IMC claims via Eclipse
This is an introduction to Eclipse billing in eClaims.
eClaims Specialist Edition can provide access to IMC (Inpatient Medical Claims) through the Eclipse network. Eclipse is an extension to Medicare Australia’s online claiming solutions and offers a secure connection between practices, public and private hospitals, billing agents, Medicare, Department of Veterans’ Affairs and health funds to settle claims electronically.
An In-patient Medical Claim relates to claims while a patient was admitted to hospital as opposed to an outpatient claim that is provided in a doctor’s rooms. Medicare will rebate the patient part of the scheduled fee and the health fund will pay an additional amount.
There are five (5) types of in-patient medical claims available in eClaims
Agreement
Scheme
Patient Claim
Medicare Only
Medicare Benefit
Agreement
- The patient is not required to make any payments
- The servicing Doctor receives 100% or more of the scheduled fee (75% of scheduled fee paid by Medicare, the remaining amount is paid by the Heath Fund)
- The provider has signed an Agreement with the Fund (of which the patient is a member) specified in the claim. Payment goes to the provider or Billing Agent via the Health Fund.
- A fund payee ID must be added to claims when they are submitted.. Contact ACSS for assistance in adding this to eClaims.
Scheme
- The patient is not required to make any payments
- The servicing Doctor receives 100% or more of the scheduled fee (75% of scheduled fee paid by Medicare, the remaining amount is paid by the Heath Fund)
- The provider is operating under a scheme with the Fund (of which the patient is a member) specified in the claim. Payment goes to the provider or Billing Agent via the Health Fund. Assumes any financial interests are disclosed to the patient.
Patient Claim
- Servicing Doctor fee’s are above the 100% scheduled rate and the patient is required to pay the Gap (the difference between the amount charged and the scheduled fee)
- The patient has the option to pay up front, pay the gap or paying nothing on the day of the service
- If the claim has been paid in full by the patient, payment from Medicare and Health Fund goes to the patient or claimant
- If the claim has not been paid, the payment from Medicare and the Fund goes to the patient, via Cheque (made out to the provider), who will then pass it on to the servicing provider.
Most IMC Claims will be agreement or scheme. Patient, medicare only and medicare benefit are only used rarely.
Medicare Only
- The patient is not required to make any payments
- Billed by a Billing Agent for example a Public Hospital would be an approved billing agent
- Billing agent receives 75% of the scheduled fee from Medicare
- There is no fund involvement
- Billing is the same as in-hospital bulk billing. For administration reasons a hospital will use IMC as opposed to bulk billing to classify revenue generated from in patients or outpatients.
Medicare Benefit
- The patient is not required to make any payments
- Billed by a Billing Agent for example a Public Hospital would be an approved billing agent
- Billing Agent receives 100% of the scheduled fee (75% paid by Medicare, 25% paid by the Heath Fund)
For more information refer to the Medicare website.
Click here to download details directly from the Medicare website Eclipse billing.
Click here for a list of health funds using Eclipse and their contact details.
Before sending claims it’s necessary to contact the health fund and it may be necessary to complete an agreement to send claims using the eclipse network. The health fund may ask for a minor ID. The minor ID starts with the letters ADV and is displayed in the bottom right corner of eClaims.
If you haven’t yet started using eClaims and are not sure what your Minor ID is, please call the ACSS Sales team on 02 9632 0026 and press option 1.
Related Topics
How to import health fund fees