External Breast Prostheses Reimbursement Program (EBPRP) quality checking in QST 111-22050000

The Work Item is allocated to the checker by the Quality & Support Tool.

To access the Quality Tool:

• Go to OPRA Home page and select Quality Tool (QT)
• Select the Give Me Work button
• The work Item for checking will appear as a Filenet link in the Document link box.

Log on to the appropriate system for the work type - EBPRP-EBPRP

• EBPRP Claim enquiry screen
• Customer records in CDMS

Log on to required systems to access supporting documents and associated notes.

Log into PANDA to access supporting documents and view PANDA comment.

Check:

• Information on the source documents is complete
• Claim form has been completed and signed by
• EBPRP recipient (claimant), or
• Executor/administrator
• Documentation is on file or attached
• Details on the form match details on the online system, including:
• Address
• Contact details
• Bank details
• Associated documents (such as letters) are uploaded to the correct system and a comment left in CDMS
• The claim has been processed correctly via the EBPRP Claim enquiry screen, including:
• Date of lodgement
• Left/Right/Both
• Date of purchase (date prosthesis was paid for)
• Purchase amount (using calculator to determine cost after any discount)
• Private health/other assistance entered
• If discretionary request the approval number entered into comments in EBPRP claim screen

Record the results on the Quality Tool & Support, including any errors identified and feedback.

Record the outcome in the Quality Control Status field of the Quality Tool:

• select Outcome Error Free, auto - populates error code, or
• select Outcome contains Error
• select appropriate error code/classification from the Explanation field

Provide feedback to the Service Officer and Team Leader by selecting Create report image for email feedback. Quality Tool creates an image that is pasted in to the body of the email.

To finalise, select Record Outcome. This will complete the item.

Were errors identified?

• Yes, the Quality Tool will return to the Home page
• Select Cancel to cancel the action
• Select Close to close the Quality Tool, or
• Go to Step 5 to amend error
• No, select Give Me Work to perform another check. Procedure ends here

Identified errors must be amended immediately. If the Service Officer is not available, the Team Leader must ensure another staff member with the correct knowledge and skills can complete the remedial action.

If a file fix is required, the Quality Checker must send the request for this to be done.

To amend a quality check error result completed in the Quality & Support Tool, email Quality Operations & Technical Support.

Select:

• Search
• Program – Miscellaneous
• Work Type – External Breast Prosthesis Reimbursement

Key Medicare number as per claim form.

Confirm details on system match details on claim form.

Confirm details on receipt match details on claim form.

Check the documents to make sure:

• any attachments have been uploaded
• Letters
• Discretionary requests
• Additional information which was previously missing
• appropriate comment has been left
• EBPRP claim number – PHI checked – <processed, rejected, other reason/information>
• Letter sent - <reason>
• PaNDA naming conventions are correct and completed
• SurnameFirstname
• Medicare card number

Record the results of the quality check in the External Breast Prostheses Reimbursement Program Quality Reporting Form.

Ensure feedback is given to the Service Officer on the checking results.

Were errors identified?

• Yes, go to Step 5
• No, no further action is required

Ensure the error is corrected.

Error documentation must be kept onsite for analysis if required.

Access PANDA

Search using customer /Medicare card details in PANDA

• Program – Miscellaneous
• Work Type – External Breast Prosthesis Reimbursement
• Enter Medicare number or SunameFirstname in the appropriate field
• Comment has been left advising reason for letter
• Has the letter been uploaded
• Open letter and claim details
• Has an attempt to contact the customer been noted? (In some cases the paper work needs to be sent to the customer so a call is not necessary)

Access CDMS

• Enter Medicare card details
• Access member tab in group to confirm customer
• Access address tab to confirm address
• Access customer personal tab
• Confirm details on claim form match details held in CDMS and match letter.
• Has house-keeping been completed?
• Has a comment been entered in CDMS?
  EBPRP Claim DOL 01/01/2000 – Letter sent <reason>

Access EBPRP enquiry screen

Check EBPRP claim history to see if there is any information listed which may affect the letter

• Is the letter required
• Is the previously purchase date correct
• Is the previous benefit paid correctly
• If rejected has the information been entered in correctly as per claim processing procedure

Ensure customer details on letter are correct:

• Name
• Address

Ensure the correct references have been used:

• Our reference: IBPR/P#####
• Your reference: EBPR123456 or 100564568
• EBPRP claim number ( this is only if it’s refereeing to a claim already in the system eg: rejected or previously paid claim)
• PANDA work item id (if claim has not been processed eg: incomplete claim form), or
• Medicare card item number (this is rarely used as the above should be first options)

Ensure the letter is required and make sure the most appropriate letter is used

Conduct a search to ensure the documentation is not uploaded over 2 work items. Using Medicare Card number and then another using just customer name

Ensure:

• If letter advises the section of the claim form highlighted this has been highlighted
• Letter has not been ‘free texted’ ( Program support can free text a letter and request for it to be uploaded in PaNDA)
• All documentation has been attached to the letter when printed
• Documents are printed one sided
• Internal information is not given to customers
• Scanning confirmation check sheet
• Email attached to claim

In PaNDA:

• Quality checker to record a comment:
  Letter QC
• Give feedback to the Service Officer on the results
• Hand letter back to Service Officer
• Discuss feedback
• Explain corrections required and request they resubmit again for quality checking
• Record the letter check in Quality checking stats sheet, record any errors