Patient Claims quality checking processing 111-22090020

Services Australia uses digitally enabled processing (DEP) to create a PaNDA work item ready for allocation.

To receive a new work item for quality checking in Work Optimiser Worklist, Quality Checker to select the Ready button once.

For more information, see Work Optimiser for staff.

When selecting a PaNDA work item from Worklist, staff are automatically redirected to the Work Item and Document Details screen.

To open documents associated with the work item:

• Select the Document ID line to view the document image
• A new window will open and display the document in a tabular format
• Information on the right of the table will have the details from Quality Control System (QCS) QBBI needed for checking the work

When staff receive their own work item for checking:

• add a processing note to the PaNDA record 'own work' and select Save
• use the HSDD Local Peer Support - SO4's Microsoft team's chat, seek QC support from a Service Officer (SO4) on processing duties to have their work checked:
• SO4 available:
  • Yes - reassign the work item to that staff member using reason code 'Service Support Referral'
  • No - email it to Workload Management Health to reassign the work item. Key 'QBBI QC' in the subject line and the PaNDA work item detail in the body of the email

When staff do not have the skills to check the work item:

• add a processing note to the PaNDA record 'not trained in worktype' (e.g.: 'not trained in PCADJ) and select Save
• click 'unassign' and select reason 'Capability adjusted' in PaNDA. See Table 2 > Step 7 in Work Optimiser for staff
• add skill and then select relevant details. Check the Capability adjusted Worktype table

Log into Medicare Mainframe (CICS) using the Source Office Code (SOC) included in the PaNDA document for completing the quality check.

• Key 'QBBI,ST/ALL,DOP,OPER/NO' and press [Enter]
  e.g.: QBBI,ST/ALL,DDMMYY,OPER/nnnnn
  Note: key the processing staff logon number without the 'P' letter prefix
• The QBBI screen displays details of selected transactions
• Compare the details in the PaNDA document
• Locate the QBBI line for quality checking. Note: QBBI screen may display with a list of transactions for the OPERNO. Compare and quality check the Medicare card number only listed in the PaNDA document

The details returned on the QBBI screen format for patient claims transactions include:

• PRC DT - processing date
• TIME - time of processing
• OPER - logon ID of the Service Officer who processed the transaction
• TY - transaction type - values are:
  • CT - Credit EFTPOS (payee code 7)
  • FT - EFT (payee code 9)
  • QD - cheque to doctor via claimant (payee code 2)
• TRAN - transaction that was updated
• REFERENCE DETAILS - the Medicare card number selected for quality checking

Note: for more information on how to interpret information on the QBBI screen, see the Quality Control System (QCS) for Medicare in Resources.

Select the transaction to be checked by positioning the cursor in the 'S' (select) field then pressing [Enter].

The Medicare patient history screen displays the claims history of the transaction selected.

To view the transaction timestamp for each item line, press [F9]. The timestamp on history must uniquely match the time of the selected transaction on QBBI.

Manual

• Find the transaction source document, that is, hard copy/digital image
• Compare the source document(s) with the claim's history displayed and determine if the patient claim was processed correctly
• Go to Step 6

Online

• Examine history to determine what Service Officer intervention has occurred
• Check PI codes, reason codes, rejections, and text messages to determine if the patient claim has been processed correctly

If the intervention cannot be determined, update the transaction as error free.

After examining the transaction and source documents, press [F3] to exit from history and return to the QBBI screen.

QBBI shows b (browse) in the S field and is now ready to accept status codes in the STATUS field to indicate whether the transaction has been processed correctly or incorrectly. See Resources for status codes.

Where no errors are detected, the status code is 001.

Where errors are identified in the STATUS field for the transaction selected, key all status codes (critical and non-critical) and press [Enter]. Where more than 4 errors are found, refer to error status 199.

QBBI returns a lower case u in the S field to advise that the selection has been updated with a status code.

For multiple transactions related to the same Medicare number that have:

• the same time stamp:
  • quality checkers must only action the first transaction line with a valid status code
  • leave additional duplicate transaction lines unactioned. They will automatically be removed from QBBI after 21 days
• different time stamps:
  • quality checkers must action all transaction lines with a valid status code
  • the relevant status code must be applied against the corresponding time stamp

Note: if no status codes have been keyed, the system returns a b to show that the selection has been browsed, but not finalised.

Each time a quality check is completed, the quality checker must:

• email the Service Officer and their Team Leader advising the quality check outcome
• give feedback with a brief description of the action required by the Service Officer for correction
• use the relevant QBBI quality checking email template for sending emails. The Resources page contains these templates

Press [F3] to exit the QBBI screen.

On completion of quality checking, update the status to Complete on the Work Item and Document Details screen:

• select Complete in the Status field
• select Save

A message will display at the bottom of the screen advising that the work item has been successfully saved.

It may take several minutes for the work item to disappear from the Worklist.