{"templateId":"markdown","sharedDataIds":{"sidebar":"sidebar-docs/sidebars.yaml"},"props":{"metadata":{"markdoc":{"tagList":["admonition"]},"type":"markdown"},"seo":{"title":"Operational workflow","llmstxt":{"hide":false,"sections":[{"title":"Table of contents","includeFiles":["**/*"],"excludeFiles":[]}],"excludeFiles":[]}},"dynamicMarkdocComponents":[],"compilationErrors":[],"ast":{"$$mdtype":"Tag","name":"article","attributes":{},"children":[{"$$mdtype":"Tag","name":"Heading","attributes":{"level":1,"id":"operational-workflow","__idx":0},"children":["Operational workflow"]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["This page describes the operational workflow for private health fund claiming. It covers the"," ","workflows for private health insurance, overseas student cover and overseas visitor cover insurer"," ","transactions, and applies to both the JS library and the .NET library. For the methods and payloads,"," ","see ",{"$$mdtype":"Tag","name":"MarkdownLink","attributes":{"href":"/docs/in-person-payments/pay-in-person/features/private-health-fund/getting-started"},"children":["Getting started"]},"."]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":2,"id":"transaction-types","__idx":1},"children":["Transaction types"]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["Five transaction types are supported:"]},{"$$mdtype":"Tag","name":"ol","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Claim"]}," — processes a health fund member's claim for benefits at the point of service."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Rebate estimate"]}," — retrieves an estimate of patient eligibility, benefit and gap amounts"," ","without financial settlement. See ",{"$$mdtype":"Tag","name":"MarkdownLink","attributes":{"href":"/docs/in-person-payments/pay-in-person/features/private-health-fund/rebate-estimate"},"children":["Rebate estimate"]},"."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Void"]}," — invalidates the most recently processed claim because of rejection, abort or system"," ","error."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Cancellation"]}," — cancels a previously accepted claim within the same calendar day."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Reports"]}," — generates reports from the PMS covering transactions and settlements. See"," ",{"$$mdtype":"Tag","name":"MarkdownLink","attributes":{"href":"/docs/in-person-payments/pay-in-person/features/private-health-fund/reports-and-reconciliation"},"children":["Reports and reconciliation"]},"."]}]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":2,"id":"claim","__idx":2},"children":["Claim"]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["Claims use a gap payment method, so health fund members can submit claims at the point of service"," ","in real time. The health fund pays the benefit directly to the provider, and the member pays the"," ","gap, which is the difference between the service fee and the benefit amount."]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":3,"id":"claim-submission-requirements","__idx":3},"children":["Claim submission requirements"]},{"$$mdtype":"Tag","name":"ul","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Health fund membership number"]},", captured by swiping or tapping the membership card."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Patient number"]},", displayed on the front or back of the membership card and corresponding to"," ","the patient."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Provider number"]},", a Medicare- or health fund-issued number associated with the healthcare"," ","provider at the point of service."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Date of service"]},", typically limited to the current date."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Service item numbers and associated costs"]},". A single transaction can claim up to 16 items."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Body part or tooth number"]},", if applicable."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["ICD-10 code and preferred provider details"]},", required for specific funds such as HCF and for"," ","enrolled providers. See ",{"$$mdtype":"Tag","name":"MarkdownLink","attributes":{"href":"/docs/in-person-payments/pay-in-person/features/private-health-fund/preferred-providers"},"children":["Preferred providers"]},"."]}]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["The health fund membership card must be swiped or tapped for a claim to be submitted. Health fund"," ","details stored in a PMS must not be presented to the terminal."]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":3,"id":"claim-approval-process","__idx":4},"children":["Claim approval process"]},{"$$mdtype":"Tag","name":"ol","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Enter and review the health service details in the PMS."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Swipe or tap the patient's health fund membership card."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Enter the patient number if the PMS hasn't already provided it."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Process the claim and receive a real-time response from the health fund."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Print the claim assessment receipt and display the result in the PMS."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["The patient reviews the claim and chooses to accept or reject it."]}]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":3,"id":"approved-claims","__idx":5},"children":["Approved claims"]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["On approval, the health fund returns an overall approval status and a benefit amount for each"," ","service item. An approved claim can include items that are approved and items that are declined."," ","Unless otherwise indicated, any response code other than \"00 – APPROVED\" means the health fund"," ","declined that service item."]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["If the patient accepts"]},", the claim is finalised. The member pays the gap to the provider, and the"," ","health fund pays the benefit to the provider."]},{"$$mdtype":"Tag","name":"ul","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":["The patient signs the assessment receipt, which the practice retains for five years."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Print a second receipt for the patient."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Process the gap payment using the method the patient selects."]}]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["If the patient rejects"]},", a void is sent to the health fund to invalidate the claim, and the member"," ","pays the provider the full service fee."]},{"$$mdtype":"Tag","name":"ul","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Activate ",{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Reject"]}," in the PMS."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Print the void receipt."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Offer the options to adjust the claim details, or to discard the claim and pay the full service"," ","fee."]}]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":3,"id":"declined-claims","__idx":6},"children":["Declined claims"]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["On a decline, the health fund's reason codes are shown on the assessment receipt. The fund can"," ","return a ",{"$$mdtype":"Tag","name":"MarkdownLink","attributes":{"href":"https://help.tyro.com/s/article/HealthPoint-claim-response-codes#four"},"children":["claim level response code"]}," ","and an ",{"$$mdtype":"Tag","name":"MarkdownLink","attributes":{"href":"https://help.tyro.com/s/article/HealthPoint-claim-response-codes#five"},"children":["item level response code"]}," ","for each service item. 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The patient"," ","may seek to claim directly with their fund."]}]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":2,"id":"void","__idx":7},"children":["Void"]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["A void can happen because of:"]},{"$$mdtype":"Tag","name":"ol","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Claim rejection"]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["Operator abort"]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["System communication error"]}]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":3,"id":"void-rejection","__idx":8},"children":["Void (rejection)"]},{"$$mdtype":"Tag","name":"ul","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":["The claim is processed and the health fund sends its response in real time."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["A claim assessment receipt is printed, and displayed in 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Refunding a claim would mean the provider who received the benefit"," ","returns it to the health fund. Automated refunds can't be processed through HealthPoint, so the"," ","provider must contact the patient's health fund to return the original benefit amount."]}]},{"$$mdtype":"Tag","name":"Heading","attributes":{"level":2,"id":"reports","__idx":12},"children":["Reports"]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["The PMS should provide these reports:"]},{"$$mdtype":"Tag","name":"ul","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Health fund summary"]}," — the payment totals only, for each health fund."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Health fund totals by day"]}," — transactions (claim, void, cancellation) by day, grouped either by"," ","health fund or by day."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Transaction detail"]}," — patient names with the health fund transaction, including item codes and"," ","billing and payment detail."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":[{"$$mdtype":"Tag","name":"strong","attributes":{},"children":["Settlements"]}," — a consolidated payment view for health funds that use the HealthPoint settlement"," ","service, and an individual payment view for funds that pay directly, as the payment would appear"," ","in the provider's bank account."]}]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["A health fund pays a provider in one of two ways:"]},{"$$mdtype":"Tag","name":"ol","attributes":{},"children":[{"$$mdtype":"Tag","name":"li","attributes":{},"children":["The fund uses the HealthPoint consolidated settlement service to make a single, aggregated"," ","payment to the provider."]},{"$$mdtype":"Tag","name":"li","attributes":{},"children":["The fund pays the provider directly."]}]},{"$$mdtype":"Tag","name":"p","attributes":{},"children":["All HealthPoint-supported funds use consolidated settlement except HCF, which is planned to migrate"," ","later. 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