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The Bupa Australia Medical Gap Scheme Practitioner's Guide

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					The Bupa Australia Medical Gap Scheme
Practitioner’s Guide
                                                                 Bupa Australia Medical Gap Scheme
    Bupa Australia is one of Australia’s largest health funds,
    insuring over 3 million Australians and is part of world-
    wide health and care specialist BUPA, which looks after
    the health needs of more than 8 million people world-
    wide.                                                        Practitioner’s Guide
    Bupa Australia comprises HBA, Mutual Community,
    MBF and MBF Alliances.
                                                                 Eliminating the Gap                                          Benefits of the Bupa Australia
    Bupa Australia also provides health insurance under
                                                                   Bupa Australia believes that the care a patient receives   Medical Gap Scheme
    other brands including, NRMA Health Insurance, SGIO,
                                                                   is of utmost importance and that part of that care is      For Practitioners
    SGIC and ANZ Health Insurance.

                                                                                                                                 •
                                                                   eliminating the financial pain that may be caused by
                                                                   medical gaps.                                                     No contract with Bupa Australia;

                                                                   Bupa Australia’s Medical Gap Scheme eliminates the            •   You are free to use the Medical Gap Scheme on a
                                                                                                                                     case by case basis;

                                                                                                                                 •
                                                                   medical gap paid by your patients when they are
                                                                   hospitalised. It provides gap cover without the need for          You maintain complete clinical independence;
                                                                   a contract between Bupa Australia and the practitioner
                                                                   and allows the practitioner to participate in the Scheme
                                                                                                                                 •   Potential for increased practice volume as members
                                                                                                                                     seek a no gap experience;
                                                                   on an episode by episode basis.
                                                                   It makes the process simple for you and your patients –
                                                                                                                                 •   One full payment to you representing both the
                                                                                                                                     Medicare and Bupa Australia benefit;
                                                                   saving you time, reducing your paperwork and reducing
                                                                   bad debts. Plus, we have an electronic system called          •   No need to pursue unpaid accounts from Bupa
                                                                                                                                     Australia members - no bad debts;
                                                                   Eclipse available, which makes claims processing fast
                                                                   and easy.                                                     •   No need to write off gap amounts for patients facing
                                                                                                                                     financial constraints;
                                                                   This guide contains everything you need to know
                                                                   – from becoming a Bupa Australia Medical Gap Scheme           •   Administratively simpler – one payment deposited to
                                                                                                                                     your nominated bank account;
                                                                   provider to processing claim payments.
                                                                   Please read on, or visit our provider websites                •   Available for all MBS in-patient services at all licensed
                                                                                                                                     hospitals and day surgeries;
                                                                   - www.bupaproviders.com.au or http://provider.mbf.com.au
                                                                   for more information on how our partnership can work for      •   Increased patient satisfaction, as quality care is
                                                                                                                                     delivered without financial concerns;

                                                                                                                                 •
                                                                   you and your patients.
                                                                                                                                     A weekly statement detailing all payments will be
                                                                                                                                     available via our secure website.
                                                                                                                              For Patients

                                                                                                                                 •   Financial certainty of no medical gap for in-patient
                                                                                                                                     services;


CONTENTS                                                                                                                         •   Patients continue to have their choice of medical
                                                                                                                                     practitioner;
    Eliminating the Gap
    Benefits of the Medical Gap Scheme
                                                   3
                                                   3
                                                                                                                                 •   Simplified billing process – no need for patients
                                                                                                                                     to claim through a number of sources;

    How to Join the Medical Gap Scheme             4                                                                             •   Improved value perception of private healthcare,
                                                                                                                                     further supporting the private system.
    Patient Eligibility                            4
                                                                                                                              For Bupa Australia

                                                                                                                                 •
    Billing and Payment                            5
                                                                                                                                     Restoring the surety to private health by covering
    Claim Forms                                    6                                                                                 the in-patient medical gap;
    Payment and Rejection Reports
    Claim Rejection Codes
                                                   10
                                                   12
                                                                                                                                 •   Increased member satisfaction and value, leading
                                                                                                                                     to improved retention within private health;

    Common Questions Answered
    Provider Support
                                                   14
                                                   15
                                                                                                                                 •   Enhancing relationships with healthcare
                                                                                                                                     professionals.




2                                                                                                                                                                                           3
                                                                                                                               Billing and payment
How to Join the Medical Gap Scheme                             Patient Eligibility
    Eliminate gaps, save time and reduce your paperwork,          The Medical Gap Scheme is available under all Bupa
    here’s how to join:                                           Australia’s hospital tables, given the following patient
                                                                  criteria:
    1.	 Complete the application form which can be                                                                             There are two ways you can process Medical Gap Scheme payments. You can use
        downloaded from any of our provider websites.
    2.	 Attach a bank deposit slip, cancelled cheque or bank
                                                                  •   The patient is a member of a Bupa Australia
                                                                      hospital table;
                                                                                                                               Eclipse, which allows you to process payments electronically or you can process your
        statement to verify your account details.
                                                                  •   The service is eligible for a Medicare benefit;          payments manually by using forms.
    3.	 Return the above to Bupa Australia at the
                                                                  •   The service is not excluded under the patient’s level


                                                                                                                                                                                                  •
        following address:                                            of hospital cover;

                                                                  •
                                                                                                                                  If you’re using Eclipse, payment can be expected Monday             Lower incidence of error and shortened review
        Provider Operations                                           The service is not a compensable service, that is,
                                                                                                                                  to Friday within 11 working days of lodgement. Payments             times – giving you faster resolutions and immediate
        Po Box 14639 Melbourne, Victoria 8001                         where compensation , damages or benefits may
                                                                                                                                  submitted manually will take 20 working days. EFT payments          knowledge of any rejections

                                                                                                                                                                                                  •
    4.	 Upon receipt you will be issued with:                         be claimed from another source (e.g. Workers’
                                                                                                                                  are paid into accounts every Wednesday. Read below to               No hub transaction fees

                                                                                                                                                                                                  •
       i. A Practice ID Number;                                       Compensation, Compulsory Third Party Insurance,
                                                                                                                                  find out more about your billing and payment options.
                                                                      Common Law Damages, Government Programs and                                                                                     View rejection codes and explanations online
       ii. Personalised stationery for claims processing.             Agencies, Travel Insurance and Sports Insurance, etc);   Payment using Eclipse                                           Payment using forms
    Once you have joined the Bupa Australia Medical Gap
                                                                  •   The patient is up to date with fund payments;               Not interested in all the forms and paperwork? Then this        If you haven’t got Eclipse, you can still process your
    Scheme, it’s important to brief your staff and advise
    your patients that you now use the Medical Gap                •   The patient has served applicable waiting periods,
                                                                      including the 12 months waiting periods for
                                                                                                                                  is the option for you. Eclipse is the in-patient claiming
                                                                                                                                  tool that can be used by your practice to send the Bupa
                                                                                                                                                                                                  Medical Gap Scheme payments manually. It’s easy,
                                                                                                                                                                                                  simply follow our step-by-step guide.
    Scheme system.                                                    pre-existing ailments and obstetrics.                       Australia Medical Gap Scheme claims electronically. This
                                                                                                                                  means no more paper claims and improved payment              Step 1: Capture the correct details
                                                                  If these criteria are not met, the claim may be rejected.
                                                                                                                                  turnaround times.                                               To ensure quick processing use this checklist for all the
                                                                  If you wish to check your patients’ eligibility, please                                                                         information you need.

                                                                                                                                                                                                  •
                                                                                                                                  Eclipse enables providers and practices to exchange
                                                                  call 131 243 during business hours, or preferably,
                                                                                                                                  and settle claims electronically, safely and securely over          Patient’s name, address and date of birth

                                                                                                                                                                                                  •
                                                                  if you have access, you may do so via Eclipse.
                                                                                                                                  the Internet.                                                       Current Medicare card number and patient suffix

                                                                                                                               The benefits of Eclipse                                            •   Correct health fund name and membership number

                                                                                                                                  Eclipse will save you time and money, here’s how:               •   Hospital Provider number and the name of the
                                                                                                                                                                                                      hospital where the patient was admitted
                                                                                                                                  You’ll get 98% of your claim outcomes within
                                                                                                                                  12 minutes                                                      •   All service details: Date of service, Medical Benefit
                                                                                                                                                                                                      Schedule item number, fee charged per item, the

                                                                                                                                  •   There’s no limit to the amount of claims or batches
                                                                                                                                      you can submit
                                                                                                                                                                                                      account total and special exemptions (time of
                                                                                                                                                                                                      operation, not normal aftercare etc)

                                                                                                                                  •   Improved financial management through faster
                                                                                                                                      resolution of claims and quicker payment times
                                                                                                                                                                                               Step 2: Submit your accounts for payment
                                                                                                                                                                                                  You can submit your payments by using the Batch Header

                                                                                                                                  •   Better data integrity, less manual intervention and
                                                                                                                                      improved claiming automation
                                                                                                                                                                                                  Form and your own account forms (if you do not have any
                                                                                                                                                                                                  of your own forms please use our Doctor Account Forms)

                                                                                                                                  •   Online patient verification of Medicare enrolment
                                                                                                                                      and health fund membership within 4 seconds
                                                                                                                                                                                               Step 3: Batch
                                                                                                                                                                                                  We recommend that you submit up to 20 accounts daily

                                                                                                                                  •   Online viewing of payments                                  per batch, together with a Batch Header Form. Once we

                                                                                                                                  •   One single point of contact and one system for
                                                                                                                                      all health funds
                                                                                                                                                                                                  receive your accounts we’ll validate the data and forward
                                                                                                                                                                                                  it onto Medicare for processing.

                                                                                                                                                                                               Step 4: Payment
                                                                                                                                How do I become an Eclipse user?                                  We’ll raise a payment for your claim. This includes the
                                                                                                                                   If you would like to register for Eclipse or want to know      75% Medicare Schedule fee benefit, the 25% Medical
                                                                                                                                   more about electronic claiming or software vendors,            gap benefit, and any additional Medical Gap Scheme
                                                                                                                                   please contact the Australia Medicare eBusiness Service        amount. You’ll receive reports from us detailing the
                                                                                                                                   Centre on 1800 700 199, alternatively you can email            outcome of your payment. Approved payments will be
                                                                                                                                   co.eclipse@medicareaustralia.gov.au or call the Provider       credited to your nominated bank account.
                                                                                                                                   Operations team (see inside back cover for details).




4                                                                                                                                                                                                                                                             5
Forms
If you’re processing claim payments manually (not electronically), there are two
main forms that you’ll need to use. Here’s an overview of each form and a glossary
                                                                                                                                   Batch Header Form
list to help you complete them.                                                                                                 1.		 Please	complete	your	practice	details:

                                                                                                                                   Practice Name:                                                                               Practice ID:

Batch Header Form                                                  Batch	header	number	– This is the date the batch
                                                                   of claims leave your rooms, with an alphabetical             2.	 Complete	this	form,	attach	all	accounts	and	send	to	the	address	below
     The Batch Header Form summarises the number of
                                                                   character signifying the number of batches for that day.        Bupa Australia
     claims for an individual provider and the total amount                                                                        Medical Claims
     that all the claims add up to. It will help you to track      For example, if three batches were sent for 1 January           PO Box 9809
                                                                   2010 the format would be:                                       Brisbane Qld 4001
     and reconcile your weekly or fortnightly submission of
     claims. There’s a space for staff to make comments and        1 January 2010
                                                                                                                                   This medical practice agrees to bill the health fund directly for the services attached and accepts the Medical Gap Scheme
     it includes your declaration that services provided are




                                                                                                                                                                                                                                                  LY
                                                                   Batch 1 = 01012010A (ddmmyyyyA)                                 Terms and Conditions as supplied by the fund. The members have been advised that no further payment is required in relation
     for a private in-patient or day patient of a hospital or an                                                                   to the services specified in the attached claims.
                                                                   Batch 2 = 01012010B (ddmmyyyyB)
     approved day hospital facility. It also confirms that the




                                                                                                                                                                                                                                                 N
     benefits are not claimable from any other source. By          Batch 3 = 01012010C (ddmmyyyyC)                                 Provider name:
     submitting this form you accept the the Medical Gap           It’s important that this number is unique per batch – this
                                                                                                                                   Provider number:




                                                                                                                                                                                                                                      O
     Scheme Terms and Conditions. A Batch Header Form              number plus your provider number help us to identify
                                                                                                                                   Telephone number:                                                                            Date:
     must accompany all medical claims.                            your batches. If you have a query with one of your              Batch header number:                                                                         Total number of claims:




                                                                                                                                                                                                                           E
                                                                                                                                   Total fee charged:                                                                           Total amount claimable:
                                                                   batches, all you need to do is quote the batch header
How is the Batch Header Form used?




                                                                                                                                                                                                         PL
                                                                   number together with your provider number to enable
     A Batch Header Form is to be completed for each                                                                               Declaration
                                                                   us to locate it quickly.
     provider within a practice and the original must be                                                                           The professional services specified on the attached forms were provided by me or on my behalf.
     stapled to the claims submitted in that batch. Keep a         Total	amount	claimable	– This is the total amount               These services were rendered as an inpatient of a hospital or approved day hospital facility.




                                                                                                                                                                                            M
     photocopy of the completed form to use when                   you are expecting to claim back from Bupa Australia.
     reconciling the Medical Payment Summary Report                Our Medical Claims Summary Report will total both the           Comments




                                                                                                                                                                                 A
     you will receive from us.                                     amount of claims approved for payment and the rejections.
                                                                   This total should equal your total amount claimed.




                                                                                                                                                               EX
We have included a list of key terms to assist                     This will assist you in reconciling claim payments.
you in completing your Batch Header Form:                          Total	fee	charged	– This is the total fee charged
     Practice	ID	– Your Practice ID is the number given            for all claims submitted in the batch. This figure is used
     to you by Bupa Australia to identify the Medical Gap          to verify that the assessor has entered all claims for
     Scheme practice location. To ensure your payment is           that batch.
     deposited into the correct bank account, your Practice
                                                                   Total	number	of	claims	– This is the total number of
     ID must be visible on the Batch Header and Doctor
                                                                   claims submitted in the batch. Remember that the number
     Account Forms.                                                                                                                This form can be downloaded from our provider websites:
                                                                   of claims submitted per batch cannot exceed 20.
                                                                                                                                   www.bupaproviders.com.au	or	http://provider.mbf.com.au
     Provider	number	– The provider number for your
     practice or location is given to you by Medicare
     Australia. This helps us and Medicare to identify you.        Please	note: Printable versions of the Medical Gap
                                                                   Scheme forms can be downloaded from our websites -
                                                                   www.bupaproviders.com.au or http://provider.mbf.com.au.
                                                                   Please ensure that you include your Practice ID.




                                                                                                                                   Bupa Australia Pty Ltd ABN 81 000 057 590 trading as HBA, Mutual Community, MBF and provider of insurance under the brands NRMA Insurance, SGIO, SGIC and ANZ Health Insurance.   02846-05-10S




 6                                                                                                                                                                                                                                                                                                                                  7
Doctor Account Form                                               Health	fund	card/membership	number	–
    Bupa Australia and Medicare use the information sup-          The patient’s health fund card or membership number
    plied on the Doctor Account Form to assess medical            must be provided. This information can be obtained
                                                                  from the patient or by contacting Provider Services. See

                                                                                                                             Doctor Account Form
    claims. You may use your own account form as long as
    you provide us with the health fund number, current           inside back cover for details.
    Medicare number and hospital name.                            Health	fund	name	– The name of the health fund
                                                                  or plan that the patient belongs to must be quoted.        This medical practice agrees to bill the health fund directly for the services outlined below and accepts the Medical Gap Scheme
How is the Doctor Account Form used?                              Funds and plans include HBA, Mutual Community, MBF,        Terms and Conditions as supplied by the health fund. The fund member has been advised that no further payment is required
                                                                                                                             in relation to the services specified on this account form.
    Completed Doctor Account Forms should be collated             NRMA Insurance, SGIO, SGIC and ANZ Health Insurance.
    into batches (20 maximum) and forwarded to Bupa
                                                                  Medicare	number	and	suffix	– The current Medicare          Please	complete	your	practice	details:
    Australia with a Batch Header Form. All fields on the
                                                                  card number and suffix must be obtained from the
    Doctor Account Form must be completed.
                                                                  patient. This can be found on the patients card and is     Practice name:                                                                                   Practice ID:
    We have included a list of key terms to assist you in         used by Medicare to uniquely identify the person within
    completing your Doctor Account Form:                          their records.                                             Doctor	Account	Details
    Account	reference	– The account reference is                                                                             Practice name:
                                                                  Suffix	number	– This is the two digit number found
    assigned by you and should match your patient’s                                                                          Provider name:
                                                                  before the patients name on their membership card (eg.




                                                                                                                                                                                                                                          LY
    accounting record. This information is recorded as part                                                                  Health fund card/membership no:                                                                  Health fund name:
                                                                  01) that helps the fund to identify which dependant on
    of the claim. This will enable us to quote your account                                                                  Member’s name:                                                                                   Account reference:
                                                                  the membership the claim is for. If you do not know this




                                                                                                                                                                                                                                         N
    (claim) reference on the Medical Payment Detail Report        information leave this field blank.                        Patient’s name:                                                                                  Date of birth:                 /       /               Suffix no:

    for reconciliation.                                                                                                      Address:                                                                                                                                                Postcode:
                                                                Ordering Medical Gap Scheme Stationery




                                                                                                                                                                                                                              O
                                                                                                                             Facility at which the service was provided:
    Applicable	service	conditions	– This section on the
    reverse of the Doctor Account Form must be completed.         If at any stage you need more Medical Gap Scheme           Patient’s Medicare number:                                                                       Medicare suffix number:




                                                                                                                                                                                                                   E
    If you answer YES to any of the seven questions listed        stationery, simply call or email your order to us.
                                                                  Alternatively, you can visit our provider websites




                                                                                                                                                                                                  PL
    please use the space provided to make comments and                                                                         MBS/MBAC
                                                                                                                                                                    Description of service
                                                                                                                                                                                                                          Number of                   Date of
                                                                                                                                                                                                                                                                         Provider number                 Charge
                                                                                                                                Item No.                                                                                 patients seen                service
    indicate which item it relates to.
                                                                                                                                                                                                                                                                                                     $
    Facility	at	which	the	service	was	provided	–                                                                                                                                                                                                                                                     $




                                                                                                                                                                                     M
    The name and provider number of the hospital or                                                                                                                                                                                                                                                  $
    approved day care facility must be entered in this field.                                                                                                                                                                                                                                        $




                                                                                                                                                                            A
    Any claims submitted without this information will be                                                                                                                                                                                                                                            $
    rejected and will need to be re-submitted with the cor-                                                                                                                                                                                                                                          $




                                                                                                                                                        EX
    rect information.                                                                                                                                                                                                                                                                                $
                                                                                                                                                                                                                                                                                                     $
                                                                                                                                                                                                                                                                                                     $
                                                                                                                                                                                                                                                                                                     $
                                                                                                                                                                                                                                                                                           Total $



                                                                                                                             Referral	Account	Details
                                                                                                                             Referral date:                  /          /                        Referral period:              3 months                  12 months                 Indefinite
                                                                                                                             Provider name:                                                                                   Provider number:
                                                                                                                             Address:                                                                                                                                                Postcode:

                                                                                                                             continued overleaf




                                                                                                                             Bupa Australia Pty Ltd ABN 81 000 057 590 trading as HBA, Mutual Community, MBF and provider of insurance under the brands NRMA Insurance, SGIO, SGIC and ANZ Health Insurance. 02845-05-10S




8                                                                                                                                                                                                                                                                                                                           9
Payment and rejection reports
                                                                                                                                             Medical Rejection Detail Report
                                                                                                                                               This is a breakdown of all the rejected payments for each provider in your practice. It provides you with a code and reason as
                                                                                                                                               to why the payment could not be processed. You’ll receive this report when Bupa Australia rejects a batch of claims or items.
                                                                                                                                               See page 12 for more information on claim rejections.
To assist you in reconciling your submitted claim batches, we’ll send you the
following reports. If you are using Eclipse release 4.0 or later, you can view your                                                                                                       BUPA AUSTRALIA HEALTH INSURANCE

payment reports online via your software package. You can also view these reports
via our secure provider websites.

Medical Payment Detail Report
     This is a breakdown of all the approved and rejected claims in each batch per provider, and the total benefit being paid.
     You will receive this report once a batch of claims has been paid for by Medicare or Bupa Australia.


                                                  BUPA AUSTRALIA HEALTH INSURANCE




                                                                                                                                             Medical Rejection Summary Report
                                                                                                                  This reference number        This report will be forwarded to you with the Medical Rejection Detail Report and summarises the total amount rejected for
                                                                                                                  relating to your payment     each provider within the practice.
                                                                                                                  is found here and will
                                                                                                                  appear on your bank
                                                                                                                  statement.
                                                                                                                                                                                         BUPA AUSTRALIA HEALTH INSURANCE




Medical Payment Summary Report
     This report provides you with an overview detailing the total benefits paid to each provider within your practice.
     You’ll receive this report once funds have been credited into your account.


                                                    BUPA AUSTRALIA HEALTH INSURANCE




10                                                                                                                                                                                                                                                                         11
Claim rejections                                                                                                                           Medicare	rejection	codes
                                                                                                                                           Code        Description                                                   When a claim is rejected

What occurs when a claim is rejected?
                                                                            •   If the member is not up-to-date with membership
                                                                                                                                           124         Item is restricted to person of opposite sex to patient
                                                                                                                                                                                                                     •   Please check in the MBS book that the item number selected is
                                                                                                                                                                                                                         the correct one.
     There can be many reasons why a payment has not
     been made. When a claim is rejected it can relate to
                                                                            •
                                                                                payments at the time of treatment or service
                                                                                If the claim is covered by another source
                                                                                                                                                                                                                     •
                                                                                                                                                                                                                     •
                                                                                                                                                                                                                         Check that the correct patient has been selected.
                                                                                                                                                                                                                         If you have selected the wrong patient, please correct the de-

                                                                            •
                                                                                                                                                                                                                         tails and re-submit the claim in a seperate batch and mark
     either Medicare and/or Bupa Australia assessment.                          Where any waiting periods have not been served
                                                                                                                                                                                                                         ‘re-submit’ in red

                                                                                                                                                                                                                     •
     Any rejected claims will be listed in your Bupa Australia                  at the time of the procedure

                                                                            •
     Medical Gap Scheme reports with a rejection code.                                                                                     137         Details of requesting provider not shown on                       Please check that all the referral details have been included on
                                                                                Where the hospital cover excludes benefits for                         account/receipt                                                   your account.
     Please refer to the following tables for a list of rejection               specific treatments and procedures
                                                                                                                                                                                                                     •   If eligible, re-submit the claim in a separate batch and mark

                                                                            •
     codes, what they mean and what action is required.                                                                                                                                                                  ‘re-submit’ in red.
                                                                                Where a Medicare benefit is not payable or where
When are the Medical Gap Scheme benefits                                        Medicare has rejected the claim                            162         A benefit for this service has been previously paid
                                                                                                                                                                                                                     •   Check your payment reports or patient accounts for a previous


                                                                            •
                                                                                                                                                                                                                         payment for this item.
not payable?
     Bupa Australia will not pay any medical insurance
                                                                                Where the claim has not been lodged within two
                                                                                years of the date of service                                                                                                         •   If you believe you have not been notified of this, please contact
                                                                                                                                                                                                                         Medical Claims Assist.
     benefits in the following situations:
                                                                            •   Where the member is not on a hospital cover
                                                                                                                                           171         Benefit not payable - provider may only act in
                                                                                                                                                                                                                     •   This means that the provider has already been paid for another

     •   If the service was not performed whilst the
         member was an in-patient of a recognised hospital
                                                                            Please refer to the Medical Gap Scheme Terms and
                                                                            Conditions for further information
                                                                                                                                                       one capacity

                                                                                                                                                                                                                     •
                                                                                                                                                                                                                         service. Please check the servicing provider details.
                                                                                                                                                                                                                         If you believe these details are correct, please contact Medical
                                                                                                                                                                                                                         Claims Assist.

                                                                                                                                                                                                                     •
         or a recognised day hospital facility
                                                                                                                                           179         Benefit not payable - associated service already paid             Please refer to the Medical Benefit Schedule or call Medicare
                                                                                                                                                                                                                         Claims Interpretation.

                                                                                                                                                                                                                     •   These claims will require you to submit clinical details (theatre
                                                                                                                                                                                                                         notes) to the fund for Medicare Adviser’s review.

 Bupa	Australia	rejection	codes
 Code         Description                                           When a claim is rejected
                                                                                                                                           252         Service possibly after care
                                                                                                                                                                                                                     •   Insufficient details on the account (not normal aftercare) - please
                                                                                                                                                                                                                         include the required Medicare information and re-submit the
                                                                                                                                                                                                                         claim in a separate batch and mark ‘re-submit’ in red.
 L06          Contributor has no hospital cover
                                                                    •   Check with the member that you have the correct personal
                                                                        and membership details.
                                                                                                                                           320         Expired Medicare card - benefit not payable
                                                                                                                                                                                                                     •   Incorrect card details. Please re-submit your claim with the


                                                                    •
                                                                                                                                                                                                                         correct card number and mark ‘re-submit’ in red.
                                                                        Check with the fund to verify that the patient is not on
                                                                        another membership.                                                414         Provider practice location is closed at the date
                                                                                                                                                                                                                     •
                                                                                                                                                                                                                     •
                                                                                                                                                                                                                         Please check the provider number with Medicare.


                                                                    •
                                                                                                                                                       of service                                                        If the provider details need to be updated, please do so and
                                                                        If the patient is not a member, no benefit is payable from the
                                                                                                                                                                                                                         re-submit your claim with the updated details and mark
                                                                        fund. Please bill the member in your normal manner.

                                                                    •
                                                                                                                                                                                                                         ‘re-submit’ in red.
 L19          Dependant ceased at date of service                       Please call the patient to see if they have another
                                                                        membership with us. If yes, re-submit the account as a             415         Referral details same as rendering provider
                                                                                                                                                       - self deemed?                                                •   Please check the referring provider number, should it be
                                                                                                                                                                                                                         self-deemed?

                                                                                                                                                                                                                     •
                                                                        separate batch and mark ‘re-submit’ in red.

                                                                    •
                                                                                                                                                                                                                         If self-deemed, please make this clear on your account and
 L22          Dependant over 20 years on a family table                 Check if the patient has his or her own cover. If yes,                                                                                           re-submit the claim in a separate batch and mark ‘re-submit’ in
                                                                        please re-submit the account as a separate batch and                                                                                             red.

                                                                                                                                                                                                                     •
                                                                        mark ‘re-submit’ in red.

                                                                    •
                                                                                                                                           429         Patient cannot be identified from the                             This patient cannot be identified by Medicare. Please check the
 L24          Date of the service is after the date paid to             The member is not financial, please contact the patient to                     information supplied                                              spelling of the patient’s name, their date of birth and Medicare
                                                                        discuss payment.

                                                                    •
                                                                                                                                                                                                                         card number.


                                                                    •
                                                                        Check with the fund for patient eligibility.
                                                                        If eligible re-submit the claim in a separate batch and mark                                                                                 •   Once you have made the correct alterations please re-submit
                                                                                                                                                                                                                         the claim in a separate batch and mark ‘re-submit’ in red.


 L29          Duplicate claim exists on the database
                                                                    •
                                                                        ‘re-submit’ in red.
                                                                        Check your reports and accounts for a previous payment
                                                                        or rejection for this claim, as it has been submitted before.
                                                                                                                                           430         Conflicting referral details
                                                                                                                                                                                                                     •   Please check that the referral provider number is current,
                                                                                                                                                                                                                         and that the referral date and referral period are correct (eg


                                                                    •
                                                                                                                                                                                                                         specialist to specialist can only refer 3 months).
                                                                        If you believe you have not been notified of this,
                                                                        please contact Medical Claims Assist..                                                                                                       •   Once this has been amended on the account please re-submit
                                                                                                                                                                                                                         the claim in a separate batch and mark ‘re-submit’ in red.
 L32
 L36
              12 month Waiting Period not served or not waived
                                                                    •
                                                                    •
                                                                        Please call us for patient eligibility.
                                                                        If eligible re-submit the claim in a separate batch and mark
                                                                                                                                           432         Item indicated as not part of multi-op
                                                                                                                                                                                                                     •
                                                                                                                                                                                                                     •
                                                                                                                                                                                                                         Please check that these items are part of a multiple operation.
                                                                                                                                                                                                                         Once this has been amended on the account please re-submit
                                                                         ‘re-submit’ in red.

                                                                    •
                                                                                                                                                                                                                         the claim in a separate batch and mark ‘re-submit’ in red.
                                                                        If not eligible please bill the member in your normal manner.
 L35          Endorsements codes not found at date of service
                                                                    •   Same as L32                                                      The rejection codes listed are subject to change. If you are still unsure why a claim has been rejected please call our Medical Claims Assist team.
                                                                                                                                         See inside back cover for contact details.




12                                                                                                                                                                                                                                                                                             13
Common questions answered                                                                                                          Provider support
Q Why should I use Eclipse?                                               batch has been finalised.                                Administration procedures                                      Call Provider Operations: 1800 060 239
     A.	 Because Eclipse is electronic, it’s a great system for     Q Who should we contact for an explanation of                     This includes any change of details which will affect the   Facsimile: (03) 9937 4419
         processing the Medical Gap Scheme payments. It will          rejection or error description?                                 practice ID number, such as:                                Email: eprovops@bupa.com.au
         improve your financial management through faster              A.	 For further clarification on a Medical Gap Scheme
                                                                                                                                      •   The appointment of a new doctor                         Web:

                                                                                                                                      •
         resolution of claims and quicker payment times.                   rejection, please refer to page 12. If you’re still            A doctor leaves your practice

                                                                                                                                      •
         Plus it gives you improved data integrity, with less              unsure, contact the Medical Claims Assist team.                                                                        www.bupaproviders.com.au or
         manual intervention and better claiming automation                                                                               A change to your bank account details                   http://provider.mbf.com.au
         – putting you in control of the process.

Q What are the main features of the Bupa
                                                                    Q When can a payment be expected?
                                                                       A.	 If you’re using Eclipse, payment can be expected
                                                                                                                                      •   A change of your address
                                                                                                                                      Please note: If there is a change of doctors at your
                                                                                                                                                                                                  Post:
                                                                                                                                                                                                  Provider Operations , Bupa Australia
                                                                           within 11 working days of lodgement. Payments sub-         Medical Claims practice you’ll need to notify us prior to
  Australia Medical Gap Scheme and why                                                                                                                                                            PO Box 14639, Melbourne VIC, 8001
                                                                           mitted manually will take up to 20 working days. EFT       sending in claims, so that we can update your details.
  should I use it?
                                                                           payments are paid into accounts every Wednesday.
     A.	 Please refer to page 3 for the many favourable
         benefits of using the the Medical Gap Scheme.              Q How do I link a claim with a payment?
                                                                       A.	 To identify the claim and the payment it relates to,    Stationery supplies

                                                                                                                                      •
Q Why is it important to supply the Medicare
                                                                           check your Medical Payment Detail Report. This                 Batch Header forms
  number and fund membership number?
                                                                           report will list:
                                                                                                                                      •   Doctor Account forms

                                                                          •                                                           •
     A.	 The Medicare number is required to identify the
         patient once the claim details have reached Medi-
                                                                              The provider batch reference number                         Benefit Schedule guide
         care Australia for processing. The fund membership                   (your reference number)
                                                                                                                                      •   Medical Claims Administration Booklet
         number is required to confirm policy details and eligi-
         bility. The patient is required to supply you with their         •   The Bupa Australia batch reference

         current Medicare number and fund membership
                                                                          •   The amount charged and benefit paid                  Medical Gap Claim agreement & reconciliation                   Call: 1800 060 237 or (03) 9937 4138
         details at the time of consultation.

Q How do anaesthetists source patient                                     •   A list of patients and the benefits relating to
                                                                              each patient
  information?
                                                                    Q Why are some items paid and others not?
     A.	 To complete accounts, anaesthetists can obtain                                                                            Patient eligibility                                            For HBA/Mutual Community patients: 131 243
         patient details from the doctor of the first refer-           A.	 All claims submitted via the Medical Gap Scheme                                                                        and choose the provider option
         ral or hospital. We have taken steps to ensure that               are subject to the normal Medicare Australia rulings.
                                                                                                                                                                                                  For MBF/MBF Alliances patients: 1800 111 623
         hospitals have all the necessary information required             If there are restrictions on medical items, some
                                                                                                                                                                                                  and choose the member eligibility option
         on the ‘Bradmar’ labels for anaesthetists to complete             benefits are not payable.
         their accounts.                                            Q How often will the fees or benefits change?
Q If there has been no payment for a patient or                        A.	 The fees and benefits are revised in line with the
  an item, how is this recognised? Where can the                           Medicare Australia MBS reviews in November
  payment amount be found?                                                 each year.                                              Claim assessment & payment                                     Call Medical Claims Assist:
     A.	 If there is a rejection for any reason, this will show     Q Can the practice account forms be used?                         For claim assessment and payment enquiries                  HBA/Mutual Community patient claims: 1300 367 877
         on the Medical Payment Detail Report with an error                                                                                                                                       MBF/MBF Alliances patient claims: 1800 111 623
                                                                       A.	 Yes, these forms can be used instead of our Doctor
         code and explanation. Payment amounts are listed in                                                                                                                                      Email: medicalclaims@bupa.com.au
                                                                           Account Forms. It’s important to note, however,
         detail on a payment report, which is sent each time a
                                                                           that a Batch Header Form must be attached and                                                                          Facsimile: 1300 130 623
                                                                           your Practice ID number must be written on the
                                                                                                                                                                                                  Post:
                                                                           Batch Header.
                                                                                                                                                                                                  Bupa Australia, Medical Claims,
                                                                                                                                                                                                  GPO Box 9809 Brisbane, QLD 4001




14                                                                                                                                                                                                                                                15
Call 1800 060 239
visit www.bupaproviders.com.au
or http://provider.mbf.com.au




Bupa Australia Pty Ltd ABN 81 000 057 590 trading as HBA, Mutual Community, MBF and provider of insurance
under the brands NRMA Insurance, SGIO, SGIC and ANZ Health Insurance. 02888-05-10S

				
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