Online Eligibility Checking (OEC)

 

Practices can perform an online eligibility check prior to the arrival of the patient on the day of the appointment.

An online eligibility check report will have details about the patient's out-of-pocket expenses, and medical benefits payable by Department of Human Services and the Health Fund, assisting the patient with providing informed financial consent.

For instance, an eligibility check can be performed for a patient who has booked an appointment for procedure (e.g. colonoscopy) in your day surgery.

 

You can select from the 3 types of Online Eligibility Checks in Eclipse;

o       Hospital-only check (ECF) determines whether the patient is eligible for the selected presenting illness or condition on the admission date. It provides the out-of-pocket expenses for excess, exclusions, and co-payments associated with the patient’s hospital episode.

o       Medicare-only check (ECM) determines whether the patient is covered by Medicare, and what benefits are payable for in-patient medical services.

o       Hospital and medical checks at both Medicare and the private health insurers (OEC) determines whether the patient is eligible for a presenting illness or condition on the admission date. It provides the out-of-pocket expenses for excess, exclusions, and co-payments associated with the patient’s hospital Episode, and the Medicare and the private health insurer benefits payable for the medical services.

 

Before you go to the trouble of conducting an Online Eligibility Check, you can confirm whether your Health Fund supports it to begin with.

To do this, select the 'Insurers' tab of either your IHC or IMC batch type. Any health funds with a against the OEC column will be able to validate the OEC. If the entire column contains empty check boxes, this indicates that you need to update the list of insurers. For more information on updating the list of insurers, see;

 

 

 


To Conduct an OEC

1.     Within the patient's record, select the Estimates menu, and then select the hospital estimate you wish to conduct an OEC for.

 

2.     Click  The Online Eligibility Checking window appears. The Check Eligibility option at the top of this window defaults to ‘Both (OEC)’ so that you can check both the out-of-pocket expenses such as excess, exclusions, and co-payments associated with the patient’s hospital episode, and the Medicare and the private health insurer benefits payable for the medical services.

 

3.     At this point, you can continue with the default Check Eligibility option of 'Both (OEC)' (as shown in the image above), or you can choose the 'Fund (ECF)' option to check the out-of-pocket expenses such as excess, exclusions, and co-payments associated with the patient’s hospital episode (stay).

o       If you wish to continue with the default option of ‘Both (OEC)’, proceed now to Step 8.

o       If you select the ‘Fund (ECF)’ option, data sourced from the estimate (including any item numbers and patient details) will be deleted. You will be alerted to this. Click to continue.



The Online Eligibility Checking window will appear with 'Fund (ECF)' selected. Proceed now to Step 8.

 

 

4.     If you wish the 'Fund (ECF)' to be defaulted so that you can check out-of-pocket expenses such as excess, co-payments, and exclusions with the associated hospital stay, an estimate with only the prosthesis and miscellaneous items used during the patient’s episode at your day surgery is created.

o       Select the estimate and click



The Online Eligibility Checking window appears. Proceed now to Step 8.

 

5.     Within the patient's record, select the Estimates menu item. Then select the estimate you wish to conduct an Online Eligibility Check for, and then click  In the example below, we have selected an estimate for Dr Bevan Ayers.

 

6.     The Online Eligibility Checking window appears. Blue Chip defaults the Check Eligibility option to ‘Both (OEC)’, so that you can check both the out-of-pocket expenses such as excess, exclusions and co-payments associated with the patient’s hospital episode, and the Medicare and the private health insurer benefits payable for the medical services.

 

7.     At this point, you can continue with the Online Eligibility Check, or you can select the Check Eligibility option of 'Medicare (ECM)' to find the only the benefits payable by Medicare.

o       If you wish to continue with the 'Both (OEC)' option, proceed now to Step 8.

o       If you select the ‘Medicare (ECM)’ option, data sourced from the estimate and patient details will be deleted, and you will be alerted to this. Click to continue.



The Online Eligibility Checking window will appear with 'Medicare (ECM)' selected. Proceed now to Step 8.

 

 

8.     Notes:

o       Mandatory fields for all the 3 options are marked in bold with an asterisk (*) and differ for each option.

o       Most of the patient data (Patient Name, Gender, Patient Alias Name, Date of Birth, Medicare No., Fund membership no, ORG Fund Payee ID) is sourced from the patient's record. The default membership number in the patient details is populated for Fund membership no. If there is no default membership number, the latest fund membership number in the patient details is populated. If there is no fund membership number in patient details, it must be entered manually.

o       Some of the fields (Service Type, Compensation Claim, Pre Existing Ailment and Accident Indicator) are populated by default. Make sure the default data is checked, and all mandatory fields (Principal Provider number, Servicing Provider Number, Admission Date, Discharge Date, Presenting Illness Item Number or Presenting illness code, Accident indicator) have been completed.

o       Most services data is sourced from the estimate.

o       Based on the service type (MBS, Prosthesis and Miscellaneous), each of the service items will have mandatory fields (Service Date, Service Quantity, Service Rate) that needs to be completed. (For e.g.  Service Date is mandatory for Service Type MBS)

 

 

9.     Click to submit the form. You will be prompted to provide any mandatory data you have missed.

10.  The Online Eligibility Check (OEC) – Processing OEC window appears. The Online Eligibility Check is sent to Medicare  and the health fund for processing.

 

 

11.  After submitting the Online Eligibility Check for processing, you will be returned to the Estimates window. Notice in the example below that the estimate is now assigned an OEC ClaimID. The status of the check is displayed. In our example, the claim's status is ‘Awaiting Process Report’.

 

12.  Click  located at bottom-right. When the Practice Explorer appears, locate and select Medicare Australia from the menu at left. The Medicare Australia window appears, where you can retrieve the Online Eligibility Check process report.

 

13.  From the Claim Type drop-down list, select the claim of type ‘Online Eligibility Checking OEC’. The list of claims becomes filtered to display online eligibility claims.

14.  Select the claim you wish to check and click  The Medicare Australia – Processing Claim(s) window appears. The Online Eligibility Check (OEC) report is downloaded.

 

15.  Click  The claim status is changed to ‘Process Report Received’ after the process report is downloaded.

 

 

16.  Select a claim with a status of ‘Process Report Received’. Click to view the result of the online eligibility check, and its Assessment Status (either 'Accepted' or 'Rejected').

 

17.  Click to finalise the OEC claim. You will be prompted to print the Online Eligibility Check Report. Click to print.

 

18.  The Print Online Eligibility Check (OEC) Report window appears. Select a printer to print to and click

o       The ‘Online Eligibility Check’ report provides a detailed explanation of the out-of-pocket expenses, and the benefits payable from Medicare and the Health Fund.

o       The information can differ depending on the type of check performed.

o       The OEC report opens in Microsoft word and can be printed.

o       You can also print the Online Eligibility Report by returning to the Estimates window, selecting an Estimate, and clicking