Medical and Eligibility User Guide for Medical 
      Practitioners V3.2
                                                                                                             
                                                                     
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  Electronic Claim Lodgement and Information
  Table of Contents
  Electronic Claim Lodgement and Information.................................................................................................................2
  Processing Service Environment (ECLIPSE)...................................................................................................................5
   Introduction...................................................................................................................................................................5
   Where does ECLIPSE fit in with Medicare Online claiming?.....................................................................................5
    Benefits of using ECLIPSE......................................................................................................................................5
    Medicare Online to ECLIPSE..................................................................................................................................6
    DVA In-patient medical claiming.............................................................................................................................6
   Getting ECLIPSE ready................................................................................................................................................6
    Transmitting ECLIPSE claims..................................................................................................................................7
    Important things to note............................................................................................................................................8
    Understanding online patient verification responses................................................................................................8
    Understanding DVA patient verification responses..................................................................................................9
   Patient eligibility checking.........................................................................................................................................10
    Patient authorisation...............................................................................................................................................11
    Multiple eligibility checks for the same patient......................................................................................................11
    Types of eligibility checks......................................................................................................................................11
    Information on eligibility checks............................................................................................................................12
    Disclaimer...............................................................................................................................................................12
    Claim information...................................................................................................................................................13
    Presenting illness....................................................................................................................................................15
    For more information, go to privatehealthcareaustralia.org.au..............................................................................15
    Accident indicator...................................................................................................................................................15
    Emergency admission.............................................................................................................................................15
    Pre-existing conditions...........................................................................................................................................15
   Eligibility processing information..............................................................................................................................16
   Interpreting eligibility response information..............................................................................................................16
    Level of cover.........................................................................................................................................................18
    Applicable admission details..................................................................................................................................19
    Medical benefits......................................................................................................................................................21
   Submitting in-patient medical claims.........................................................................................................................22
    Claim rules..............................................................................................................................................................22
    Payee provider........................................................................................................................................................25
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    Fund Payee ID........................................................................................................................................................25
    Fee charged.............................................................................................................................................................25
    Claim assessment....................................................................................................................................................26
    IMC—In-patient medical claim..............................................................................................................................26
    90 Day Pay Doctor Cheque Scheme.......................................................................................................................27
    IMC—In-patient medical claim..............................................................................................................................28
    ECLIPSE Remittance Advice (ERA).....................................................................................................................30
   Reports........................................................................................................................................................................30
    Get Participants report............................................................................................................................................30
    Status report............................................................................................................................................................30
    Processing...............................................................................................................................................................30
    Ready......................................................................................................................................................................31
    Reported..................................................................................................................................................................31
    Claim processing report..........................................................................................................................................32
    Eligibility processing report...................................................................................................................................34
    ECLIPSE Remittance Advice (ERA) report...........................................................................................................38
    Processing messages and response codes...............................................................................................................41
    Medicare explanation codes...................................................................................................................................42
   Medicare services contacts.........................................................................................................................................42
   Private health insurer contacts....................................................................................................................................43
   General information....................................................................................................................................................43
    Informed financial consent (IFC)...........................................................................................................................43
    Obtaining informed financial consent....................................................................................................................43
    Financial interest disclosure...................................................................................................................................43
    Field Notes—Patient Information...........................................................................................................................43
    Field Notes—Hospital Information........................................................................................................................44
    Field Notes—Medical Information.........................................................................................................................46
    Claim Type Code....................................................................................................................................................46
   Claim processing information.....................................................................................................................................47
    Anaesthesia.............................................................................................................................................................47
    Assisting anaesthetist..............................................................................................................................................47
    Benefits...................................................................................................................................................................48
    Time-dependent restriction override.......................................................................................................................48
    Assisting provider...................................................................................................................................................48
    Assistant provider where the assistant items are included on the surgeons account..............................................48
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    Assistant services....................................................................................................................................................49
    Locums...................................................................................................................................................................49
    Aftercare.................................................................................................................................................................50
    Reamputation..........................................................................................................................................................50
    Referrals..................................................................................................................................................................50
    Referrals—in-hospital.............................................................................................................................................51
    Lost, stolen or destroyed referrals..........................................................................................................................51
    Emergency situations..............................................................................................................................................51
    Requests for specialist services..............................................................................................................................51
    Special circumstances.............................................................................................................................................51
   DVA claiming information.........................................................................................................................................53
    Veteran verification.................................................................................................................................................54
    Fees and rounding rules..........................................................................................................................................55
    Pathology claims.....................................................................................................................................................55
   Appendix A.................................................................................................................................................................56
    What is a patient verification?................................................................................................................................56
    Types of online patient verifications.......................................................................................................................56
   Appendix B.................................................................................................................................................................57
    In-patient medical claiming latter day adjustments................................................................................................57
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