Provider Information Booklet & Schedule of Benefits. Effective November 2010 Medibank Private Limited ABN GapCover

Transcription

1 Provider Information Booklet & Schedule of Benefits Effective November 2010 Medibank Private Limited ABN GapCover

2 How to register as a GapCover Provider Review our GapCover Booklet located on our website* for Terms and Conditions Complete a GapCover Application Form* and fax to An EFT confirmation will be ed to you You can start billing under GapCover How to Claim Confirm Patient s eligibility (refer to page 6 of the GapCover Booklet*) If you are charging the patient a Known Gap you will need to provide informed financial consent before treatment commences Download and complete a GapCover Batch Header* Attach patient s accounts to the Batch Header and mail to GPO Box 1288K Melbourne VIC 3001 Medibank Private GapCover benefits will be paid provided that Medicare Australia has approved the services claimed** Payment (including Medicare Australia s benefit) and Statement of Benefit will be sent within 21 days*** * All forms can be downloaded at: Information-For-Health-Care-Providers/GapCover-Information.aspx ** If Medicare Australia do not approved the claim then Medibank Private will not pay a benefit. A statement of benefit will be sent to the claiming provider listed on the GapCover Batch Header. The Statement of Benefit will outline the reason(s) the claim is rejected. *** Provided all other aspects of your claim satisfy the requirements outlined in the GapCover Booklet.

3 What s in this booklet Medibank Private is committed to helping our members close the gap with a scheme called Medibank Private GapCover. This is a flexible private health insurance arrangement that gives you the option of removing or reducing out-ofpocket expenses for in-hospital medical services for our members. This booklet explains how the Scheme operates and the procedures for making claims under our GapCover Scheme. It also provides the forms and stationery you need to begin billing. Our GapCover Scheme Contents 3 Our GapCover Scheme 6 How to claim 8 Receiving payments 10 Frequently asked questions 12 Enquiries and further information 13 Medicare Australia Assessment/Rejection Explanation Codes 16 Medibank Private Assessment/Rejection Explanation Codes 17 GapCover Schedule of Benefits effective 1 November Forms you may need This booklet is provided for your reference and assistance and is not to be copied or distributed. How does GapCover work? The benefits Medibank Private members are entitled to receive for in-hospital medical services are based on the Federal Government s fee schedule, known as the Medicare Benefits Schedule (MBS). However, as medical practitioners, you can set your fees above this schedule. The gap is the difference between the fees charged by you and the MBS fees for the services you provide. This difference can leave our members with out-of-pocket expenses. With Medibank Private GapCover, you can help close this gap for our members. 3

4 Our GapCover Scheme How does GapCover work? No Gap Medibank Private s GapCover Schedule of Benefits shows the amount you can charge for a particular service under our GapCover Scheme, so that there will be no gap for a Medibank Private member to pay. The amounts shown in the Schedule include the MBS fee plus the additional amount that we are willing to pay for a particular service. So long as your fees do not exceed the relevant amount in the GapCover Schedule of Benefits, then there will be no gap for our members. Known Gap Alternatively you may wish to charge a Medibank Private member a Known Gap. This is any amount you charge that exceeds the amount shown in our GapCover Schedule of Benefits, up to a maximum of $500 per per claim. If you submit an account where the Known Gap exceeds $500, the benefit payable to the member for that claim will be reduced to 100% of the MBS. In other words, we will not pay any amount above the MBS. Informed Financial Consent (IFC) You are required to provide Medibank Private members with a written estimate of the costs for each hospital admission and they need to sign this if they agree to proceed with the treatment. The written estimate must be provided, prior to treatment where possible or, otherwise, as soon as practicable after the treatment. Participation in the Medibank Private GapCover Scheme is conditional on you meeting these IFC requirements. Medibank Private reserves the right to refuse entry to the GapCover Scheme to providers who fail to obtain IFC from our members. For further information about IFC please call our Medical Enquiry Line on Disclosure of financial interest You are required to disclose to Medibank Private members, any financial interest you may have in any products or services you provide or recommend they use. Disclosure should be made prior to treatment where possible or as soon as possible after the treatment. 4

5 Provider eligibility Providers participating in the GapCover arrangements must be registered medical practitioners within the State/Territory and have the rights to conduct private practice. They must also have been allocated a provider number to practice at the medical service address. Opt in or out Medibank Private staff will not make recommendations to members regarding their choice of medical practitioner. They will also make clear to members that inclusion on the GapCover specialist list does not affect the ability of practitioners to opt in or out of our GapCover Scheme at their discretion. Medical practitioner GapCover listing Medical Practitioners who use our GapCover scheme can nominate to be included in Medibank Privates GapCover specialist listing on our website, when completing the Application Form. Medical Practioners may withdraw from the list by giving Medibank Private 14 calendar days notice in writing of their intention. By fax to: What medical services are covered by GapCover benefits? Only medical services provided by a medical practitioner to a Medibank Private member who is a privately admitted patient during a period of hospitalisation are covered by Medibank Private s GapCover benefits. This includes private patients in a public hospital who are being treated by a visiting medical officer. Salaried medical practitioners at public hospitals can not claim GapCover benefits. Any consultations or treatments before or after hospitalisation are not covered by our GapCover Scheme and need to be billed separately. Please inform your patient that these expenses are not claimable from Medibank Private, but may be claimable through Medicare Australia. When are GapCover benefits not applicable? Medibank Private members will not be entitled to a GapCover benefit when any of the following applies: Where a Medicare Australia benefit is not payable or where Medicare Australia has rejected the claim. If the membership was not fully paid at the date of service you provided (i.e. the member s premiums were in arrears). If the Medibank Private member s health insurance cover does not provide benefits for the services provided (see Patient eligibility check on page 6 for more information). If the service was performed while the patient was not admitted as a Medibank Private member to a public or private hospital. If the claim was covered by workers compensation or third party insurance, or if the patient is entitled to receive compensation or damages from elsewhere, in accordance with Medibank Private s Fund Rules. If the claim was lodged more than 2 years after the date of service. If you submit an account where the Known Gap exceeds $500 per claim, the benefit payable to the patient for that claim will be reduced to 100% of the MBS. If the patient has not received written information about what amounts they can reasonably expect to pay for the treatment and the patient has not provided their acknowledgment of the information (informed financial consent) and/or you have not disclosed any financial interests you have in the products or services recommended to be provided to the patient. If the service is excluded from attracting Medicare benefits such as cosmetic surgery. If you charge any additional fees to your patient such as copayments, booking or administration fees. Payment of benefit The benefit we pay you will be based on the MBS item numbers identified by you. Payments typically take 21 days to be processed, provided all other aspects of your claim satisfy the requirements outlined in this booklet. The benefit will be paid in accordance with the Medibank Private GapCover Schedule of Benefits and the Medicare Australia assessing rules, as amended from time to time. The Medibank Private GapCover Schedule applicable from 1 November 2010 is provided starting on page 17 of this booklet. The latest Schedule can be downloaded from our website. Indexation of benefit The benefit will be indexed automatically each year on 1 November. The calculation will be made taking into account the Consumer Price Index and other indices as defined from time to time by Medibank Private. The calculation will be taken from these figures during the 12 month period ending 30 June of the year in question. 5

6 How to claim Use the information in this section to ensure your accounts can be processed as efficiently as possible. The information required on the account is the same for both your billing options. Billing Send the bill directly to Medibank Private. You will need to follow steps 1 to 4 outlined below. Simple steps to follow There are four simple steps to follow: 1. Patient eligibility check 2. Account information 3. Batch header 4. Send your accounts These are explained in further detail in the sections below. 1. Patient eligibility check Patient eligibility must be checked to ensure the Medibank Private member has the right level of cover and that their membership will be fully paid at the date you plan to provide the service. Medibank Private will confirm patient eligibility for you upon request. To ensure membership confidentiality, access to this service is restricted to participating providers. Access to this service must only be used for the purpose of checking patient eligibility for a service you plan to provide. How to check patient eligibility 1. Call Medibank Private on You will be connected to an interactive voice response enquiry service (called an IVR). 2. Select 1 (one) to be connected to the automated patient eligibility enquiry service. 3. Enter the access code Enter the patient s Medibank Private membership number and the patient s date of birth to complete the eligibility check. 5. The IVR instructions will guide you through the process and if necessary, transfer you to our staff. 6

7 Eligible Medibank Private Hospital Covers Most Medibank Private hospital covers provide benefits for medical services which are eligible for GapCover benefits. However the following Medibank Private hospital covers are not eligible for GapCover benefits: Public Hospital Cover Basic Public Hospital Cover Visitors Covers Overseas Student Health Cover Likewise, our members with only Extras cover and/or Ambulance cover are not eligible for GapCover benefits. If the member is not eligible please bill the patient. (Benefits may or may not be payable through Medicare). 2. Account information Please print only one patient account on each page. Accounts cannot be double sided or hand written. Non compliance of any of the above information will result in the claim(s) being rejected. We recommend that you set out your accounts as shown in the example on page 44. Using this format will help improve our processing of your claims. 3. Batch Header A Batch Header must accompany all medical claims billed direct to Medibank Private. Claims not accompanied by the Medibank Private GapCover Batch Header will not be accepted for processing, including resubmitted accounts. Please ensure all fields are completed. The Medibank Private GapCover Batch Header, as shown below, can be downloaded from our website. A Batch Header must accompany all medical claims billed direct to Medibank Private and provide a return address on the claim form (including resubmitted accounts). The following details are to be provided on your accounts: Patient s Medibank Private membership number Patient s name, address and date of birth Patient s Medicare card number, including the patient s card reference number (please ensure the Medicare card is current) Provider number For each service provided, the date of service and Medicare Benefits Schedule (MBS) item number. A fee for each MBS item number (this must be the exact fee payable for the service with no conditions attached eg. early payment discounts) Details of any shared fee arrangements with other medical practitioners, including MBS item number, name of other practitioner(s) and their provider number(s) Any patient out-of-pocket expense amounts and details of any shared patient out-of-pocket charging arrangements Referral details including referral date, referring provider name, number and address Any other information relevant to assessment of the service as outlined in the MBS. Please note that Medibank Private cannot process claims that do not include an MBS item number, even though Medicare Australia accepts either an MBS item number or description. Why is the Batch Header required? The Provider Practice number determines where the payment is to be made. Only 1 provider number on the batch header is accepted. It includes an indication that the patient received in writing all relevant financial information about their treatment and Informed Financial Consent has been provided. It will indicate that you disclosed to the patient all relevant financial interests you had in any product or service you provided or recommended to them. It includes your declaration that the relevant services were provided to a private patient, admitted overnight or for the day, in an approved hospital or an approved day hospital facility. It indicates your acceptance of the Medibank Private GapCover procedures outlined in this booklet. 4. Send your accounts Send your GapCover accounts by mail to Medibank Private for payment: Medibank Private GapCover GPO Box 1288K Melbourne VIC

8 Receiving Payments This section explains the process for payment of Medibank Private GapCover benefits, Statement of Benefit and what to do if your account has been rejected. Payment of claims Services eligible for Medibank Private GapCover benefits will be paid by Medibank Private provided that Medicare Australia has approved the claim(s). When the benefit is received from Medicare Australia, Medibank Private will make an EFT payment to you, up to the level of entitlement under the Medibank Private GapCover Schedule of Benefits, which represents the total Medicare Australia and Medibank Private benefits for the claim(s). Medibank Private will forward payment for each account as soon as assessment is complete regardless of the processing status of the other accounts submitted within the same batch. If you submit an account where the Known Gap exceeds $500 per doctor per claim, the benefit payable to the member for that claim will be reduced to 100% of the MBS. Using the Batch Header provider number The provider number on the Batch Header determines who the payment will be made to. This provider number does NOT need to be the same as the service provider number on your accounts. EFT Payments Benefits are paid as direct deposits into a nominated account by EFT. You can nominate one account for all of your provider numbers or nominate a different account for each provider number. If you have not nominated an account for each of your provider numbers you will need to complete a GapCover Application Form. You will find this form at the back of the booklet or you can download a copy from our website ( 8

9 Statement of Benefits Allow approximately 10 working days after the EFT payment to receive your statement. Your Statement of Benefit will be automatically sent to the address of the provider number listed on the Batch Header. To nominate a different postal address for your Statement of Benefits you will need to specify this on the GapCover Application Form, which can be found on our website Fields on your statement Proc Date: This is the date which Medibank Private processed your account. PayGroup: This is the service provider s provider number. Account reference number (if supplied): This is the provider s account reference number. This enables accounts to be reconciled. Run No: Together with the membership number, this number assists with payment enquiries. Lodgement Date: The lodgement date is the same date as recorded on your Batch Header. Service: The MBS item number. Date: Date on which the service was performed. Doctor s charge: The amount the doctor has charged the patient for the service and will include any Known Gap. Schedule Benefit: This is the Medibank Private GapCover Schedule Benefit. Where the assessment/rejection relates to Medicare Australia, M/C will appear immediately before the code number. Claims Rejection/Assessment If a claim has been rejected you will be notified in one of two ways. 1. You will receive a letter detailing why the claim has been rejected 2. The Statement of Benefits will outline the reason(s) a claim is rejected by either Medibank Private or Medicare Australia. Refer to pages for a list of assessment/rejection explanation codes. Depending on the reason for rejection you may need to: Amend the account as necessary and resubmit the account with your next batch. Please indicate on the account that it is being resubmitted. Check the account details in accordance with the rejection reason. If Medibank Private benefits are not payable, please bill the patient directly using your normal billing procedures. Remember to mark the account The amount on this account is claimable through Medicare Australia only. Review of payment overpayments/ underpayments/non-payment To further improve our service, we have implemented a new claims and reassessment system. All payment reviews need to be logged with our Medical enquiry line on You will be allocated a reference number and be notified of status updates via . Please note a Medical Claim Review form is no longer required. Benefit: Benefit amount paid. Sub-total of benefit for each patient: The benefit paid for each individual patient. EXP: Numeric assessment/rejection explanation code. Total for Provider: Total amount of benefits for claims paid for the date of lodgement on that statement. Total Benefits for this Statement: This is the total for all dates of lodgement contained within that statement. Lodgement Reference Number: Depending on your bank s procedures, this reference may appear on your bank statement next to our EFT payment. This may assist in the reconciling of accounts. Explanation of Codes: Explanation code number that appears under EXP (above) plus the actual explanation. 9

10 Frequently asked questions Item numbers and provider fees Should I use the MBS fees or the GapCover Schedule to work out the order of items for multiple operations? You will need to use the Medicare Australia assessing rules as described in the MBS and MBS fees to determine the order of items for multiple operations. Does it matter in what order I bill anaesthetic items? Anaesthetic items must be billed in the order required by the Medicare Australia rules. Refer to Group T/10 relative value guide for anaesthesia in the MBS book. How do I work out a derived fee for GapCover? Where the GapCover Schedule lists a percentage and not a fee against an item number, it is a derived fee. Work out the MBS fee for the item number using the Medicare Australia assessing rules and then apply the GapCover Schedule percentage to the MBS fee you calculate. Can I bill for item numbers not listed in the GapCover Schedule? If you claim for item numbers that are not listed on the GapCover Schedule you will only be paid at the MBS rates. You can only claim these items when accompanied with valid GapCover item/s. Assistant fees and billing Should I use the MBS fees or the GapCover Schedule to work out which assistant item number to use? You should use the MBS fees to work out which assistant item number to use. Refer to Group T9 Assistant Operations in the MBS book for the fee calculation. When you have worked out which item number to use from the MBS, apply the GapCover Schedule percentage to the MBS fee you calculate. 10

11 What information does Medibank Private require on an account for assistant fees only? The account should be on the assistant s letterhead and indicate the assistant item number, date of service and relevant fee together with the assistant s provider number. Separately, list the surgeon s provider number and the surgical item numbers. Please indicate on the account who is the assistant and who the surgeon is. No fee is required against the surgical item numbers as they are not being claimed. What if the surgeon is billing for the assistant s fees? The account should be on the surgeon s letterhead and have all the surgical items listed with date of service and fee for each item. The account should then have the assistant s item number, date of service and fee plus the assistant s provider number, name and address. Other questions What referring provider details do I need to include? The Provider Number, name and address for the referring provider, the date of referral and the referral period. Why does Medibank Private need the Medicare patient reference number? The Medicare patient reference number is extremely important to Medibank Private as it reduces delay in payments due to a possible mismatch with Medicare Australia records. For example, the patient is registered with Medicare Australia as William, but with Medibank Private as Bill. The reference number must be put at the end of the Medicare number on your account. 11

12 Enquiries and further information Stationery Supplies We will provide you with the following supplies, when required: Facsimile Stationery Order forms Pre-addressed envelopes Medibank Private brochures To obtain these items, complete a Facsimile Stationery Order Form and fax it to (03) You can also download this form from our website. You can download, save and pre-populate the fields on the Batch Header. If you pre-populate the fields we advise you use the industry standard, Arial font 14pt. Website Our website at medibank.com.au provides: details on the GapCover Scheme a noticeboard which includes the most recent updates to our GapCover Scheme and will be the forum for Medibank Private to communicate ongoing changes and improvements to our GapCover arrangements the latest versions of all the forms and stationery you need to bill Medibank Private the latest GapCover Schedule (should you wish to have the GapCover Schedule ed to you, please medical_provider@medibank.com.au. Account enquiries should not be ed to this address.) The GapCover page is accessible at Providers/Information-For-Health-Care- Providers/GapCover-Information. Phone If you have any further questions, please call our Medical Enquiry Line on This service is available from 8.30am to 5.30pm Monday to Friday Eastern Standard time. 12

13 Medicare Australia Assessment/Rejection Explanation Codes Note: The following Medicare Australia codes will appear on the Medibank Private Statement of Benefit with a leading number of one (1), eg. code 106 will appear as Code Explanation 106 M/C Provider requesting/providing service cannot be identified 108 M/C Benefit is not payable for the service claimed 123 M/C Benefit paid on radiology item other than service claimed 124 M/C Item is restricted to persons of opposite sex to patient 129 M/C Service is not payable without the base item/s 131 M/C Individual dates of service required refer to provider 137 M/C Details of requesting provider not shown on account/receipt 138 M/C Item is only payable if self-determined or deemed necessary 141 M/C Benefits not payable for service performed by this provider 151 M/C Associated service already paid adjustment being processed 154 M/C Diagnostic Imaging Multiple Service Rule applied to service 159 M/C Item associated with other service on which benefit payable 160 M/C Maximum number of services for this item already paid 162 M/C Benefit has been previously paid for this service 163 M/C Surgical/Anesthetic Item/s already paid for this date 164 M/C Assistant surgeon benefit not payable 168 M/C Associated operations/anaesthetic item not on account 171 M/C Benefit not payable provider may only act in one capacity 179 M/C Benefit not payable associated service already paid 211 M/C Patient not covered by this card number at date of service 227 M/C Date of service prior to date eligible for Medicare benefit 228 M/C Date of service after benefit period for overseas visitor 252 M/C Service possibly aftercare NOTE: The above lists may not be exhaustive and are subject to change 13

14 Code Explanation 253 M/C Radiotherapy assessed with other item number on statement 261 M/C Associated surgical items/anaesthetic time not supplied 265 M/C Service not covered by Reciprocal Health Care Agreement 267 M/C Service not payable associated service not present 316 M/C Benefit not payable item cannot be self-determined 320 M/C Quoted Medicare card number is incorrect. 325 M/C Laboratory not accredited for benefits for this service 326 M/C Laboratory not accredited for benefits at date of service 333 M/C Provider must claim time based items 335 M/C Service is not payable without nuclear medicine service 336 M/C Benefit paid on nuclear medicine item other than one claimed 338 M/C Provider not registered to claim benefits at date of service 353 M/C Transaction fee not accompanied by pathology episode 373 M/C Expired card benefit not payable 374 M/C Expired card issue used benefit not payable also 378 M/C Referring/requesting provider not registered 400 M/C Equipment number missing or invalid 401 M/C Benefit not paid charge amount missing or invalid 402 M/C Benefit not paid number of patients attended required 403 M/C Subsequent consultation referral details required 404 M/C Benefit not paid referral/request details required 405 M/C Equipment number invalid for servicing provider 406 M/C Unable to assess claim please forward documents 410 M/C Age restriction applies for this item verify details 412 M/C Benefit not payable provider unable to claim this service 414 M/C Provider practice location is closed at date of service 415 M/C Referral details same as rendering provider self deemed? 416 M/C Services form a composite item composite item required 417 M/C Referral needed it no referral, NR item to be transmitted 421 M/C Wrong assistant item used for the operation/s performed 426 M/C Indicate whether new treatment or continuing management 428 M/C Date of service greater than 2 years please forward documents 429 M/C Patient cannot be identified from information supplied 14

15 Code Explanation 430 M/C Conflicting referral details please clarify 432 M/C Item indicated as not part of multi-op no explanation? 434 M/C Expired or Invalid Card. Benefit not payable 436 M/C Non in-hospital service not claimable under simplified bill 475 M/C Patient/Service details invalid or missing 500 M/C Rejected in association with another item in this voucher 514 M/C Required Equipment type code not on LSPN register. 515 M/C Equipment greater than 10 years old. 516 M/C Benefit Paid for base and derived radiotherapy items claimed. 536 M/C Location Specific Practice Number not supplied 537 M/C Location Specific Practice number invalid 538 M/C Location Specific Practice not recognised 539 M/C Location Specific Practice not valid at date of serv 551 M/C Specimen collection point is incorrect or not supplied 553 M/C Approved collection centre number not supplied 555 M/C Benefit paid on main RVG Anaesthetic item 556 M/C RVG time item not claimed 557 M/C Associated RVG anaesthetic item not claimed 558 M/C RVG Anaesthetic item not claimed 559 M/C Patient outside age range please verify age 560 M/C RVG Item restriction 561 M/C Benefit paid on RVG Item claimed 562 M/C Benefit paid on associated RVG Anaesthetic Item 563 M/C associated RVG service already paid 604 M/C Service over 6 months old late lodgement form required 605 M/C Referral expired No benefit payable 606 M/C Referring provider practice location is closed. 709 M/C Another assistant item should be claimed 710 M/C Associated surgical items not present 711 M/C Unable to determine associated surgery 712 M/C Base item not present or in incorrect order 718 M/C Provider location closed at date of service 732 M/C Referring period invalid for referring Provider. NOTE: The above lists may not be exhaustive and are subject to change 15

16 Medibank Private Assessment/Rejection Explanation Codes Code Explanation 0039 Letter of explanation being sent separately 0058 Pre-existing ailment. No benefit payable 0547 Insufficient details to permit claim payment 0548 Compensation claim 800 No GapCover paid service is not a valid service for GapCover claims 801 No GapCover paid service is not covered by the member s cover type 802 Internal use only 803 No GapCover paid Claim charges exceeded the claim benefits 804 Internal use only 805 Service benefit is equal to the service charge 16

17 GapCover Schedule of Benefits effective 1 November

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