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Invoicing a Private Health Fund (ECLIPSE)

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In this article:

Gentu has full ECLIPSE integration, meaning you can easily create electronic private health fund claims directly from the invoice screen.

 

Billing a health fund

  1. Access the patient's file and select Add > Invoice.
  2. Select the Health Fund option from the Account Type drop down menu:

  3. Once the Health Fund account type is selected, several other radio buttons and drop down menus will be revealed.


At this stage the process differs slightly, depending on whether you are creating a No Gap or a Known Gap claim.

See below for more information on billing these kinds of accounts.

 

Known Gap claim

  1. Select the Known Gap radio button.
  2. From the Assign Gap drop down menu, select the person to whom the gap amount is assigned. By default, this will be the primary account holder for the patient (i.e. the patient themselves, or the parent/guardian).
  3. Select the Hospital where the service was provided. You can add hospitals via the Address Book.
  4. Add the billing items to the invoice.
  5. Set any item overrides or service text by clicking the + icon to the left of an item.
  6. Use the Assist Item button to add any assistant items, or if you are billing as an assistant.  
  7. The fund’s Known Gap amount should have pre-filled into the Known Gap field at the bottom of the window. If not, you can key this in manually. Press Apply This Gap to apply.
  8. Alternatively, if you are billing an AHSA fund, you can choose to press Apply AHSA Gap to apply the per-item AHSA gap.
  9. At the bottom of the screen, press the Claim button. 
     
  10. The Eclipse Claiming Information window will open.
  11. Ensure the appropriate claim type (Scheme or Agreement) is selected, and that you have ticked the Financial Interest Disclosed checkbox, if relevant. You will also need to select the consent type from the Consent drop down menu.
  12. Once a claim is successfully submitted, it will appear at the top of the Claims Control list (under Financials > Claims Control).

 

No Gap claim

  1. Select the No Gap radio button.
  2. Choose the service location from the Hospital drop down menu. 
  3. Enter the item numbers.
  4. Add item overrides and/or service text by clicking the + icon next to each item. 
  5. Add the assistant if appropriate via the Assist Item button.
  6. Press Claim to open the claim information window.
  7. Select the claim type (Scheme or Agreement), check the Financial Interest Disclosed checkbox (if relevant), and select the consent type (e.g. Written).
  8. Press Claim to submit the claim. 
  9. Once a claim is successfully submitted, it will appear at the top of the Claims Control list (under Financials > Claims Control).

Private claim

Please see the Invoicing Patient Claims article for more information on billing an ECLIPSE Patient Claim.

 

FAQ

Click here to see frequently asked questions.

> How do I add a new Hospital to the invoice drop down menu?

You can add new hospitals via the Address Book panel. Select Add > Hospital, enter the details, then save. Hospitals added here can be selected in the invoice screen when billing.

 

> I need to bill Medibank Private. Do I send it through as an Agreement type, or a Scheme type claim?

ECLIPSE claim transmissions use two different channels, 'Scheme' and 'Agreement'. The channel you will need to use to transmit claims will depend on the arrangement made between a provider and the Health Fund.

Medibank Private and AHM are slightly different to other health funds. All of your Medibank Private and AHM claims - both No Gap and Known Gap - should be sent through as a Scheme type.

The exception is if you have a Medical Purchaser Provider Agreement (MPAA) with Medicare, in which case you can send through No Gap claims as Agreement type.

The 'Scheme' transmission type is set by navigating to Settings > Health Funds, clicking on the fund and then clicking on the Practitioner under Practitioner Details. In the box which appears, set the claim type as Scheme. Then press Save.

 

> What does 'Financial interest disclosed' mean, and why do I have to tick this box?

The Financial interest disclosed checkbox (visible on the Claim Information window) is required when sending claims to health funds participating in the Approved Gap Cover scheme, i.e. funds that offer No-Gap claiming.

'Financial interest disclosure' means that the servicing practitioner must inform the patient of any financial profit that the practitioner stands to gain when recommending a product or service to the patient.

To give an example, if a practitioner has shares in a company that makes prostheses, and they recommend one of these specific prosthetics to a patient; the patient must be informed that the practitioner stands to profit financially from recommending the product.

 

> Gentu changes the order of items once I add them to the invoice. Why is this?

Gentu will automatically calculate the MPR for item rebates and re-order the items appropriately. This means that as you add items to the invoice, Gentu will re-order them and apply the rebate MPR based on the MBS schedule fee for the item.

If you are billing a Known Gap claim, you will also see the Apply MPR button on the invoice. Clicking this button will apply the MPR to the item fees. Alternatively, clicking Apply This Gap will automatically calculate the fees based on the MPR after adding the gap.

 

> Can I send a claim via ECLIPSE if a patient does not have a Medicare Card?

It is not possible to send a claim via ECLIPSE if a patient does not have a Medicare card due to the way the ECLIPSE channel has been setup. If you encounter this situation, you will need to send the claim manually to the Health Fund.

 

To register for ECLIPSE, please contact our Sales team at sales@geniesolutions.com.au, or call (07) 3870 4085.