Online Eligibility Check

Online Eligibility Check

Online Eligibility Check [OEC] allows Healthcare Locations the ability to check the eligibility of a patient in relation to their Medicare and Health Fund status and obtain an estimate of out-of-pocket expenses relating to: 
  1. a hospital stay 
  2. prosthetic and miscellaneous services 
The ability of the OEC functionality to access and collate financial data relevant to the service costs and Medicare and/or Fund benefits applicable to a proposed episode of care can assist a Servicing Provider to provide the patient with sufficient information for the patient to give Informed Financial Consent [IFC].

There are 3 Types of OEC.
ECM which is Medicare only.
This Will go to Medicare only and will check only;
Medical services of 1 patient including Medicare details.
Medical service details to a maximum of 50 services per ECM 
1 principal provider and at least one servicing provider.

OEC which is Medicare and Fund. 
Medicare and the Health Fund and will check both medical and hospital eligibility and miscellaneous services.
Consists of 1 patient including Medicare and Health Fund membership details, hospital details. 
Medical service details to a maximum of 50 services per OEC, 
1 principal provider and at least one servicing provider.

ECF which is Fund Only.
Will go to the nominated Health Fund only and will only check for hospital eligibility and prosthetic and miscellaneous services. 
Consists of 1 patient including Health Fund membership details, hospital details, admission details, prosthetic and miscellaneous service details.
The OEC Report returned when this functionality is used can become the quote for the patient so that the patient is aware of any out of pocket expense.

ECM [Medicare only] OEC Check
Select Patient Details, Search and Select the patient.
  1. Check the patient Medicare card is entered.
Select System\Create Online Eligibility Check.
  1. A screen similar to the billing screen opens.
  2. Select the Hospital location and the Servicing Provider.
  3. Select fee type MS if you are using the schedule fee or select a Private fee type.
  4. In Item code select the MBS item number for the service being provided.
  5. Tick any service elements that pertain to this service.
  6. When all details have been entered select the Eligibility button from the Invoice section at the bottom of the billing window.
OEC Disclaimer
The OEC disclaimer prints to screen immediately after the online eligibility button is clicked. The patient must read this disclaimer. It is advisable to have a printed copy of this document to hand to the patient so that when you select to close this disclaimer and the OEC is transmitted to Medicare the patient has agreed to the terms of the disclaimer.

View the list of OEC checks performed for the patient.
  1. Main select Patient Details, search and select the patient.
  2. Select System\View Online Eligibility Check list.
  3. Select date Range and Report and Click SEND
  4. Perform a status request on the ECM. A transmitted time stamp is put on the request to show Medicare has received this. 
  5. Retrieve the report: This report is retrieved from Medicare Australia and states all details of the claim being lodged to check the status of benefit Medicare will or will not pay. The patient should be handed this document as the out of pocket expense on this service will be an amount as stated in the Balance column.
  6. Report can now be viewed by clicking View the report.
Performing an OEC [Medicare and Fund] Request.
Select Patient Details.
  1. Select System\Create Online Eligibility Check.
  2. A window similar to the billing screen opens.
  3. Select the Use Invoice for IMC.
  4. Select the Hospital Location and the Servicing Provider.
  5. Change the Service Date to be the date of Admission. A rule applies for OEC that states the Admission Date must be less than or equal to the service date.
  6. Select fee type MS if you are using the schedule fee or select a Private fee type.
  7. Select Health Fund.
  8. In Item code select the MBS item number for the service being provided.
  9. Select a Presenting Illness code.
  10. Double click Admissions and add details of the admission, dates for this service, Informed consent, Eligibility Check Type, Presenting illness Code.
  11. When all details have been entered select the Eligibility button from the Invoice section at the bottom of the billing window.
The patient must read and accept the disclaimer conditions.

Proceed to System\List Online Eligibility Checks and Send OEC .
Perform a status request on the OEC.
Retrieve the report and view.
This report is more detailed as the fund gives an explanation of services.

ECF [Fund] OEC Request.
Conditions apply to all ECF OEC requests:
  1. Servicing Provider has agreement or scheme with fund.
  2. Principal Location and Provider must not be set
  3. The Service type code can only be P Prosthetics and M Miscellaneous.
  4. Presenting illness item numbers must correspond with these service codes.
  5. Medicare (MBS) item numbers cannot be used.
  6. The Billing Service elements must not be set.
Prosthetic item number is to be used and must have been set up in item maintenance with Group O5 or M8

Select Patient details.
  1. Add Other payer incident for Prosthesis Company.
Select System\Create Online Eligibility Check.
A screen similar to the billing screen opens.
  1. Tick the option IMC.
  2. Select the Hospital location and the servicing provider.
  3. Change the Service date to be the date of admission.  
  4. Select Fund ID
  5. In Item code select Prosthetic or Miscellaneous item that has been set up in item maintenance.
  6. Select a Presenting illness item code.
  7. Double click Admissions and select the admission date for this service , Informed consent, Eligibility Check Type ECF, Presenting illness Code.
  8. When all details have been entered select the Eligibility button from the Invoice section at the bottom of the billing window.
The patient must read and accept the disclaimer conditions.
Proceed to System\List online eligibility checks.
Select ECF and click Send.
Perform a status request on the OEC.

Retrieve the report and view.
The OEC Fund Report is more detailed as the fund gives an explanation of services.
Patient Details Include: Account Reference ID, Patients First name and Surname, Patient Medicare Card Number, Patient IRN, Medicare Status, Medicare Explanation Code.
Fund Details include: Fund Reference Id, Table Description, Exclusion Description, Table Scale, Financial Status, Excess Amount, Excess Bonus Amount, Excess Amount Description, Benefit Limitations, Co Payment Amount, Co Payment Days Remaining.
Estimate results include: DateOfService, Item Number, Charge Amount, Schedule Fee, Medicare Benefit Amount, Fund Benefit Amount, Medicare Explanation Code, Fund Explanation Code, Service Assessment Code

 



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