Importing Specialist Claims
Bulk Bill / Veterans / Patient Claims
To save time double handling your specialist claim data, import your data into eClaims and have the claims paid within 1-3 working days for Medicare and DVA claims.
Minimum Data Set
Everything is mandatory unless stated otherwise.
- Patient Info
- External Patient ID
- First Name
- Middle Initial (optional)
- Last name
- Date of Birth
- Gender
- Veterans Affairs Number (conditional)
- Medicare Number (conditional)
- Medicare Reference Number (conditional)
- Claimant Details (conditional – required for Patient Claims only)
- Bank Account Details (conditional – required for Patient Claims only)
- Claim Data
- Type of Service
- Service Type Code
- External Invoice ID (optional)
- External Servicing Provider ID
- Referring Dr Title (optional)
- Referring Dr First name (optional)
- Referring Dr Last name (optional)
- Referring Dr Provider Number
- Referral Date
- Referral Period
- Referral Period Type Code
- Veterans Service Type (conditional)
- Treatment Location (conditional)
- Benefit Assignment Authorised
- Total Invoice/Claim Amount (optional)
- Number of Items
- Item/s
- Date of Service
- Hospital Indicator (conditional)
- Number of Patients Seen (conditional)
- Self Deemed
- Multiple Procedure Override
- Duplicate Service Override
- Charge for Item (optional)
- Service Text (conditional)
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
Type of Service – this sets the type of claim i.e. a Medicare (bulk bill) or a Veterans claim.
- M – Medicare
- V – Veterans
- P – Patient Claims
Token name is: TypeOfService
Service Type Code – this sets the service type i.e. General or Specialist This should be set to Specialist.
- S – Specialist
Token name is: ServiceTypeCde
Veterans Service Type – Indicates the type of claim, only required if ‘Type of Service’ is V for Veterans. If your services do not fit one of these categories, then it is not required.
- F – Community Nursing
- G – Dental
- L – Optical
- I – Speech Pathology
- J – Allied Health
- K – Psych
Token name is: VaaServiceTypeCde
Treatment Location Code – This is only required when ‘Type of Service’ = V (Veterans). For non Veterans claim, keep the token in the file, simply without a value.
- V – Home Visit
- H – Hospital
- R – Rooms
- N – Residential Care facility
- C – Community health centres
Token name is: TreatmentLocationCde
External Servicing ID – 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. You do not have to provider the actual provider number, you can place your own unique code, and we will map that code to your actual provider number.
Token name is: ExtServicingDoctor
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
Referring Dr Title / First name / Last name – these are optional, but we would recommend including it in the file. But not a deal breaker.
Tokens available:
- RefDrFirstName
- RefDrLastName
- RefDrTitle
- RefDrAddress
- RefDrSuburb
- RefDrState
- RefDrPostcode
- RefDrPhone
- RefDrfax
- RefDrEmail
Referring 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 = ReferralPeriodTypeCde
Benefit Assignment Authorised – Indicates that the patient has authorised the assignment of their rights of benefit to a provider. Always indicate authorised.
Required when ‘Type of Service’ is M or V, not required when Service Type = P. If set to N, the claim will not import.
- Y – Authorised
Token name = BenefitAssignmentAuthorised
Number of Items – this is like checker, that confirms how many items we should be expecting within the claim/invoice.
Token name = NumberItems
Invoice / Claim Amount [Total] – this is not required, as eClaims can work out the amount per item and thus the total charge for Bulk Billed claims. If however, you are not charging the Medicare/DVA rate, then you will need to provide the total charge amount.
Token name = BClmAmt
Charge [for each Item] – you do not need to provide any amounts as eClaims can work out the amount when we import the data. If however, you are not charging the Medicare/DVA rate, then you will need to provide the charge amount for each item.
Token name = 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 (no longer supported by Medicare)
- SS – Substituted Service
- N – Not Self Deemed
Token name: 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: 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: DuplicateServiceOverrideInd
Number of Patients Seen – this is only required when the item number being billed requires it. For example home visits, you will need to specify the number of patients seen in that session.
If 5 patients were seen in one session by one provider, then all 5 patients would have a 5 as the ‘Number of Patients Seen’.
Token name is: NoOfPatientsSeen
Hospital Indicator – Indicates if the service was rendered in hospital or not. This field is conditional.
- Y – In hospital
- N – Not in hospital
If the ‘Type of Service’ is M or P, this field is required.
If the ‘Type of Service’ is V, then this field is not required, and not required in the file at all.
If Y, then the hospital provider number needs to be provided in the service text field.
Since this is at the item level, if 2 items are invoiced and the service was provided in hospital, the provider number (of the hospital) would be in the service text for both items.
When In Hospital and ‘Type of Service ‘ is set to V, then the only thing to do place the hospital provider number in the service text.
Token name: HospitalInd
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.
Limited to 100 characters for Veterans claims, otherwise limited to 50 characters.
Token name = ServiceText
Only applicable to Patient Claims i.e. Type of Service = P
Claimant Details – provide this if the claimant is other than the patient. If required, then the following is mandatory: First name, Surname, Medicare Number, Medicare Reference Number, Date of Birth. An example of when this is required, is when the patient is a child under 18 years of age.
The address is not required, it is only required, if you need to indicate a temporary address. The address can not be a PO BOX.
Tokens available:
- ClaimantFamilyName
- ClaimantFirstName
- ClaimantDateOfBirth
- ClaimantMedicareCardNum
- ClaimantReferenceNum
- ClaimantAddressLine1
- ClaimantAddressLocality
- ClaimantAddressPostcode
Bank Details – Only required if, the claimant wishes the payment to go to a different account to what they have registered with Medicare.
Account Paid Indicator – Indicates whether or not an account has been paid in full.
Token name = AccountPaidInd
Claim Submission Authorised – Indicates that the claimant has authorised the location to submit the claim on their behalf. Must be set to Y to submit the claim.
- Y – Authorised
- N – Unauthorised
Token name = ClaimSubmissionAuthorised
Patient Contribution [Total] – Indicates the total the patient has paid for the claim.
Patient Contribution [for each item] – Indicates the amount the patient has paid allocated to the item.
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/
