CARE HANDBOOK - randmutual.co.za RMA Healthcare Provider Guide... · 6 6 TREATING AN RMA INJURY ON...
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CARE HANDBOOK FOR HEALTHCARE PROVIDERS: Injury on duty patients
Transcript of CARE HANDBOOK - randmutual.co.za RMA Healthcare Provider Guide... · 6 6 TREATING AN RMA INJURY ON...
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CARE HANDBOOKFOR HEALTHCARE PROVIDERS:
Injury on duty patients
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I N D E X
02What makes treating an RMA IOD patient different?
03Registering online 05
O1Overview 03
05Tariffs 09
09Medicine exclusions 15
11In summary 18
13Contact us 19
07Uploading documents online 13
08Ensuring valid switched invoices 14
10Join our network 17
12Important links 19
06Required documents 10
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04Treating an RMA IOD patient 06
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OVERVIEW01
We would like to extend a warm welcome to RMA.
We are the administrator of Compensation for Occupational Injuries and Diseases (COID) benefits within the mining and the iron, metal and steel industries in South Africa.
We trust that this is the beginning of a long and successful partnership between us.
This booklet is designed to help guide you through your journey in dealing with us for all your injury on duty (IOD) patients.
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WHAT MAKES TREAT ING AN IOD PATIENT FROM RMA D IFFERENT?
Claiming for your IOD patient is different to a medical aid in that every claim must be supported by a medical report that directly links the injury or disease diagnosis with the employee’s work-related accident.
COID benefits cover reasonable medical costs for an occupational injury or disease. The billing submitted by the treating healthcare provider must be aligned to the codes and tariffs specified in the COID gazette or as per agreement.
What makes RMA different when it comes to treating IOD patients?
Providing all RMA’s requirements are met, we pay within 10 working days. In other words, it takes us 10 days to process a valid invoice from capture to payment.
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What are the advantages of registering on the portal?• You can search for a claim number, thereby confirming that the
claim has been reported to RMA.
• You can confirm a liability decision on a claim i.e. has RMA accepted medical liability for the claim?
• You can view the status of your medical invoice. You will be able to see if it has been captured, validated, allocated, whether payment has been requested or whether it has been paid.
• You can draw a report on Paid/Pended/Rejected invoices, which will assist you with the reconciling of your invoices and allow you to take corrective action on pended or rejected invoices.
• You can capture a medical report directly to the system, thereby reducing delays.
• You don’t need to phone in for any of the above, you have it all at your fingertips at any time.
REGISTER ING ONLINEWe offer you an online portal that is a quick and easy solution to uploading your medical reports, and tracking medical invoices and drawing reports online.
A STEP-BY-STEP GUIDE TO REGISTERING ON THE PORTAL
Once you have received the email specified in Step 3, you may access the portal HERE
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RMA’s system will automatically email a username and password to your registered email address.
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P03Complete the online registration form and click “Register” once completed.
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TREAT ING AN RMA INJURY ON DUTY PATIEN T
4.1 Accepting liability for an IOD claim
In order for RMA to accept liability on a claim it is important to note that the injury or disease must be proven to be work related for it to be a valid COID claim. It also must have a corresponding First Medical Report.
Sometimes we need to investigate an incident further before we can make a liability decision on a particular case. Only once a liability decision has been made can payment for services be made if liability has been accepted. If liability is not accepted, the employer or employee will be responsible for payment.
Once we have accepted liability on a claim, reasonable medical expenses related to the occupational injury/disease will be paid until it has stabilised.
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For on-going treatment, we need to be informed of the progress of the patient’s medical condition at least once a month. Days taken off work and when the employee will resume work must be indicated.
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4.2 Pre-authorisation for an acute injury
Pre-authorisation helps as confirmation that we have taken liability for the cost of specific treatment, and is thus a form of guarantee of payment. Pre-authorisation can only be generated, however, once the accident has been reported to us by the injured patient’s employer, we have accepted liability and the details of the specific treatment or intervention has been submitted.
Send a request for pre-authorisation to: [email protected]
4.3 Treating emergency cases
In an emergency, medical treatment should continue without pre-authorisation, which can then be obtained retrospectively.
Whilst pre-authorisation is not a pre-requisite for treatment in emergency or acute cases, we recommend that you
notify us of all hospital admissions to assist us with expediting liability decisions. This in turn will help to
ensure quicker payment of your medical invoice.
Send a request for pre-authorisation to: [email protected]
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4.4 Physiotherapy and Occupational Therapy pre-authorisation
As from 1 April 2018, all treatment by a physiotherapist or occupational therapist must be pre-authorised and based on an acceptable treatment plan. The patient will require a formal referral from the treating doctor and the treatment must be related to the type and nature of the injury or disease.
Please note that a claim cannot be re-opened for basic investigations.
Send a pre-authorisation request for a re-opening to: [email protected]
4.5 Re-opening of a claim
Authorisation is compulsory if a claim that has previously been finalised is being re-opened for further medical treatment and we are expected to pay the medical costs of the re-opened claim. The requested treatment should be aimed at further reducing the impairment.
Re-opening of a claim should be for specific treatment, and you are required to first submit a request with supporting documents and a treatment plan.
If we find the treatment to be related, we will accept liability through the process of pre-authorisation and by issuing you with a confirmation.
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TARIFFS
You can access the COIDA tariff for your specific discipline HERE
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Medical benefits are paid up to a maximum of the COIDA tariff, or in specific cases as per the negotiated or agreed to tariffs.
In instances where a COIDA treatment code or tariff is not available, consultation with, and authorisation from, RMA is needed to confirm and agree on the code and tariff to be used. If no amount has been determined for a particular medical treatment, we will pay up to what was agreed and deem reasonable.
The COIDA tariffs are increased annually in April by the Department of Labour.
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REQUIRED DOCUMENTS
6.1 First Medical Reports
A medical report must be submitted to RMA after the first consultation. This should be a detailed report to be completed in the prescribed format. This report is critical as it helps us to make liability decisions and to determine the cover that the claimant will receive in terms of COIDA, based on the nature and extent of the specific injuries and the treatment that has been provided. Subsequent and future treatment decisions are based on the injuries that have been reported in the first medical report.
6.2 Progress Medical Reports
You need to submit a progress medical report for all further treatment. This means that a progress medical report must accompany your invoice for every consultation or treatment.
Even if pre-authorisation has been obtained, if there is no accompanying medical report, we will be unable to pay your invoice for that service date.
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6.3 Referral Letters
Should the patient consult an allied health professional (physiotherapist, chiropractor, occupational therapist, biokineticist, dietician etc.), the following documents must be submitted after the first consultation:• a referral letter from the treating doctor;
• a medical report from the allied professional; and
• a detailed treatment plan
A detailed treatment plan must be submitted for pre-authorisation and approval for any treatment extending beyond the initial consultation. If additional treatment is required beyond what had been pre-authorised, an updated treatment plan must be submitted for approval and supported by a motivation.
6.4 Final Medical Reports
Once the patient has reached Maximum Medical Improvement (MMI), a final medical report must be submitted. MMI occurs when an injured employee reaches a state where their condition cannot be improved with any further treatment, or when a treatment plateau is reached in their healing process. It can mean that they have fully recovered from their injury or that their medical condition has stabilised to the point that no further major changes are expected in their medical condition. At this point it is believed that no additional healing or
improvement will take place even if continuing with medical treatment or participating in rehabilitative programmes.
The final medical examination and associated report is used to assess functional loss and must therefore
summarise all the medical interventions that have taken place, together with the clinical findings.
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WHERE TO ACCESS OUR DOCUMENTS:
All medical report forms, and other required forms, are available HERE
This information is used to determine whether the claimant should receive a permanent disablement benefit and therefore partially or incomplete final medical reports are not accepted. Where an insufficient report has been submitted, a more detailed medical report will be requested before payment is considered or processed. Please ensure that you use the RMA designed medical reporting templates to guide you in terms of the information that is required to make informed adjudication and assessment decisions.
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UPLOADING DOCUMENTS ONL INE
Once you are registered on our portal, you can upload documents online including:
• Medical reports; • Required forms; and• Authorisation requests.
Log into the portal HERE.
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Click on the Documents tab. This will give you two options:
a. document list – enables you to check documents that have already been uploaded;
b. upload documents – click on this option to upload new documents.
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Once you have clicked on “upload documents”, a pop-up form will appear that you need to complete regarding the details of the document.
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Click on the browse button to upload the document.
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Click submit after capturing and uploading the relevant document. If the upload was successful, a “file successfully uploaded” pop-up message display.
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To verify that the document has been uploaded successfully or to check the status of the document, you can check it on the document list.
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If you do not have access to the online portal, you can email the documents to: [email protected]
Please refrain from duplicating the documentation, and only submit online OR by email.
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ENSUR ING VAL ID SWITCHED INVOICES
• Name of employee
• Valid RMA claim number
• Service provider’s reference and invoice number
• Practice number
• Date of service
• Item codes according to the officially published tariff guides
• ICD 10 codes
• Nappi codes
• Amount claimed per item code and total of account.
To ensure that your medical invoices are processed on first submission without delays, ensure that all electronically switched invoices contain the following critical information:
We require up to 10 days to process valid invoices from capture to payment. We assure you that we only require an invoice to be submitted once for us to process your payment, provided it includes all the correct critical information.
More than one submission will result in traffic, making it that much longer to process the claims.
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MEDIC INE EXCLUSIONS
Categories of acute and chronic medicine exclusions:• Contraceptive preparations and devices
• Preparations used specifically to treat and/or prevent obesity
• Diagnostic and monitoring agents and appliances
• Medicines used specifically to promote fertility
• Medicines used specifically to treat alcoholism
• Oxygen and the purchase or hire of oxygen delivery systems
• Aphrodisiacs
• Preparations to treat smoking
• Disease management monitoring agents
• Namibian products
• Allergens
• Topical acne preparations
• Essential fatty acid preparations and combinations
• Voluntarily withdrawn products
• Medicines used specifically to treat acquired immune deficiency syndrome
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Take note of the below list of exclusions when prescribing acute or chronic medicines for injury on duty patients in order to avoid any unnecessary rejections.
Should you believe that medicines within any of the below excluded categories are clinically necessary for a specific injury on duty or occupational disease, then a motivation is required which will be assessed on an individual basis.
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• Anabolic steroids
• Over-the-counter reading glasses
• Contact lens preparations
• Hospital non-recoverables
• Anti-malarials for prophylactic use
• Screening tests
• Professional services excluding screening tests
• Non-chargeable discontinued products
• Geriatric vitamins and vitamin/mineral supplements
How to submit a motivation1. Complete the Pre-authorisation and Re-opening of
a Claim form available HERE2. Upload the document on the online portal or email
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JO IN OUR NETWORK
We pride ourselves on offering a caring and compassionate approach to compensation and as part of this approach would like to offer our claimants a provider network where they are guaranteed speedy, quality service.
The list of providers in our network will be available for all our claimants.
The benefits for you include:• Your details will be shared with employers in your geographical
area and will be available on our website;
• We will make every effort to follow up on claims and any outstanding medical requirements, prioritise training, offer support and prioritise payments to providers within the network; and
• Payment priority on pre-authorised treatment as long as all the requirements are met.
HOW TO JOIN: Email us on [email protected]
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We invite you to join our network.
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SUMMARY
Employer note
First medical reportProgress medical reports
Final medical report
RMA assesses claim & accepts liability
Pre-authorisation
Submit invoice for payment
Emergency treatment
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IMPORTANT L INKS
CONTACT US
RMA medical portal
Important forms
Medical Reports
Class XIII industry classification
Class IV industry classification
The Compensation for Occupational Injuries and Diseases Act
COIDA Tariffs
TEL: 0860 222 132
EMAIL:Medical invoice enquiry: [email protected]
Pre-authorisation requests: [email protected]
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