st.lukes GAP cover Billing and Claiming Guidelines

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st.lukes GAP cover Billing and Claiming Guidelines

January 2008

Closing the gap in private health care.

23334566778

INTRODUCTION

BILLING AND CLAIMING GUIDELINESWho is eligible for St. Luke’s Gap Cover?

What waiting periods apply to St. Luke’s Gap Cover?

When are St. Luke’s Gap Cover benefits not payable?

Charging No Gap

Charging a Known Gap

How are claims paid through the St. Luke’s Gap Cover arrangement?

Payment of benefits

Statement of Benefit

Claim rejection procedures

How to use the Batch Summary?

Enquiry Support and Stationery Supplies

APPENDICESStationery Order Form

Batch Summary (Sample)

Estimate of Medical Fees (Sample)

1st.lukes GAP cover - Billing and Claiming Guidelines

St. Luke’s Gap Cover is a medical gap

cover arrangement that is designed to

provide Medical Practitioners with the

option of eliminating or reducing the

medical gap for eligible St.LukesHealth

members requiring hospital in-patient

medical services.

These Billing and Claiming Guidelines provide

information to participating practitioners on

the claiming process associated with St.

Luke’s Gap Cover. The guidelines should

be read in conjunction with the Operating

Guidelines contained within the St.

Luke’s Gap Cover Information for Medical

Practitioners booklet.

Introduction


WHO IS ELIGIBILE FOR ST. LUKE’S GAP COVER?Eligible Services

An eligible service is a service:

•which has been rendered to an eligible

St.LukesHealth member who has been

admitted as a private patient to an approved

hospital or day hospital facility;

•where informed financial consent has

been obtained from the patient where a

known gap has been charged and financial

disclosure has been provided to the patient;

•where the feecharged for theservice is in

accordance with the “No Gap” or “Known

Gap” levels provided for within St. Luke’s Gap

Cover;

•whichhasbeensubmittedtotheFundpriorto

being submitted to Medicare.

Services provided to “out-patients” or patients

using facilities of the hospital but who are not

formally admitted as a “day patient” or “overnight

patient” do not qualify for St. Luke’s Gap Cover

benefit.

Any consultations or treatments before or after

hospitalisation need to be billed separately. The

patient should also be advised that these services are

only claimable through Medicare.

Eligible St.LukesHealth members

St.LukesHealth members who are covered on the

following hospital products are eligible for St. Luke’s

Gap Cover:

Product Name Plan Code

Hospital Platinum J

Hospital 100 to Hospital 1000 J1 to J5 & JT

Limited Excess Top Private Hospital K

Pasplan & Status 85 P1 to P4

Packaged Basic EP

Packaged 300 & 500 Z3 & Z5

Packaged Platinum Plus ZP

In addition, an eligible St.LukesHealth member means a person:

1. Who during an episode of hospital care:

a) is a financial member of St.LukesHealth and holds

an appropriate level of health insurance cover;

b) is not subject to a Waiting Period;

c) is registered for and entitled to receive Medicare

rebates for the services performed;

d) is a “patient” as defined in Section 3(1) of the Health

Insurance Act 1973; and

2. Who during an episode of hospital care, received

services:

a) which are not eligible for compensation, damages or

any other indemnification;

b) which do not relate to a Pre-Existing Ailment where

such services are provided within the first 12 months

of commencing a membership with a registered

private health insurer;

c) which are not excluded from attracting a Medicare

rebate, such as cosmetic surgery.

Where the member’s level of hospital cover carries

an excess, this excess does not apply to the St. Luke’s

Gap Cover benefit.

Confirmation of patient eligibility

You should confirm with the patient whether they

have private health insurance and obtain both their

current Medicare number including their Medicare

card reference number and their St.LukesHealth

membership number.

On confirmation of the above, the following six

points should be checked:

1. Is the patient a St.LukesHealth member?

2. Is the service eligible for Medicare rebates?

3. Does the member hold appropriate cover?

4. Is the member up to date with payments?

5. Have waiting periods been served?

6. Are the services eligible for compensation? (Benefits

are not payable where compensation or damages

may be claimed from another source.)

Billing and claiming guidelines


We recommend your administration staff contact

St.LukesHealth Customer Service on 1300 651988 to

confirm the patient’s eligibility.

WHAT WAITING PERIODS APPLY TO ST. LUKE’S GAP COVER?The following Waiting Periods apply to all new

members who were previously uninsured. These

waiting periods may also apply when an existing

member increases their level of cover or when a

member transfers to St.LukesHealth from another

Fund where the previous Fund did not offer an

equivalent Gap Cover arrangement.

•A two (2) month waiting period applies to all

benefits except as further specified below.

•A twelve (12) month waiting period applies to

all obstetric related services whether or not the

member was pregnant at the time of joining

or changing cover. This includes miscarriage,

threatened miscarriage, termination and

treatment for other obstetric conditions.

•A twelve (12) month waiting period applies to

pre-existing ailments. A pre-existing ailment is an

ailment, illness or condition the signs or symptoms

of which, in the opinion of a Medical Practitioner

appointed by St.LukesHealth existed at any time in

the period of 6 months ending on the day on which

the member became insured under the policy.

Waiting periods commence from the date of joining

a private health insurer or from the date of changing

cover. For previously uninsured members, no

benefit is payable during the application of a waiting

period. Members who have transferred from another

registered private health insurer receive continuity of

membership for benefit entitlements for which they

were previously covered, provided the St.LukesHealth

cover includes those equivalent benefits and the

member has served the required waiting periods with

their previous insurer. Where the St.LukesHealth cover

or benefit is higher than that of the previous insurer’s

membership entitlements, then benefits will be

payable at the previous (lower) level of benefits

during the application of a waiting period.

When a waiting period is applied to a member

changing their level of cover, benefits will be paid

at either the previous level of cover or the new

level of cover, whichever is the lesser.

WHEN ARE ST. LUKE’S GAP COVER BENEFITS NOT PAYABLE?St. Luke’s Gap Cover benefit will not be paid:

•if the member was charged a known gap and

informed financial consent was not obtained from

the patient or if financial disclosure was not given

to the patient.

•ifthefeechargedisinexcessoftheknowngaplimits

applicable to St. Luke’s Gap Cover.

•iftheservicewasnotaneligibleserviceasdescribed

on page 2.

•if the member was not an eligible member as

described on page 2.

•wheretheMedicarerebateisnotpayable,orwhere

Medicare has rejected the claim.

•if theclaimwaslodgedmorethantwoyearsafter

the date of service.

•if the member has received their Medicare

rebate prior to the account being submitted to

St.LukesHealth.

Note: Where St.LukesHealth does not pay a St.

Luke’s Gap Cover benefit, the maximum payable

is the difference (25% medical gap) between the

Medicare rebate and the Commonwealth Medicare

Benefits Schedule Fee. In these circumstances

you may wish to come to an arrangement with

the member.


CHARGING NO GAP If you wish your patient to be fully covered for

the service you are providing, your fee should

not exceed the level shown in the St. Luke’s

Gap Cover Schedule of Fees.

Where your fee is equal to or less than the

St. Luke’s Gap Cover Schedule Fee, an eligible

member will be fully covered under St.

Luke’s Gap Cover providing all other eligibility

requirements have been met.

In all aspects, St.LukesHealth benefit

assessment will be based on Medicare

assessment rules.

Billing Multiple Procedures with No Gap

In arriving at the charge for a multiple

procedure under St. Luke’s Gap Cover, the same

multiple procedure rule or formula is to be used

as contained in the Commonwealth Medicare

Benefits Schedule. In all cases, the MBS fee level

should be used to determine the order in which

the multiple procedure is to be calculated.

Once the order is determined, the appropriate

percentages should be applied to the St. Luke’s Gap

Cover Schedule Fee for each item.

Example of a multiple procedure

MBS

item

MBS

Fee

St. L

uke’

s Fe

e

100%

Fee

50%

Fee

25%

Fee

Procedure 1

$500

$600

$600

Procedure 2

$400

$650

$325

Procedure 3

$300

$500

$125

The total no gap fee for this multiple procedure is $1050

In the above example the 100% fee was applied to

Procedure 1 even though the St. Luke’s Gap Cover

Schedule Fee for Procedure 2 was higher. This is

because the MBS Fee for Procedure 1 was higher

than for Procedure 2. Under Medicare assessing

rules, the MBS Fee is used to determine the order in

which the multiple procedure is to be calculated.

Billing Multiple Anaesthetics with No Gap

Where a multiple anaesthesia is provided the Medicare

rules under the Relative Value Guide for Anaesthesia

apply. That is, the RVG item with the highest basic

unit value should be charged. However, the time

component should include the total anaesthesia time

taken for all services.

Derived Fees

When calculating a derived fee through the gap cover

scheme, the MBS Schedule Fee should first be calculated

using the formula stated in the Medicare Benefits

Schedule for the relevant item. The derived MBS schedule

fee should then be multiplied by the percentage shown

in the St. Luke’s Gap Cover Schedule of Fees.

CHARGING A KNOWN GAPIf you elect to charge your patients a known gap, you

need to obtain written informed financial consent from

the patient prior to treatment, or in the case of an

emergency, as soon after treatment as practical.

If you charge a known gap to eligible St.LukesHealth

members, St. Luke’s Gap Cover benefit will only apply

if the known gap for each service is within 10% of

the St. Luke’s Gap Cover Schedule of Fees.

Billing Multiple Procedures with a Known Gap

The rules to apply when billing a multiple procedure

or multiple anaesthetic with a known gap are the

same as shown on page 4.

For example:

MBS

item

MBS

Fee

St. L

uke’

s Fe

e

Max

. Kno

wn

Gap

Fee

100%

Fee

50%

Fee

25%

Fee

Procedure 1

$500

$600

$660

$660

Procedure 2

$400

$650

$715

$375

.50

Procedure 3

$300

$500

$550

$137

.50

The total known gap fee for this multiple

procedure is $1155

Billing and claiming guidelines (cont’d)


HOW ARE CLAIMS PAID THROUGH THE ST. LUKE’S GAP COVER ARRANGEMENT?The following special claiming facilities are provided as

part of the St. Luke’s Gap Cover arrangement.

Billing the fund direct

To bill the fund directly, follow these steps:

1. Confirm that the patient is a member of

St.LukesHealth.

2. Obtain the patient’s St.LukesHealth membership

number, Medicare Card number and Medicare

Card reference number.

3. Obtain informed financial consent in writing

from the patient if a patient contribution or

known gap is being charged and provide

financial disclosure by using the “Estimate of

Medical Fees” form or similar. A sample of an

appropriate Estimate of Medical Fees form is

included in the Appendices.

4. Ensure your fee charged is within the allowable

limits of St. Luke’s Gap Cover.

5. Ensure the following details are provided on

your account:

•Patient’sname,addressanddateofbirth.

•Patient’sAccountReference.

•Medicare card number, including the patient’s

Medicare card reference number.

•St.LukesHealthmembershipnumber.

•Nameandprovidernumberofthehospitalwhere

the service was performed.

•All service details ie. Date of service, MBS item

number, special exemptions, etc.

•Whethertheclaimwaseligibleforcompensation.

•Fees charged for each MBS item, including any

patient contribution. (Do not use a notional fee).

•Referraldetails.

•HospitalCollectionPoint(HCP)code

(if the account includes pathology services).

•LocationSpecificPracticeNumber(LSPN)(ifthe

account includes radiology services)

•Anyotherinformationrelevanttoassessment

of the service.

•AustralianBusinessNumber(ABN)

Note: The St.LukesHealth membership number,

the hospital detail, Medicare Card number and

patient Medicare Care reference number can be

included on the Batch Summary if this information

is not provided on your account.

6. Forward all accounts for eligible services to

St.LukesHealth as they are raised individually or in

batches.

7. Complete, and attach, a “Batch Summary” to each

batch of accounts submitted. If only one account is

to be submitted, a “Batch Summary” still needs to

be completed. A sample of the “Batch Summary” is

included in the Appendices.

Online claiming using ECLIPSE

As an alternative to issuing paper based accounts,

you can also claim electronically through your practice

management software by using the ECLIPSE functionality.

ECLIPSE stands for Electronic Claim Lodgement and

Information Processing Service Environment.

You may already use online claiming to lodge claims

directly to Medicare. ECLIPSE is an extension of

Medicare Australia’s online claiming system that

incorporates direct communication and claiming for

providers with Medicare and private health insurers,

all in the one transaction. If you wish to connect

to ECLIPSE you should contact your software

vendor to ask whether they currently offer ECLIPSE

functionality.

You can obtain more information about ECLIPSE

from the following sources:

•call Medicare Australia’s eBusiness Service

Centre on 1800 700 199

•[email protected]

•www.medicareaustralia.gov.au/onlineclaiming


Claims processing

When a batch of accounts is received,

St.LukesHealth will confirm the member’s

eligibility for the Gap Cover benefit, including

whether the requirements for Informed

Financial Consent and Financial Disclosure

have been met.

St.LukesHealth will then validate the account

data and forward it electronically to Medicare

for processing. Medicare will process the

accounts and pay the Medicare rebate to

St.LukesHealth. If claims are processed

electronically through ECLIPSE, the claim will

go to Medicare first and then to the Fund by

way of an automated service.

St.LukesHealth will raise a payment for the

Provider that covers the Medicare rebate, the 25%

medical gap and the additional St. Luke’s Gap Cover

benefit. You will receive a Statement of Benefit

listing payments and rejections. This statement will

be mailed to you at the time of payment.

Any St.LukesHealth/Medicare rejection will

(depending on the reason for the rejection) need to

be either resubmitted to St.LukesHealth for processing

or sent to the patient for payment.

Late lodgement of a claim

Subsection 20B(2)(b) of the Health Insurance Act 1973

provides that a claim for assigned Medicare benefits

must be lodged with Medicare Australia within 2 years

of the date of a professional service. As a claimant, you

may make an application to extend the 2 year time limit

for lodging a claim for an assigned Medicare benefit.

Claims submitted over 2 years from the date of

service are not eligible for St.LukesHealth benefit even

if late lodgement approval has been obtained from

Medicare Australia.

PAYMENT OF BENEFITSPayments will be made by Electronic Funds Transfer

(EFT) direct to your nominated bank account usually

within 21 calendar days of receipt of your patient’s

claim, providing Medicare payment has been received

by the insurer.

You will need to supply St.LukesHealth with your

banking details on the “EFT Payment Form” included in

the Appendices.

If bank account details are not provided payment will be

made by cheque.

St.LukesHealth 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.

STATEMENT OF BENEFITA Statement of Benefit will be posted to you at the

time payment is made by EFT (in the case of cheque

payment, the statement will accompany the cheque).

Please allow approximately 3 working days for

receipt of the statement after payment by EFT.

The Statement of Benefit will detail payments and

rejections together with assessment/rejection

explanations. St.LukesHealth will pay accounts

(and forward payment for each account) as soon

as assessment is complete regardless of the

processing status of other accounts submitted by

you in a particular batch.

A Statement of Benefit may contain payment details

relating to accounts from more than one batch.

A Statement of Benefit will also be sent to the

member detailing the benefit payment.



CLAIM REJECTION PROCEDURESAs mentioned previously the Statement of Benefit

will contain assessment/rejection explanations. These

can relate to either Medicare and/or St.LukesHealth

assessment.

Medicare Assessment/ Rejection Explanation Codes

Medicareassessment/rejectioncodeswillappearon

the St.LukesHealth Statement of Benefit. A full list

oftheMedicareassessment/rejectioncodescanbe

foundontheMedicareAustraliawebsiteathttp://

www.medicareaustralia.gov.au/provider/vendors/

reason-codes/medicare.shtml

St.LukesHealth Assessment/ Rejection Letter

If an account cannot be processed by St.LukesHealth

the account will be returned to you along with a

letter of explanation.

The following list provides examples of reasons

which may result in an account being returned:

•Membershipisunfinancial

•NocoverheldwithSt.LukesHealth

•Not a private in-patient when the service was

rendered

•WaitingPeriodsnotserved

•Insufficientdetailsuppliedonaccount

•Claimpreviouslypaid

•Claimisover2yearsoldandisthereforenoteligible

for insurer benefit

Depending on the reason for rejection you may need to:

•Amend the account as necessary and resubmit

with your next batch.

•Check account details in accordance with the

rejection message. If correct and if Medicare

and St.LukesHealth benefits are not payable, bill

your patient direct. Please remember to mark

your account ‘The amount on this account is NOT

claimable through Medicare or St.LukesHealth’.

•IfSt.LukesHealthbenefitsarenotpayable,pleasebill

the member direct in your normal manner. Remember

to mark the account ‘The amount on this account is

claimable through Medicare only’.

•If you have a query about an adjusted benefit

please contact St.LukesHealth. If the adjustment

is correct, nothing further will be payable for

this service.

If you require any assistance please contact

St.LukesHealth. Detail on enquiry support is provided

on page 8 of this document.

HOW TO USE THE BATCH SUMMARYA Batch Summary must accompany any patient

accounts sent direct to the insurer for processing

through the St. Luke’s Gap Cover scheme. A sample of

the Batch summary is included in the Appendices.

Why is the Batch Summary required?

•It will summarise the number of accounts

submitted for reconciliation.

•Thebatchlodgmentdatewillassistintracking

accounts prior to processing and in payment

reconciliation.

•Itincludesyourdeclarationthattheseservices

were provided to a patient of a recognized

hospital and that the requirements of informed

financial consent and financial disclosure have

been met.


•It signifies your request for the accounts

to be processed under the St. Luke’s Gap

Cover Scheme in accordance with the

operating and billing guidelines supplied by

St.LukesHealth.

How is the Batch Summary used?

The Batch Summary is to be completed and

stapled to the accounts submitted in that

batch. If only one account is being submitted,

a Batch Summary still needs to be completed.

The following guidelines should be followed

when completing the Batch Summary:

SECTION 1 – Provider details

All fields in this section should be completed.

The contact name should be the name of the

person to be contacted in the event of an

account enquiry.

SECTION 2 – Batch details

Lodgment date: This is the date on which you

forward the batch of accounts for processing.

Account Reference / Surname: This is the account

reference assigned by you to each account attached

to the batch. This will assist St.LukesHealth to identify

the accounts included in the batch. If you do not

use an account reference, please show the patients

surname in this field.

St.LukesHealth Member Number: This is the patient’s

insurer membership number.

Card Reference: This is the patient’s reference number

shown on the Medicare card. It is used by Medicare to

identify which patient on the Medicare card received

the treatment.

Hospital Name: This is the name of the hospital where

the service took place.

The St.LukesHealth member number, Medicare number,

Medicare card reference and Hospital name only need

to be completed if this information is not shown on the

individual patient accounts.

SECTION 3 - Comments

Comments: The comment section is supplied to enable

you to add or supply any supporting information you

feel is necessary regarding the batch of accounts.

ENQUIRY SUPPORTFor all enquiries please call 1300 651 988.

When making an enquiry please request one of the

following services:

•Member eligibility check: We will require you to

identify your practice and we will also request the

patient’s name and date of birth.

•Claim enquiry: We will require you to identify your

practice and we will also request the patient’s name

and date of birth. Details of the patient account may

also be requested.

•St. Luke’sGapCoverarrangementenquiry:Youwill

be transferred to the appropriate person dependent

on the nature of your enquiry.

STATIONERY SUPPLIESSupplies of the following can be obtained from

St.LukesHealth.

•BatchSummaryforms

•StationeryOrderforms

•EstimateofMedicalFeesproforma

•Envelopes

•St.Luke’sGapCoverBrochures

•St.LukesHealthProductBrochures

•St.Luke’sGapCoverPosters

Simply complete the stationery order form (a copy

is included in the Appendices) and forward it to

St.LukesHealth in one of the following ways:

Fax: (03) 6334 0711

Post: PO Box 915, Launceston, TAS, 7250. or

Sendyourorderbyemail:[email protected]


Provider details for delivery purposesProvider Name Date

//

Address

Postcode

Contact Name

Contact Telephone Number

Stationery order

ITEM NUMBER REQUIRED

Batch Summary Forms

Stationery Order Forms

Envelopes

St. Luke’s Gap Cover Brochures

St.LukesHealth Product Brochures

St. Luke’s Gap Cover Posters

Estimate of Medical Fees Pro Forma Electronic copy Paper copy

If electronic copy requested,

please supply email address below.

Any special delivery instructions

Please return this form to St.LukesHealth, PO Box 915, Launceston, Tasmania, 7250 or fax to (03) 6334 0711

Stationery order form


This page has been left blank intentionally

SAMPLE

ONLY

SECTION 1 – Provider Details Provider Name Provider Number

Practice Address

Contact Name Phone No. Fax No.

SECTION 2 – Batch Details

LodgmentDate//The Account Reference column must be completed. The other columns need to be completed if the

requested information is not shown on the patient account.Account Ref /

SurnameSt.LukesHealth

Member Number Medicare Number Medicare Card Ref. Hospital Name1.2.3.4.5.6.7.8.9.

10.11.12.13.14.15.

Batch Total $

SECTION 3 – Comments:

Declaration:

1. Have the patients included in this batch been provided with an “Estimate of Medical Fees” and has informed financial consent been obtained?

YES NO Not Applicable as “No Gap” applies.

2. Have you disclosed to all patients any financial interests you have in any product or service recommended or given to the patient?

YES NO N/A

I declare that the services listed on the attached account(s) were provided by me or on my behalf and that the services were rendered to the patient(s) whilst admitted as a private patient of a recognised hospital.

This medical practice agrees to bill St.LukesHealth directly for the services listed on the attached account(s) and for these accounts accepts the operating, billing and claiming guidelines of the St. Luke’s Gap Cover scheme as advised by St.LukesHealth.

Signature of authorised person Name of authorised person

Batch summary

SAMPLE

ONLY


SAMPLE

ONLY


Health insurer

private health insurer

SAMPLE

ONLY

abn 81 009 479 618

A Registered Health Benefits Organisation

1300 651 988w stlukes.com.aue [email protected]

Head Office17 The Quadrant MallLaunceston 7250t 03 6331 9255f 03 6334 0711

Branch Offices50a Murray StreetHobart 7000t 03 6234 8866f 03 6223 2824

26 Rooke StreetDevonport 7310t 03 6424 5188f 03 6424 9716

43 Cattley StreetBurnie 7320t 03 6431 3433f 03 6431 6797

24 Smith StreetSmithton 7330t 03 6452 1659f 03 6452 2649

Orr StreetQueenstown 7467t 03 6471 2719f 03 6471 2567

64 Emu Bay RoadDeloraine 7304t 03 6362 2333f 03 6362 2995

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