ECLIPSE setup & Claims Control overview

Gentu directly integrates with ECLIPSE, meaning that you can easily submit electronic health fund claims directly from Gentu.

ECLIPSE is an optional addition to the standard Gentu subscription. If you would like to use ECLIPSE, please contact our Sales team on sales@geniesolutions.com.au or 1300 889 362.

Please note that ECLIPSE is only used to submit inpatient health fund claims. You do not need ECLIPSE to send Medicare Patient Claims, Bulk Bill claims, or DVA batch claims - this functionality is included in Gentu by default.

Looking for instructions on billing ECLIPSE claims? Please see the Invoicing a Private Health Fund (ECLIPSE) article.

Before you get started with claiming, there are a few configuration steps necessary to get Gentu set up.

Register for online claiming

Before using online claiming, you must register your details with Medicare and with each private health fund. Click here to visit the Human Services Australia website for more information.

Add your Provider Numbers

To use online claiming you must ensure your provider number(s) are entered into Gentu.

You can record multiple provider numbers for one practitioner, each one linked to a particular site of service.

1. Navigate to Settings > Manage Users.
2. Select the practitioner from the list.
3. Select the Practitioner Details tab.
4. Click the + icon next to the Sites of Service heading to add a new site-specific Provider Number.
5. Enter the relevant details, then click Save.
6. Press Save at the very bottom of the window.

You can create a site of service for each location the provider practices at.

Note: it is important to click Save at the bottom of the Manage Users screen after adding a new Site of Service - otherwise, the new Site will not be saved successfully.

Hospital details & Facility ID

Hospitals where surgery is performed must be entered into the Address Book in Gentu, with their Facility ID recorded.

Similar to a practitioner's provider number, the Facility ID uniquely identifies the location where service was provided.

A Facility ID is required for online ECLIPSE claims.

Facility IDs are issued by the Department of Health and the list of hospitals is updated regularly. If you're unsure of the Facility ID for a hospital please confirm it with the hospital administration directly, or check the list of hospitals on the Department of Health's website.

To record a hospital in Gentu:

1. Navigate to the Address Book.
2. Select Add > Hospital.
3. Enter the Hospital details, including the Facility ID.
   
4. If you are performing procedures at this hospital, tick the Procedures will be performed at this Hospital checkbox.
   • This will make the hospital selectable in Gentu's Procedure window.
5. Click Save.

Set up health funds

Before claiming from a fund for the first time, you will need to enter the details of the doctor's fund agreement(s) into Gentu.

To enter the details of a doctors' agreement with a health fund:

1. Navigate to Settings > Health Funds.
2. Select the relevant fund from the list.
3. Under Practitioner Details, select the Doctor's name.
   
4. Enter the doctor's details as per their agreement with the fund, including:
   • Fee Schedule (usually Gentu will automatically select the correct schedule for you)
   • Billing Type (Known Gap/No Gap)
   • Max Known Gap (if applicable)
   • Claim Type
   • Payee ID.
5. Click Save.

Fund-specific settings

• All BUPA umbrella funds use the same Payee ID, so you should enter it for each fund:
  • ANZ
  • BUPA
  • HBA
  • Health Cover Direct
  • MBF
  • MBF Alliances
  • Mutual Community
• The Payee ID is required by these above funds in order to process your online claim.
• If you are unsure of your Payee ID, please check your documentation from the fund, or contact the fund directly.
• Medibank Private and AHM should always be set to Scheme claim type.
• HBF and HCF use a different schedule of fees in Western Australia. If your practice is located in WA, confirm your fee schedule is set to the correct schedule per your agreement (rather than the default AHSA schedule)
• HCF offers two separate schedules for No Gap and Known Gap billing. Depending your agreement with HCF, you must select the appropriate schedule here.
  • If you bill HCF using both No Gap and Known Gap billing, then you will need to change the fee schedule here each timeyou wish to use the other billing type/schedule.

AMA Fees

Some health funds are AHSA members, meaning their fee schedule is based on fees set by the Australian Medical Association (AMA).

The AMA fee schedule is not globally available in Gentu.

Instead, you must download the AMA fee schedule from the AMA website and then upload it into Gentu.

Please see the Upload AMA fee schedule to Gentu article for instructions on uploading your AMA fees into Gentu.

Claiming workflow overview

The claim workflow in Gentu works as follows:

1. An invoice is created and electronically transmitted to the health fund.
2. Within 14 days, the electronic processing report is returned for the claim.
3. Any exceptions noted in the processing report can then be resolved.
   • At this stage, any rejected items can be fixed and reclaimed.
4. Within another 14 days, the electronic payment advice is returned for the claim.
5. Gentu automatically receipts the claim.
   • At this stage, any underpaid items can be adjusted to write off the outstanding balance.
6. The claim is then finalised.

Claims Control 

Claims Control is the screen where Gentu displays all of your online claims. You can access Claims Control via the Reports panel (Reports > Claims Control).

Claims Control shows you information about the claims you've sent, including:

• The claim's ID and type (e.g. "Bulk Bill: Outpatient"). If the claim is a private health fund claim, the Claim Type column will list the name of the health fund instead (e.g. BUPA Australia).
• The claim's provider & service date.
• The name of the patient.
• The invoice number and total fee.
• The date on which the claim was sent.
  • If the claim did not send successfully, the Sent column will instead display an Error icon. (See: Claim has Error in Sent column)
• When the processing report was returned, including:
  • Notification of the report status (Successful, exceptions, or rejected)
  • A link to view the processing report (click on the date in the Reported column).
    
• If and when the claim was resubmitted.
• The claim's payment status (Not applicable, auto-receipted, or receipting required).
• A link to the electronic payment advice.
  
• The Reviewed column allows you to mark a claim as under review.
  • This does not affect the claim's status, but is simply a visual reminder to notify you that a claim is being looked into by a user at your Gentu practice.
    

Filtering Claims

The Claim Status checkboxes at the top of the Claims Control screen let you choose which claims to display:

• claims with exceptions
• claims still in progress (awaiting their processing report or payment advice)
• finalised claims
• or any combination thereof.

Simply check and uncheck the relevant boxes as needed.

You can also select claims belonging to a certain provider, and/or those within a certain date range by using the drop down menus provided at the top of Claims Control.

The vertical triple dot icon  will allow you to set a pre-made date range (e.g. Today, Last Month, This Financial Year).

Claim notes and activity history

You can add notes to a claim to track its claim history:

1. Click on a claim in Claims Control.
2. The invoice drawer will slide out to reveal the invoice.
3. At the bottom of the invoice drawer you will find the activity history section.
   
4. Click on the Add Note icon  to add a new note.
5. Enter the desired details about the claim's history.
   
6. Press Save Note to save the new note.

After you have added a claim note, it will be visible at the bottom of the invoice drawer when you open the claim from Claims Control.

Claims that have had notes added to them will also display an icon in the Reviewed column of Claims Control.

It is not possible to delete a claim note, so please double check each entry carefully before saving.

Note that claim notes are for your reference only - they will not be transmitted to the health fund along with the claim.

Automatic Bulk Bill Batching

• As you Bulk Bill patients throughout the day, Gentu places your Bulk Bill accounts (including DVA batch claims) in a holding queue.
• At 10pm each night, Gentu batches all the accounts and then automatically sends them off to Medicare.

• If there are any Bulk Bill or DVA-type invoices waiting to be transmitted, you will see a banner at the top of the Claims Control tab similar to that shown above, letting you know how many invoices are pending transmission.

Note that Gentu will always transmit these pending claims at 10pm daily. This is a default setting and is not able to be changed.

See also: Invoicing Bulk Bill & DVA

Payments & Benefits

When Medicare/the fund deem the claim as payable:

1. Medicare/the fund generates and sends an electronic payment advice back to you.
2. Gentu receives the payment advice into Claims Control.
3. Medicare/the fund deposit the benefit payable into the doctor's nominated bank account.
4. Gentu automatically receipts the payment based on the information in the payment advice.
5. The receipt is shown in Financials > Banking Report.

When Medicare/the Fund pays the benefit for a claim, the money will be deposited directly into the doctor's nominated bank account.

This is the bank account that the doctor has registered with Medicare Australia under their Payee Provider Number.

Medicare/the fund will simultaneously provide an electronic payment advice; a statement of payment advising what you have been paid for each claim.

After you have received the payment advice, Gentu will automatically process a receipt using the figures provided.

Gentu will only receipt each item up to the payable benefit amount stated in the processing report. Therefore, even if a claim has been auto-receipted, it may still be necessary to adjust the item if there are exceptions in the processing report and the item has been underpaid as a result.

Please note: The payment advice is returned directly from Medicare. Gentu does not have any influence over the contents of the payment advice or how Medicare/the fund chooses to pay for a claim. If you are concerned about the contents of the payment report, please contact the relevant party directly (DVA, Medicare, or the private health fund).

FAQ

> What is the Fund Payee ID?

The Fund Payee ID is a reference unique to each practitioner which identifies them to the health fund. Certain funds (such as BUPA and Medibank Private) require the fund payee ID in order to process your claims. If you are not sure of your fund payee ID, you can check the registration documentation supplied to you by the fund, or contact the fund directly.

> What is a health fund agreement?

A 'health fund agreement' is an arrangement between a practitioner and a private health fund. Under a health fund agreement, a doctor can use the private health fund's fee schedule to set the item charge, and the health fund pays the gazetted rebate amount. (This is true for both No-Gap and Known Gap claims.)

If your doctor doesn't have a health fund agreement, they can still send claims to the health fund. However, the health fund will treat the claim as a private-type bill, and you will receive a reduced rebate amount from the fund in payment.

> Can I add a health fund to Gentu and then bill them via ECLIPSE?

Gentu comes pre-loaded with all Australian health funds which are ECLIPSE-capable.

If you need to add an additional health fund to Gentu, it is possible to do so (via Settings > Health Funds), however the custom-added health fund will not be ECLIPSE-capable and you will not be able to send electronic claims to them.

Instead, you would need to print the invoice and manually send it to the fund for payment.

See also:

Resolving, Reclaiming & Manually Receipting

Common Exceptions