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PRACTITIONER’S GUIDE
BUPA MEDICAL GAP SCHEME
BUPA. FIND A HEALTHIER YOU
About Bupa
Bupa is a healthcare leader proudly looking after the needs of more than 3 million Australians. We have been around for over 60 years and we’re part of a global group whose care and expertise now stretches across 190 countries.
It is our purpose that makes us different. Bupa exists to help our members live longer, healthier, happier lives. Which is why our global family reinvests its profits to provide better services for members and to ensure high-quality healthcare remains affordable.
Contents
Practitioner’s guide 2
Eliminating the Gap 2
Benefits of the Medical Gap Scheme 2
How to Join the Medical Gap Scheme 3
Patient Eligibility 3
Billing and payment 4
Payment using ECLIPSE 4
The benefits of ECLIPSE 4
Payment using forms 5
Claim forms 6
Batch Header Form 8
Doctor Account Form 9
Claim rejection codes 10
Bupa Rejection Codes 11
Medicare Rejection Codes 12
Common questions answered 14
Provider support 16
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BUPA MEDICAL GAP SCHEME PRACTITIONER’S GUIDEBupa Medical Gap Scheme eliminating the gapBupa believes that the care a patient receives is of utmost importance and that part of that care is eliminating the financial pain that may be caused by medical gaps.
Bupa’s Medical Gap Scheme eliminates or reduces the medical gap paid by your patients when they are hospitalised. It provides gap cover without the need for a contract between Bupa and the practitioner and allows the practitioner to participate in the Scheme on an episode by episode basis.
It makes the process simple for you and your patients – saving you time, reducing your paperwork and reducing bad debts. Plus, we have an electronic system called ECLIPSE available, which makes claims processing fast and easy.
This guide contains everything you need to know – from becoming a Bupa Medical Gap Scheme provider to processing claim payments.
Please read on, or visit bupa.com.au/for‑providers
Bupa Medical Gap Scheme Options Practitioners may register as either No Gap or Known Gap under our Medical Gap Scheme.
No Gap practitioners who use the Medical Gap Scheme accept the Bupa benefit as full payment for the episode of care, with no extra fees to the member.
Known Gap practitioners are able to charge a Known Gap, in addition to the Bupa Medical Gap Scheme benefit. The practitioner can charge a maximum Known Gap of up to $500 over a whole episode of care. The total Known Gap charge within a single episode of care cannot exceed the nominated Known Gap maximum approved by Bupa.
The practitioner must obtain Informed Financial consent for the Known Gap from the eligible Bupa member at the first consultation leading to the episode of care.
Additional fess cannot be raised under the guise of other miscellaneous items such as administration fees, booking fees or any other item not being a professional service described by a Medicare MBS item number.
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Benefits of the Bupa Medical Gap Scheme For Practitioners:
° no contract with Bupa
° you are free to use the Medical Gap Scheme on a case by case basis
° you maintain complete clinical independence
° potential for increased practice volume as members seek a no gap experience
° one full payment to you representing both the Medicare and Bupa benefit (for Known Gap practitioners, there is an additional payment of up to $500 from the member)
° no need to pursue unpaid accounts from Bupa members – no bad debts
° no need to write off gap amounts for patients facing financial constraints
° administratively simpler – one payment deposited to your nominated bank account
° available for all MBS in-patient services at all licensed hospitals and day surgeries
° increased patient satisfaction, as quality care is delivered without financial concerns
° a weekly statement detailing all payments will be available via our secure website.
For Patients:
° financial certainty of no or reduced medical gap for in-patient services
° patients continue to have their choice of medical practitioner
° simplified billing process – no need for patients to claim through a number of sources
° improved value perception of private healthcare, further supporting the private system.
For Bupa:
° restoring the surety to private health by covering the in-patient medical gap
° increased member satisfaction and value, leading to improved retention within private health
° enhancing relationships with healthcare professionals.
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How to join the Medical Gap SchemeEliminate gaps, save time and reduce your paperwork, here’s how to join:
1 Complete the application form which can be downloaded from bupa.com.au/for‑providers.
2 If you wish to register for Known Gap, please specify this in the Application Form.
3 Attach a bank deposit slip, cancelled cheque or bank statement to verify your account details.
4 Return the Application Form with the bank verification document to Bupa by email to: [email protected]
5 Upon receipt you will be issued with a Practice Identification (ID) number.
Once you have joined the Bupa Medical Gap Scheme, it’s important to brief your staff and advise your patients that you now use the Medical Gap Scheme system.
Publication of your details by BupaAs part of promoting the Bupa Medical Gap Scheme (Scheme) when you register and become a Scheme provider, Bupa will publish and distribute information about your participation in the Scheme. This includes information identifying you as a practitioner registered for the Scheme, information about your utilisation of the Scheme and the location(s) at which you practice, including any contact details. This information may be distributed to Bupa members and published in any Bupa media or materials, including on any Bupa website.
Practitioners may opt out of this type of promotion at the time of registration, by indicating accordingly on the Application Form, or at any time after initial registration by contacting Bupa by email at [email protected]
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Privacy StatementBupa Australia Pty Ltd (“Bupa”) collects your personal information to enable your registration to the Bupa Medical Gap Scheme (“Scheme”), and to administer your ongoing participation in the Scheme. Bupa may disclose your information on a confidential basis to our related companies within the Bupa Group of companies. Bupa may also disclose your information to Government or regulatory bodies or as otherwise required or permitted by law. Bupa may also publish or distribute your details as outlined above under “Publication of your details by Bupa” unless you have withdrawn your consent for us to do so. You can access the personal information we hold about you by contacting Bupa at [email protected]. You should refer to Bupa’s Information Handling Policy (available at bupa.com.au) for further details on how we handle personal information, or how you can make a complaint.
Patient eligibility The Medical Gap Scheme is available under all Bupa hospital tables, given the following patient criteria:
° the patient is a member of a Bupa hospital table
° the service is eligible for a Medicare benefit
° the service is not excluded under the patient’s level of hospital cover
° the service is not a compensable service, that is, where compensation, damages or benefits may be claimed from another source (e.g. Workers’ Compensation, Compulsory Third Party Insurance, Common Law Damages, Government Programs and Agencies, Travel Insurance and Sports Insurance. etc.)
° the patient is up to date with fund payments
° the patient has served applicable waiting periods, including the 12 months waiting periods for pre-existing ailments and obstetrics.
If these criteria are not met, the claim may be rejected.
Patient eligibility may be checked electronically via ECLIPSE or by calling 134 135 and choosing the provider option (3).
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BILLING AND PAYMENT There are two ways you can process Medical Gap Scheme payments. You can use ECLIPSE, which allows you to process payments electronically or you can process your payments manually by using forms.
In both cases, if you are a registered Known Gap Practitioner, the gap must be shown with the claim.
If you’re using ECLIPSE, payment can be expected Monday to Friday within 11 working days of lodgement. Payments submitted manually will take 20 working days. EFT payments are paid into accounts every Wednesday. Read below to find out more about your billing and payment options.
Payment using ECLIPSE Not interested in all the forms and paperwork? Then this 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 claims electronically. This means no more paper claims and improved payment turnaround times.
ECLIPSE enables providers and practices to exchange and settle claims electronically, safely and securely over the Internet.
The benefits of ECLIPSE ECLIPSE will save you time and money, here’s how:
° there’s no limit to the amount of claims or batches you can submit
° improved financial management through faster resolution of claims and quicker payment times
° better data integrity, less manual intervention and improved claiming automation
° online patient verification of Medicare enrolment and health fund membership within 4 seconds
° online viewing of payments
° one single point of contact and one system for all health funds
° lower incidence of error and shortened review times – giving you faster resolutions and immediate knowledge of any rejections
° no hub transaction fees
° view rejection codes and explanations online.
How do I become an ECLIPSE user? If you would like to register for ECLIPSE or want to know more about electronic claiming or software vendors, please contact the Australia Medicare eBusiness Service Centre on 1800 700 199, alternatively you can email [email protected] or [email protected]
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Payment using forms If you haven’t got ECLIPSE, you can still process your Medical Gap Scheme payments manually. It’s easy, simply follow our step-by-step guide.
Step 1: Capture the correct details
To ensure quick processing use this checklist for all the information you need.
° patient’s name, address and date of birth
° current Medicare card number and patient suffix
° Bupa membership number
° Hospital Provider number and the name of the hospital where the patient was admitted
° all service details: Date of service, Medicare Benefit Schedule item number, fee charged per item, the account total and special exemptions (time of operation, not normal aftercare etc).
° For Known Gap practitioners the full fee charged must be included on your accounts (that is, the Medical Gap Scheme benefit plus the patient gap of up to $500).
Step 2: Submit your accounts for payment
You can submit your payments by using the Batch Header Form and your own account forms (if you do not have any of your own forms please use our Doctor Account Form).
Step 3: Batch
We recommend that you submit up to 20 accounts daily per batch, together with a Batch Header Form. Once we receive your accounts we’ll validate the data and forward it onto Medicare for processing.
Step 4: Payment
We’ll raise a payment for your claim. This includes the 75% Medicare Schedule fee benefit, the 25% Medical gap benefit, and any additional Medical Gap Scheme amount. You’ll receive reports from us detailing the outcome of your payment. Approved payments will be credited to your nominated bank account.
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CLAIM FORMSIf 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 list to help you complete them.
Batch header form The Batch Header Form summarises the number of claims for an individual provider and the total amount that all the claims add up to. It may help you to track and reconcile your weekly or fortnightly submission of claims. There’s a space for staff to make comments and it includes your declaration that services provided, are for a private in-patient or day patient of a hospital or an approved day hospital facility. It also confirms that the benefits are not claimable from any other source. By submitting this form you accept the Medical Gap Scheme Terms and Conditions. A Batch Header Form must accompany all medical claims.
How is the batch header form used? A Batch Header Form is to be completed for each provider within a practice. Keep a photocopy of the completed form to use when reconciling the Medical Payment Summary Report you will receive from us.
We have included a list of key terms to assist you in completing your batch header form: Practice ID – Your Practice ID is the number given to you by Bupa to identify the Medical Gap Scheme practice location. To ensure your payment is deposited into the correct bank account, your Practice ID must be visible on the Batch Header and Doctor Account Forms.
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.
Batch header number – This is the date the batch of claims leave your rooms, with an alphabetical character signifying the number of batches for that day. For example, if three batches were sent for 1 January 2010 the format would be:
1 January 2010
Batch 1 = 01012010A (ddmmyyyyA)
Batch 2 = 01012010B (ddmmyyyyB)
Batch 3 = 01012010C (ddmmyyyyC)
It’s important that this number is unique per batch – this number plus your provider number help us to identify your batches. If you have a query with one of your batches, all you need to do is quote the batch header number together with your provider number to enable us to locate it quickly.
Total number of claims – This is the total number of claims submitted in the batch. Remember that the number of claims submitted per batch cannot exceed 20.
Please note: Printable versions of the Medical Gap Scheme forms can be downloaded from bupa.com.au/for‑providers.
Please ensure that you include your Practice ID.
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Doctor account form Bupa and Medicare use the information supplied on the Doctor Account Form to assess medical claims. You may use your own account form as long as you provide us with the Bupa membership number, Medicare number and hospital name.
How is the doctor account form used? Completed Doctor Account Forms should be collated into batches (20 maximum) and forwarded to Bupa with a Batch Header Form. All fields on the Doctor Account Form must be completed.
We have included a list of key terms to assist you in completing your Doctor Account Form:
Account reference – The account reference is assigned by you and should match your patient’s accounting record. This information is recorded as part of the claim. This will enable us to quote your account (claim) reference on the Medical Payment Detail Report for reconciliation.
Applicable service conditions – This section on the reverse of the Doctor Account Form must be completed. If you answer YES to any of the seven questions listed please use the space provided to make comments and indicate which item it relates to.
Facility at which the service was provided – The name and provider number of the hospital or approved day care facility must be entered in this field. Any claims submitted without this information will be rejected and will need to be re-submitted with the correct information.
Bupa membership number – The patient’s membership number must be provided. This information can be obtained from the patient or by contacting Bupa Customer Service on 134 135.
Medicare number and suffix – The current Medicare card number and suffix must be obtained from the patient. This can be found on the patient’s card and is used by Medicare to uniquely identify the person within their records.
Suffix number – This is the two digit number found before the patient’s name on their membership card (e.g. 01) that helps the fund to identify which dependant on the membership the claim is for. If you do not know this information leave this field blank.
Ordering Medical Gap Scheme stationery If at any stage you need more Medical Gap Scheme stationery, simply visit bupa.com.au/for‑providers
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Bupa Australia Pty Ltd ABN 81 000 057 590
1/102846-06-14E
0284
6061
4E
BATCH HEADER FORM
1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a CROSS. Start at the left of each answer space and leave a gap between words. PLEASE DO NOT STAPLE.
2. Read the declaration and sign all the signature panels required.
Practice name Practice ID
SECTION B: Complete this form, attach all accounts and either post or fax to:
SECTION C: Declaration
SECTION D: Comments
SECTION A: Please complete your practice details
Bupa Medical Claims GPO Box 9809 BRISBANE QLD 4001
Fax: 1300 130 623
Provider name
Provider number
Telephone number
Date
D D M M Y Y
Batch header number
Total number of claims
Total fee charged
$ .
This medical practice agrees to bill Bupa Australia Pty Ltd (Bupa) directly for the services attached and accepts the Bupa Medical Gap Scheme Terms and Conditions as supplied by Bupa. The members have been advised that no further payment is required in relation to the services specifi ed in the attached claims.
The professional services specifi ed on the attached forms were provided by me or on my behalf.
These services were rendered as an inpatient of a hospital or approved day hospital facility.
Signature
D D M M Y Y
This form can be downloaded from our provider website: www.bupa.com.au/for-providers
EXAMPLE O
NLY
10
Bupa Australia Pty Ltd ABN 81 000 057 590
1/202845-06-14E DOCTOR ACCOUNT FORM
0284
5061
4E
DOCTOR ACCOUNT FORM
This medical practice agrees to bill Bupa Australia Pty Ltd (Bupa) directly for the services outlined below and accepts the Bupa Medical Gap Scheme Terms and Conditions as supplied by Bupa. The member has been advised that no further payment is required in relation to the services specifi ed on this account form.
Practice name Practice ID
SECTION B: Doctor account details
SECTION A: Please complete your practice details
Provider name
Provider number
Health fund card/membership no.
Patient’s name
Member’s name
Address
Postcode
Facility at which the service was provided
Patient’s Medicare number
Account reference
Date of Birth
D D M M Y Y
MBS Item number
No. of patients seen Description of service Site Date of service
Service Provider number Charge
$
$
$
$
$
$
$
$
$
$
TOTAL $
REFERRAL DETAILS PLEASE SEE OVERLEAF
EXAMPLE O
NLY
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CLAIM REJECTION CODES What occurs when a claim is rejected?There can be many reasons why a payment has not been made. When a claim is rejected it can relate to either a Medicare and/or Bupa assessment. Any rejected claims will be listed in your Bupa Medical Gap Scheme reports with a rejection code. Please refer to the following tables for a list of rejection codes, what they mean and what action is required.
When are the Medical Gap Scheme benefits not payable? Bupa will not pay any medical insurance benefits in the following situations:
° if the service was not performed whilst the member was an in-patient of a recognised hospital or a recognised day hospital facility
° if the member is not up-to-date with membership payments at the time of treatment or service
° if the claim is covered by another source
° where any waiting periods have not been served at the time of the procedure
° where the hospital cover excludes benefits for specific treatments and procedures
° where a Medicare benefit is not payable or where Medicare has rejected the claim
° where the claim has not been lodged within two years of the date of service
° where the member is not on a hospital cover.
Please refer to the Medical Gap Scheme Terms and Conditions for further information.
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Bupa rejection codes Code Description When a claim is rejected
L06 Contributor has no hospital cover
° Check with the member that you have the correct personal and membership details.
° Check with the fund to verify that the patient is not on another membership.
° If the patient is not a member, no benefit is payable from the fund. Please bill the member in your normal manner.
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 separate batch and mark ‘re-submit’.
L22 Dependant over 20 years on a family table
° Check if the patient has his or her own cover. If yes, please re-submit the account as a separate batch and mark ‘re-submit’.
L24 Date of the service is after the date paid to
° The member is not financial, please contact the patient to discuss payment.
° Check with the fund for patient eligibility.
° If eligible re-submit the claim in a separate batch and mark ‘re-submit’.
L29 Duplicate claim exists on the database
° Check your reports and accounts for a previous payment or rejection for this claim, as it has been submitted before.
° If you believe you have not been notified of this, please contact Medical Claims Team.
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 ‘re-submit’.
° If not eligible please bill the member in your normal manner.
L35 Endorsements codes not found at date of service
° Same as L32.
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Medicare rejection codes Code Description When a claim is rejected
124 Item is restricted to person of opposite sex to patient
° Please check MBS online that the item number selected is the correct one.
° Check that the correct patient has been selected.
° If you have selected the wrong patient, please correct the details and re-submit the claim in a separate batch and mark ‘re-submit’.
137 Details of requesting provider not shown on account/receipt
° Please check that all the referral details have been included on your account.
° If eligible, re-submit the claim in a separate batch and mark ‘re-submit’.
162 A benefit for this service has been previously paid
° Check your payment reports or patient accounts for a previous payment for this item.
° If you believe you have not been notified of this, please contact Medical Claims Team.
171 Benefit not payable – provider may only act in one capacity
° This means that the provider has already been paid for another service. Please check the servicing provider details.
° If you believe these details are correct, please contact Medical Claims Team.
179 Benefit not payable – associated service already paid
° Please refer to the Medicare 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.
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’.
320 Expired Medicare card – benefit not payable
° Incorrect card details. Please re-submit your claim with the correct card number and mark ‘re-submit’.
619 Provider practice location is closed at the date of service
° Please check the provider number with Medicare.
° If the provider details need to be updated, please do so and re-submit your claim with the updated details and mark ‘re-submit’.
14
Medicare rejection codes Code Description When a claim is rejected
415 Referral details same as rendering provider – self deemed?
° Please check the referring provider number, should it be self-deemed?
° If self-deemed, please make this clear on your account and re-submit the claim in a separate batch and mark ‘re-submit’.
429 Patient cannot be identified from the information supplied
° This patient cannot be identified by Medicare. Please check the spelling of the patient’s name, their date of birth and Medicare card number.
° Once you have made the correct alterations please re-submit the claim in a separate batch and mark ‘re-submit’.
430 Conflicting referral details
° Please check that the referral provider number is current, and that the referral date and referral period are correct (e.g. specialist to specialist can only refer 3 months).
° Once this has been amended on the account please re-submit the claim in a separate batch and mark ‘re-submit’.
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 the claim in a separate batch and mark ‘re-submit’.
505 Medicare requires further details before they can make their assessment of this procedure
° Clinical details may be required by Medicare.
The rejection codes listed are subject to change. If you are still unsure why a claim has been rejected please call our Medical Claims Team. See inside back cover for contact details.
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COMMON QUESTIONS ANSWERED Q Why should I use ECLIPSE? A Because ECLIPSE is electronic, it’s
a great system for processing the Medical Gap Scheme payments. It may improve your financial management through faster resolution of claims and quicker payment times. Plus it gives you improved data integrity, with less manual intervention and better claiming automation – putting you in control of the process.
Q What are the main features of the Bupa Medical Gap Scheme and why should I use it?
A Please refer to page 2 for the many favourable benefits of using the Medical Gap Scheme.
Q Why is it important to supply the Medicare number and fund membership number?
A The Medicare number is required to identify the patient once the claim details have reached Medicare Australia for processing. The fund membership number is required to confirm policy details and eligibility. The patient is required to supply you with their current Medicare number and fund membership details at the time of consultation.
Q How do anaesthetists source patient information?
A To complete accounts, anaesthetists can obtain patient details from the doctor of the first referral or hospital. We have taken steps to ensure that hospitals have all the necessary information required on the ‘Bradmar’ labels for anaesthetists to complete their accounts.
Q If there has been no payment for a patient or an item, how is this recognised? Where can the payment amount be found?
A If there is a rejection for any reason, this will show on the Medical Payment Detail Report with an error code and explanation. Payment amounts are listed in detail on a payment report, which is sent each time a batch has been finalised.
Q Who should we contact for an explanation of rejection or error description?
A For further clarification on a Medical Gap Scheme rejection, please refer to page 11. If you’re still unsure, contact the Medical Claims Assist Team.
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Q When can a payment be expected? A If you’re using ECLIPSE, payment can
be expected within 11 working days of lodgement. Payments submitted manually will take up to 20 working days. EFT payments are paid into accounts every Wednesday.
Q How do I link a claim with a payment? A To identify the claim and the payment
it relates to, check your Medical Payment Detail Report. This report will list:
° the provider batch reference number (your reference number)
° the Bupa batch reference
° the amount charged and benefit paid
° a list of patients and the benefits relating to each patient.
Q Why are some items paid and others not?
A All claims submitted via the Medical Gap Scheme are subject to the normal Medicare Australia rulings. If there are restrictions on medical items, some benefits are not payable.
Q How often will the fees or benefits change?
A The fees and benefits are revised in line with the Medicare Australia MBS reviews.
Q Can the practice account forms be used? A Yes, these forms can be used instead
of our Doctor Account Forms. It’s important to note, however, that a Batch Header Form must be attached and your Practice ID number must be written on the Batch Header.
17
PROVIDER SUPPORT Administration procedures This includes any change of details, which will affect your Practice ID number such as:
° the appointment of a new doctor
° a doctor leaves your practice
° a change to your bank account details
° a change of your address
° access to online Medical Statements.
Please note: If there is a change of doctors at your medical practice you’ll need to notify us prior to sending in claims, so that we can update your details.
Please ensure that you include your Practice ID number in all correspondence sent to Bupa.
Call the Operations Team 1800 060 239
Email [email protected]
Web bupa.com.au/for‑providers
Stationery supplies ° Batch Header form
° Doctor Account form
° Benefit Schedule
All forms and the benefits schedules can be downloaded from bupa.com.au/for‑providers
Patient eligibility Call 134 135 and choose the provider option (3)
Claim assessment & payment For all claim assessment and payment enquiries
Call the Medical Claims Assist Team 134 135 and choose the provider option (3)
Facsimile 1300 130 623
Post Bupa, Medical Claims GPO Box 9809 Brisbane QLD 4001
18
19
Effective March 2016 10598-06-16E
