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st.lukes GAP cover Billing and Claiming Guidelines
January 2008
Closing the gap in private health care.
Page
1
23334566778
INTRODUCTION
BILLING AND CLAIMING GUIDELINESWho is eligible for St. Luke’s Gap Cover?
What waiting periods apply to St. Luke’s Gap Cover?
When are St. Luke’s Gap Cover benefits not payable?
Charging No Gap
Charging a Known Gap
How are claims paid through the St. Luke’s Gap Cover arrangement?
Payment of benefits
Statement of Benefit
Claim rejection procedures
How to use the Batch Summary?
Enquiry Support and Stationery Supplies
APPENDICESStationery Order Form
Batch Summary (Sample)
Estimate of Medical Fees (Sample)
1st.lukes GAP cover - Billing and Claiming Guidelines
St. Luke’s Gap Cover is a medical gap
cover arrangement that is designed to
provide Medical Practitioners with the
option of eliminating or reducing the
medical gap for eligible St.LukesHealth
members requiring hospital in-patient
medical services.
These Billing and Claiming Guidelines provide
information to participating practitioners on
the claiming process associated with St.
Luke’s Gap Cover. The guidelines should
be read in conjunction with the Operating
Guidelines contained within the St.
Luke’s Gap Cover Information for Medical
Practitioners booklet.
Introduction
2st.lukes GAP cover - Billing and Claiming Guidelines
WHO IS ELIGIBILE FOR ST. LUKE’S GAP COVER?Eligible Services
An eligible service is a service:
•which has been rendered to an eligible
St.LukesHealth member who has been
admitted as a private patient to an approved
hospital or day hospital facility;
•where informed financial consent has
been obtained from the patient where a
known gap has been charged and financial
disclosure has been provided to the patient;
•where the feecharged for theservice is in
accordance with the “No Gap” or “Known
Gap” levels provided for within St. Luke’s Gap
Cover;
•whichhasbeensubmittedtotheFundpriorto
being submitted to Medicare.
Services provided to “out-patients” or patients
using facilities of the hospital but who are not
formally admitted as a “day patient” or “overnight
patient” do not qualify for St. Luke’s Gap Cover
benefit.
Any consultations or treatments before or after
hospitalisation need to be billed separately. The
patient should also be advised that these services are
only claimable through Medicare.
Eligible St.LukesHealth members
St.LukesHealth members who are covered on the
following hospital products are eligible for St. Luke’s
Gap Cover:
Product Name Plan Code
Hospital Platinum J
Hospital 100 to Hospital 1000 J1 to J5 & JT
Limited Excess Top Private Hospital K
Pasplan & Status 85 P1 to P4
Packaged Basic EP
Packaged 300 & 500 Z3 & Z5
Packaged Platinum Plus ZP
In addition, an eligible St.LukesHealth member means a person:
1. Who during an episode of hospital care:
a) is a financial member of St.LukesHealth and holds
an appropriate level of health insurance cover;
b) is not subject to a Waiting Period;
c) is registered for and entitled to receive Medicare
rebates for the services performed;
d) is a “patient” as defined in Section 3(1) of the Health
Insurance Act 1973; and
2. Who during an episode of hospital care, received
services:
a) which are not eligible for compensation, damages or
any other indemnification;
b) which do not relate to a Pre-Existing Ailment where
such services are provided within the first 12 months
of commencing a membership with a registered
private health insurer;
c) which are not excluded from attracting a Medicare
rebate, such as cosmetic surgery.
Where the member’s level of hospital cover carries
an excess, this excess does not apply to the St. Luke’s
Gap Cover benefit.
Confirmation of patient eligibility
You should confirm with the patient whether they
have private health insurance and obtain both their
current Medicare number including their Medicare
card reference number and their St.LukesHealth
membership number.
On confirmation of the above, the following six
points should be checked:
1. Is the patient a St.LukesHealth member?
2. Is the service eligible for Medicare rebates?
3. Does the member hold appropriate cover?
4. Is the member up to date with payments?
5. Have waiting periods been served?
6. Are the services eligible for compensation? (Benefits
are not payable where compensation or damages
may be claimed from another source.)
Billing and claiming guidelines
3st.lukes GAP cover - Billing and Claiming Guidelines
We recommend your administration staff contact
St.LukesHealth Customer Service on 1300 651988 to
confirm the patient’s eligibility.
WHAT WAITING PERIODS APPLY TO ST. LUKE’S GAP COVER?The following Waiting Periods apply to all new
members who were previously uninsured. These
waiting periods may also apply when an existing
member increases their level of cover or when a
member transfers to St.LukesHealth from another
Fund where the previous Fund did not offer an
equivalent Gap Cover arrangement.
•A two (2) month waiting period applies to all
benefits except as further specified below.
•A twelve (12) month waiting period applies to
all obstetric related services whether or not the
member was pregnant at the time of joining
or changing cover. This includes miscarriage,
threatened miscarriage, termination and
treatment for other obstetric conditions.
•A twelve (12) month waiting period applies to
pre-existing ailments. A pre-existing ailment is an
ailment, illness or condition the signs or symptoms
of which, in the opinion of a Medical Practitioner
appointed by St.LukesHealth existed at any time in
the period of 6 months ending on the day on which
the member became insured under the policy.
Waiting periods commence from the date of joining
a private health insurer or from the date of changing
cover. For previously uninsured members, no
benefit is payable during the application of a waiting
period. Members who have transferred from another
registered private health insurer receive continuity of
membership for benefit entitlements for which they
were previously covered, provided the St.LukesHealth
cover includes those equivalent benefits and the
member has served the required waiting periods with
their previous insurer. Where the St.LukesHealth cover
or benefit is higher than that of the previous insurer’s
membership entitlements, then benefits will be
payable at the previous (lower) level of benefits
during the application of a waiting period.
When a waiting period is applied to a member
changing their level of cover, benefits will be paid
at either the previous level of cover or the new
level of cover, whichever is the lesser.
WHEN ARE ST. LUKE’S GAP COVER BENEFITS NOT PAYABLE?St. Luke’s Gap Cover benefit will not be paid:
•if the member was charged a known gap and
informed financial consent was not obtained from
the patient or if financial disclosure was not given
to the patient.
•ifthefeechargedisinexcessoftheknowngaplimits
applicable to St. Luke’s Gap Cover.
•iftheservicewasnotaneligibleserviceasdescribed
on page 2.
•if the member was not an eligible member as
described on page 2.
•wheretheMedicarerebateisnotpayable,orwhere
Medicare has rejected the claim.
•if theclaimwaslodgedmorethantwoyearsafter
the date of service.
•if the member has received their Medicare
rebate prior to the account being submitted to
St.LukesHealth.
Note: Where St.LukesHealth does not pay a St.
Luke’s Gap Cover benefit, the maximum payable
is the difference (25% medical gap) between the
Medicare rebate and the Commonwealth Medicare
Benefits Schedule Fee. In these circumstances
you may wish to come to an arrangement with
the member.
4st.lukes GAP cover - Billing and Claiming Guidelines
CHARGING NO GAP If you wish your patient to be fully covered for
the service you are providing, your fee should
not exceed the level shown in the St. Luke’s
Gap Cover Schedule of Fees.
Where your fee is equal to or less than the
St. Luke’s Gap Cover Schedule Fee, an eligible
member will be fully covered under St.
Luke’s Gap Cover providing all other eligibility
requirements have been met.
In all aspects, St.LukesHealth benefit
assessment will be based on Medicare
assessment rules.
Billing Multiple Procedures with No Gap
In arriving at the charge for a multiple
procedure under St. Luke’s Gap Cover, the same
multiple procedure rule or formula is to be used
as contained in the Commonwealth Medicare
Benefits Schedule. In all cases, the MBS fee level
should be used to determine the order in which
the multiple procedure is to be calculated.
Once the order is determined, the appropriate
percentages should be applied to the St. Luke’s Gap
Cover Schedule Fee for each item.
Example of a multiple procedure
MBS
item
MBS
Fee
St. L
uke’
s Fe
e
100%
Fee
50%
Fee
25%
Fee
Procedure 1
$500
$600
$600
Procedure 2
$400
$650
$325
Procedure 3
$300
$500
$125
The total no gap fee for this multiple procedure is $1050
In the above example the 100% fee was applied to
Procedure 1 even though the St. Luke’s Gap Cover
Schedule Fee for Procedure 2 was higher. This is
because the MBS Fee for Procedure 1 was higher
than for Procedure 2. Under Medicare assessing
rules, the MBS Fee is used to determine the order in
which the multiple procedure is to be calculated.
Billing Multiple Anaesthetics with No Gap
Where a multiple anaesthesia is provided the Medicare
rules under the Relative Value Guide for Anaesthesia
apply. That is, the RVG item with the highest basic
unit value should be charged. However, the time
component should include the total anaesthesia time
taken for all services.
Derived Fees
When calculating a derived fee through the gap cover
scheme, the MBS Schedule Fee should first be calculated
using the formula stated in the Medicare Benefits
Schedule for the relevant item. The derived MBS schedule
fee should then be multiplied by the percentage shown
in the St. Luke’s Gap Cover Schedule of Fees.
CHARGING A KNOWN GAPIf you elect to charge your patients a known gap, you
need to obtain written informed financial consent from
the patient prior to treatment, or in the case of an
emergency, as soon after treatment as practical.
If you charge a known gap to eligible St.LukesHealth
members, St. Luke’s Gap Cover benefit will only apply
if the known gap for each service is within 10% of
the St. Luke’s Gap Cover Schedule of Fees.
Billing Multiple Procedures with a Known Gap
The rules to apply when billing a multiple procedure
or multiple anaesthetic with a known gap are the
same as shown on page 4.
For example:
MBS
item
MBS
Fee
St. L
uke’
s Fe
e
Max
. Kno
wn
Gap
Fee
100%
Fee
50%
Fee
25%
Fee
Procedure 1
$500
$600
$660
$660
Procedure 2
$400
$650
$715
$375
.50
Procedure 3
$300
$500
$550
$137
.50
The total known gap fee for this multiple
procedure is $1155
Billing and claiming guidelines (cont’d)
5st.lukes GAP cover - Billing and Claiming Guidelines
HOW ARE CLAIMS PAID THROUGH THE ST. LUKE’S GAP COVER ARRANGEMENT?The following special claiming facilities are provided as
part of the St. Luke’s Gap Cover arrangement.
Billing the fund direct
To bill the fund directly, follow these steps:
1. Confirm that the patient is a member of
St.LukesHealth.
2. Obtain the patient’s St.LukesHealth membership
number, Medicare Card number and Medicare
Card reference number.
3. Obtain informed financial consent in writing
from the patient if a patient contribution or
known gap is being charged and provide
financial disclosure by using the “Estimate of
Medical Fees” form or similar. A sample of an
appropriate Estimate of Medical Fees form is
included in the Appendices.
4. Ensure your fee charged is within the allowable
limits of St. Luke’s Gap Cover.
5. Ensure the following details are provided on
your account:
•Patient’sname,addressanddateofbirth.
•Patient’sAccountReference.
•Medicare card number, including the patient’s
Medicare card reference number.
•St.LukesHealthmembershipnumber.
•Nameandprovidernumberofthehospitalwhere
the service was performed.
•All service details ie. Date of service, MBS item
number, special exemptions, etc.
•Whethertheclaimwaseligibleforcompensation.
•Fees charged for each MBS item, including any
patient contribution. (Do not use a notional fee).
•Referraldetails.
•HospitalCollectionPoint(HCP)code
(if the account includes pathology services).
•LocationSpecificPracticeNumber(LSPN)(ifthe
account includes radiology services)
•Anyotherinformationrelevanttoassessment
of the service.
•AustralianBusinessNumber(ABN)
Note: The St.LukesHealth membership number,
the hospital detail, Medicare Card number and
patient Medicare Care reference number can be
included on the Batch Summary if this information
is not provided on your account.
6. Forward all accounts for eligible services to
St.LukesHealth as they are raised individually or in
batches.
7. Complete, and attach, a “Batch Summary” to each
batch of accounts submitted. If only one account is
to be submitted, a “Batch Summary” still needs to
be completed. A sample of the “Batch Summary” is
included in the Appendices.
Online claiming using ECLIPSE
As an alternative to issuing paper based accounts,
you can also claim electronically through your practice
management software by using the ECLIPSE functionality.
ECLIPSE stands for Electronic Claim Lodgement and
Information Processing Service Environment.
You may already use online claiming to lodge claims
directly to Medicare. ECLIPSE is an extension of
Medicare Australia’s online claiming system that
incorporates direct communication and claiming for
providers with Medicare and private health insurers,
all in the one transaction. If you wish to connect
to ECLIPSE you should contact your software
vendor to ask whether they currently offer ECLIPSE
functionality.
You can obtain more information about ECLIPSE
from the following sources:
•call Medicare Australia’s eBusiness Service
Centre on 1800 700 199
•emailco.eclipse@medicareaustralia.gov.au
•www.medicareaustralia.gov.au/onlineclaiming
6st.lukes GAP cover - Billing and Claiming Guidelines
Claims processing
When a batch of accounts is received,
St.LukesHealth will confirm the member’s
eligibility for the Gap Cover benefit, including
whether the requirements for Informed
Financial Consent and Financial Disclosure
have been met.
St.LukesHealth will then validate the account
data and forward it electronically to Medicare
for processing. Medicare will process the
accounts and pay the Medicare rebate to
St.LukesHealth. If claims are processed
electronically through ECLIPSE, the claim will
go to Medicare first and then to the Fund by
way of an automated service.
St.LukesHealth will raise a payment for the
Provider that covers the Medicare rebate, the 25%
medical gap and the additional St. Luke’s Gap Cover
benefit. You will receive a Statement of Benefit
listing payments and rejections. This statement will
be mailed to you at the time of payment.
Any St.LukesHealth/Medicare rejection will
(depending on the reason for the rejection) need to
be either resubmitted to St.LukesHealth for processing
or sent to the patient for payment.
Late lodgement of a claim
Subsection 20B(2)(b) of the Health Insurance Act 1973
provides that a claim for assigned Medicare benefits
must be lodged with Medicare Australia within 2 years
of the date of a professional service. As a claimant, you
may make an application to extend the 2 year time limit
for lodging a claim for an assigned Medicare benefit.
Claims submitted over 2 years from the date of
service are not eligible for St.LukesHealth benefit even
if late lodgement approval has been obtained from
Medicare Australia.
PAYMENT OF BENEFITSPayments will be made by Electronic Funds Transfer
(EFT) direct to your nominated bank account usually
within 21 calendar days of receipt of your patient’s
claim, providing Medicare payment has been received
by the insurer.
You will need to supply St.LukesHealth with your
banking details on the “EFT Payment Form” included in
the Appendices.
If bank account details are not provided payment will be
made by cheque.
St.LukesHealth will forward payment for each account
as soon as assessment is complete regardless of the
processing status of the other accounts submitted
within the same batch.
STATEMENT OF BENEFITA Statement of Benefit will be posted to you at the
time payment is made by EFT (in the case of cheque
payment, the statement will accompany the cheque).
Please allow approximately 3 working days for
receipt of the statement after payment by EFT.
The Statement of Benefit will detail payments and
rejections together with assessment/rejection
explanations. St.LukesHealth will pay accounts
(and forward payment for each account) as soon
as assessment is complete regardless of the
processing status of other accounts submitted by
you in a particular batch.
A Statement of Benefit may contain payment details
relating to accounts from more than one batch.
A Statement of Benefit will also be sent to the
member detailing the benefit payment.
Billing and claiming guidelines (cont’d)
7st.lukes GAP cover - Billing and Claiming Guidelines
CLAIM REJECTION PROCEDURESAs mentioned previously the Statement of Benefit
will contain assessment/rejection explanations. These
can relate to either Medicare and/or St.LukesHealth
assessment.
Medicare Assessment/ Rejection Explanation Codes
Medicareassessment/rejectioncodeswillappearon
the St.LukesHealth Statement of Benefit. A full list
oftheMedicareassessment/rejectioncodescanbe
foundontheMedicareAustraliawebsiteathttp://
www.medicareaustralia.gov.au/provider/vendors/
reason-codes/medicare.shtml
St.LukesHealth Assessment/ Rejection Letter
If an account cannot be processed by St.LukesHealth
the account will be returned to you along with a
letter of explanation.
The following list provides examples of reasons
which may result in an account being returned:
•Membershipisunfinancial
•NocoverheldwithSt.LukesHealth
•Not a private in-patient when the service was
rendered
•WaitingPeriodsnotserved
•Insufficientdetailsuppliedonaccount
•Claimpreviouslypaid
•Claimisover2yearsoldandisthereforenoteligible
for insurer benefit
Depending on the reason for rejection you may need to:
•Amend the account as necessary and resubmit
with your next batch.
•Check account details in accordance with the
rejection message. If correct and if Medicare
and St.LukesHealth benefits are not payable, bill
your patient direct. Please remember to mark
your account ‘The amount on this account is NOT
claimable through Medicare or St.LukesHealth’.
•IfSt.LukesHealthbenefitsarenotpayable,pleasebill
the member direct in your normal manner. Remember
to mark the account ‘The amount on this account is
claimable through Medicare only’.
•If you have a query about an adjusted benefit
please contact St.LukesHealth. If the adjustment
is correct, nothing further will be payable for
this service.
If you require any assistance please contact
St.LukesHealth. Detail on enquiry support is provided
on page 8 of this document.
HOW TO USE THE BATCH SUMMARYA Batch Summary must accompany any patient
accounts sent direct to the insurer for processing
through the St. Luke’s Gap Cover scheme. A sample of
the Batch summary is included in the Appendices.
Why is the Batch Summary required?
•It will summarise the number of accounts
submitted for reconciliation.
•Thebatchlodgmentdatewillassistintracking
accounts prior to processing and in payment
reconciliation.
•Itincludesyourdeclarationthattheseservices
were provided to a patient of a recognized
hospital and that the requirements of informed
financial consent and financial disclosure have
been met.
8st.lukes GAP cover - Billing and Claiming Guidelines
•It signifies your request for the accounts
to be processed under the St. Luke’s Gap
Cover Scheme in accordance with the
operating and billing guidelines supplied by
St.LukesHealth.
How is the Batch Summary used?
The Batch Summary is to be completed and
stapled to the accounts submitted in that
batch. If only one account is being submitted,
a Batch Summary still needs to be completed.
The following guidelines should be followed
when completing the Batch Summary:
SECTION 1 – Provider details
All fields in this section should be completed.
The contact name should be the name of the
person to be contacted in the event of an
account enquiry.
SECTION 2 – Batch details
Lodgment date: This is the date on which you
forward the batch of accounts for processing.
Account Reference / Surname: This is the account
reference assigned by you to each account attached
to the batch. This will assist St.LukesHealth to identify
the accounts included in the batch. If you do not
use an account reference, please show the patients
surname in this field.
St.LukesHealth Member Number: This is the patient’s
insurer membership number.
Card Reference: This is the patient’s reference number
shown on the Medicare card. It is used by Medicare to
identify which patient on the Medicare card received
the treatment.
Hospital Name: This is the name of the hospital where
the service took place.
The St.LukesHealth member number, Medicare number,
Medicare card reference and Hospital name only need
to be completed if this information is not shown on the
individual patient accounts.
SECTION 3 - Comments
Comments: The comment section is supplied to enable
you to add or supply any supporting information you
feel is necessary regarding the batch of accounts.
ENQUIRY SUPPORTFor all enquiries please call 1300 651 988.
When making an enquiry please request one of the
following services:
•Member eligibility check: We will require you to
identify your practice and we will also request the
patient’s name and date of birth.
•Claim enquiry: We will require you to identify your
practice and we will also request the patient’s name
and date of birth. Details of the patient account may
also be requested.
•St. Luke’sGapCoverarrangementenquiry:Youwill
be transferred to the appropriate person dependent
on the nature of your enquiry.
STATIONERY SUPPLIESSupplies of the following can be obtained from
St.LukesHealth.
•BatchSummaryforms
•StationeryOrderforms
•EstimateofMedicalFeesproforma
•Envelopes
•St.Luke’sGapCoverBrochures
•St.LukesHealthProductBrochures
•St.Luke’sGapCoverPosters
Simply complete the stationery order form (a copy
is included in the Appendices) and forward it to
St.LukesHealth in one of the following ways:
Fax: (03) 6334 0711
Post: PO Box 915, Launceston, TAS, 7250. or
Sendyourorderbyemail:email@stlukes.com.au
Billing and claiming guidelines (cont’d)
Provider details for delivery purposesProvider Name Date
//
Address
Postcode
Contact Name
Contact Telephone Number
Stationery order
ITEM NUMBER REQUIRED
Batch Summary Forms
Stationery Order Forms
Envelopes
St. Luke’s Gap Cover Brochures
St.LukesHealth Product Brochures
St. Luke’s Gap Cover Posters
Estimate of Medical Fees Pro Forma Electronic copy Paper copy
If electronic copy requested,
please supply email address below.
Any special delivery instructions
Please return this form to St.LukesHealth, PO Box 915, Launceston, Tasmania, 7250 or fax to (03) 6334 0711
Stationery order form
10st.lukes GAP cover - Billing and Claiming Guidelines
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SAMPLE
ONLY
SECTION 1 – Provider Details Provider Name Provider Number
Practice Address
Contact Name Phone No. Fax No.
SECTION 2 – Batch Details
LodgmentDate//The Account Reference column must be completed. The other columns need to be completed if the
requested information is not shown on the patient account.Account Ref /
SurnameSt.LukesHealth
Member Number Medicare Number Medicare Card Ref. Hospital Name1.2.3.4.5.6.7.8.9.
10.11.12.13.14.15.
Batch Total $
SECTION 3 – Comments:
Declaration:
1. Have the patients included in this batch been provided with an “Estimate of Medical Fees” and has informed financial consent been obtained?
YES NO Not Applicable as “No Gap” applies.
2. Have you disclosed to all patients any financial interests you have in any product or service recommended or given to the patient?
YES NO N/A
I declare that the services listed on the attached account(s) were provided by me or on my behalf and that the services were rendered to the patient(s) whilst admitted as a private patient of a recognised hospital.
This medical practice agrees to bill St.LukesHealth directly for the services listed on the attached account(s) and for these accounts accepts the operating, billing and claiming guidelines of the St. Luke’s Gap Cover scheme as advised by St.LukesHealth.
Signature of authorised person Name of authorised person
Batch summary
SAMPLE
ONLY
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Health insurer
private health insurer
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Health insurer
private health insurer
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abn 81 009 479 618
A Registered Health Benefits Organisation
1300 651 988w stlukes.com.aue email@stlukes.com.au
Head Office17 The Quadrant MallLaunceston 7250t 03 6331 9255f 03 6334 0711
Branch Offices50a Murray StreetHobart 7000t 03 6234 8866f 03 6223 2824
26 Rooke StreetDevonport 7310t 03 6424 5188f 03 6424 9716
43 Cattley StreetBurnie 7320t 03 6431 3433f 03 6431 6797
24 Smith StreetSmithton 7330t 03 6452 1659f 03 6452 2649
Orr StreetQueenstown 7467t 03 6471 2719f 03 6471 2567
64 Emu Bay RoadDeloraine 7304t 03 6362 2333f 03 6362 2995
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