Importing Specialist Claims
ECLIPSE
To save time double handling your specialist claim data, import your data into eClaims and have the ECLIPSE claims paid within 4 weeks by the health funds.
NOTE: DVA in hospital claims would go via the Medicare Online channel not the ECLIPSE channel.
Minimum Data Set
Everything is mandatory unless stated otherwise.
Patient Information
- External Patient ID
- First Name
- Middle Initial (optional)
- Last name
- Date of Birth
- Gender
- Address (optional)
- Medicare Number or Veterans Affairs Number
- Medicare Reference Number (conditional)
- Health Fund Code
- Health Fund Membership Number
- Health Fund Universal Position Identifier (optional)
- Health Fund Payee ID “also known as practice ID” (conditional)
Claim Data
- External Invoice ID (optional)
- External Servicing Provider ID
- Type of Service
- Service Type Code
- Claim Type Code
- Financial Interest Disclosure Indicator
- Accident Indicator
- IFC Issue Code
- Benefit Assignment Authorised
- Facility Provider Number
- Referring Dr Details (optional)
- Referring Dr Provider Number
- Referral Date
- Referral Period Type
- Referral Period (conditional)
- Invoice/Claim Amount [Total] (conditional)
- Number of Items
- Item
- Date of Service
- Charge [for each item] (conditional)
- Service Text (conditional)
- Time of Service (conditional)
- Number of Patients Seen (conditional)
- Self Deemed
- Multiple Procedure Override
- Duplicate Service Override
Notes
External Patient ID – this is required so we can uniquely identify the patient. This must be unique to the patient. Everytime a claim is imported, we override the patient details (e.g. first name, last name) for a patient with that same external patient id.
Token name is: ExternalPatientID
Gender – patient gender.
- F = Female
- M = Male
Token name is: PatientGender
Address – patient address, since this is optional (not required by the ECLIPSE), unless you want to build your patient database in eClaims, leave the address tokens empty.
Tokens available:
- PatientAddressLine
- PatientAddressLocality
- PatientPostcode
Health Fund Universal Position Indicator (UPI) – The UPI appears on the patient’s fund membership card to uniquely identify the patient, it is the number in front of the patient name on the card.
Token name is: PatientFundUPI
Health Fund Brand ID – this is the health fund ECLIPSE code.
Token name is: FundBrandID
Health Fund Payee ID – (conditional) some funds require this, also known as the Practice ID. For example BUPA and Medibank Private required this. If not required, leave blank.
Token name is: FundPayeeID
External Invoice ID – This is only required, if you want to import the data back into your main system. Once claims are paid, we can send you a file back, with your external Invoice ID and Patient ID, so you can match it to the correct invoice/patient. But if you do not intend to import the data back, then you can skip this field.
Token name is: ExternalInvoice
External Servicing ID – Put the doctors provider number here, or a unique code to identify the doctor and we can map it to the correct provider number. If you are billing under the one provider number, you can skip this field. If however you are billing under multiple provider numbers then we will need something to identify which provider number to use.
Token name is: ExtServicingDoctor
Type of Service – this sets the type of claim for ECLIPSE, always set to N.
- N – Inpatient/ In-hospital
Token name is: TypeOfService
Service Type Code – this sets the service type, always set to S.
- S – Specialist
Token name is: ServiceTypeCde
Claim Type Code – Determines the processing class under which a claim is submitted.
- AG – Agreement
- SC – Scheme
Token name is: ClaimTypeCde
Financial Interest Disclosure Indicator – Indicates that the provider providing the hospital treatment under a gap cover scheme has disclosed to the patient any financial interest in any products or services recommended or given to the patient.
Must be set to Y if the Claim Type Code is set to SC
- Y = Financial Interest Disclosed
- N = No Financial Interest Disclosed
Token name is: FinancialInterestDisclosureInd
Accident Indicator – Indicates whether or not the associated information relates to the patient experiencing an accident.
- Y – Service result of an accident
- N – Service not a result of an accident or unknown
Token name is: AccidentInd
IFC Issue Code – indicates if an Informed Financial Consent (IFC) was provided to the patient prior to the episode of care.
If the Claim Type Code is set to SC, then this must be either: W or X.
If the Claim Type Code is set to AG, then this must be either: V, W or X
- V = Verbal
- W = In writing, where appropriate
- N = Not issued
- X = Not obtained
Token name is: IFCIssueCde
Benefit Assignment Authorised – indicates if the claim will go through the ECLIPSE channel or whether a paper based claim will be created, that will need to be manually delivered to the health fund.
- Y = Yes, submit through ECLIPSE
- N = No, create paper based invoice addressed to the health fund
Token name is: BenefitAssignmentAuthorised
Facility Provider Number – the provider number of the facility where the service was rendered.
Token name is: FacilityId
Referring Dr Title / First name / Last name – these are optional, but we would recommend including it in the file, at least the referring doctors first and last name, but not a deal breaker, however the provider number is mandatory. You can pass other information (but not essential) such as the referring doctor’s address, contact numbers and email address.
Tokens available:
- RefDrFirstName
- RefDrLastname
- RefDrTitle
- RefDrAddress
- RefDrSuburb
- RefDrState
- RefDrPostcode
- RefDrPhone
- RefDrfax
- RefDrEmail
Referring Doctor Provider Number – this is mandatory, whilst the referring doctors demographics are optional.
Token name is: ReferringProviderNum
Referral Date – format is dd/mm/yyyy
Token name is: ReferralIssueDate
Referral Period Type – Indicates the period of the referral.
- S – Standard (12 months for a GP and 3 months from a Specialist)
- N – Non standard
- I – Indefinite
Token name is: ReferralPeriodTypeCde
Referral Period – indicates the referral period. This is only required if the Referral Period Type is set to N or I.
Token name is: ReferralPeriod
Invoice / Claim Amount [Total] – conditional, this is the total amount of the invoice / claim for all items within the invoice. If you can not pass this information, then we can setup fees in eClaims.
Token name is: BClmAmt
Number of Items – this is a checker, that confirms how many items we should be expecting within the invoice / claim.
Token name is: NumberItems
Charge [for each Item] – conditional, this is the amount charged for the specific item. If you can not pass this information, then we can setup fees in eClaims.
Token name is: ChargeAmount
Self Deemed – A Self Deemed service is a service provided by a consultant physician or specialist as an additional service to a valid request. A substituted service is a service provided that has replaced the original service requested.
- SD – Self Deemed
- SS – Substituted Service
- N – Not Self Deemed
Token name is: SelfDeemedCde
Multiple Procedure Override Indicator – Indicates whether the service is part of a multiple procedure or not. For example, if you have to bill an item twice, because it was performed on the left and right leg.
If set to Y, then the reason for the override must be included in the Service Text.
- Y – Not Multiple
- N – Multiple
Token name is: MultipleProcedureOverrideInd
Duplicate Service Override Indicator – Indicates if the servicing dr attended the patient on more than one occasion on the same day.
- Y – Not Duplicate
- N – Duplicate
If Y, then you will need to add some service text (at the item level) or set the Time of Service field.
Token name is: DuplicateServiceOverrideInd
Number of Patients Seen – The number of patients seen. Must be set for group attendance items (e.g. counselling) or visits (home, hospital or institution) to ensure the correct payment is made. Range is 1-99, otherwise this field is not applicable.
Token name is: NoOfPatientsSeen
Time of Service – The time the service was rendered. Format HHMM, expressed in 24 hours time e.g. 1435 for 2:35 pm.
Token name is: TimeOfService
Service Text – Free text used to provide additional information to assist with the benefit assessment of the service.
Only used when absolutely required, as text will mean the claim will need to be manually assessed, which delays the processing time of your claim. Limited to 50 characters.
Token name is: ServiceText
File Naming Conventions
You will need to observe the following naming protocols, see https://alturahealth.com.au/hybrid-naming-conventions
Returned Files that can be imported back into your system
This is an optional step, and is useful provided your main system can import files. Read more at https://alturahealth.com.au/hybrid-export-files/
