handleComplete,
    statusMessageCallback: yourPosCode.handleStatusMessage,
    questionCallback: yourPosCode.questionAsked
});

Example response

{
    "result": "APPROVED",
    "transactionId": "6dbdaffd58adac4e89387f2c9d2c0cdd7c1e",
    "healthpointRefTag": "2120599",
    "healthpointTotalBenefitAmount": "10000",
    "healthpointSettlementDateTime": "20190903093316",
    "healthpointTerminalDateTime": "20190903093316",
    "healthpointMemberNumber": "0000000000",
    "healthpointProviderId": "2147661H",
    "healthpointServiceType": "P",
    "healthpointClaimItems": [
        {
            "claimAmount": "10000",
            "rebateAmount": "10000",
            "serviceCode": "00560",
            "description": "Assessment Consult",
            "serviceReference": "01",
            "patientId": "02",
            "serviceDate": "20190903",
            "responseCode": "0000"
        },
        {
            "claimAmount": "0",
            "rebateAmount": "0",
            "serviceCode": "0G560",
            "description": "More For ICD code",
            "serviceReference": "ZZZ",
            "patientId": "02",
            "serviceDate": "20190903",
            "responseCode": "0000"
        }
    ],
    "healthpointFreeText": "More For Approved",
    "healthpointGapAmount": "0",
    "healthpointPhfResponseCode": "00",
    "healthpointPhfResponseCodeDescription": "APPROVED",
    "healthpointHealthFundName": "ISOFT FUND",
    "healthpointHealthFundIdentifyingDigits": "0099"
}

Testing

The HealthPoint test host simulator supports the item numbers below, which trigger a "More for" assessment. Enter the standard service item as the first claim item, and the ICD code as the second with serviceReference set to ZZZ.

The expected outcomes are:

More For Approved — 100% rebate, no gap payable.
More For Rejected — claim level rejection code 12 (claim declined) and item level rejection code 18 (body part required).
More For Not Eligible — 50% rebate, gap payable.

Modality	Item code	ICD code	Test outcome
Chiropractic	1006	M752	More For Approved
Chiropractic	1001	None	More For Rejected
Chiropractic	1007	Z999	More For Not Eligible
Physio	560	G560	More For Approved
Physio	525	None	More For Rejected
Physio	526	Z999	More For Not Eligible
Dental	949	K029	More For Approved
Dental	961	None	More For Rejected
Dental	964	Z999	More For Not Eligible
Podiatry	12	M235	More For Approved
Podiatry	14	None	More For Rejected
Podiatry	111	Z999	More For Not Eligible
Optical	890	H578	More For Approved
Optical	632	None	More For Rejected
Optical	612	Z999	More For Not Eligible
Osteopathy	1802	R10	More For Approved
Osteopathy	1803	None	More For Rejected
Osteopathy	1804	Z999	More For Not Eligible

Example ICD codes

These are example ICD codes used by HCF. A Z99 code isn't eligible and results in a 50% rebate.

Modality	Example ICD codes
Podiatry	L90, M235, M766, Q665, Z99
Physiotherapy	G560, M069, S74, Z99
Chiropractic	M752, M755, R10, S63, Z99
Osteopathy	M752, M755, R10, S63, Z99
Dental	K029, K01, Z99
Optometry	H578, H258, Z99