Medicare eligibility quality checking processing 111-22090030

QCS is used to select Medicare eligibility transactions for quality checking and to record results.

For information on how to interpret quality checking information on the QBBI screen, see The Quality Control System (QCS) for Medicare.

The purpose of the quality checking procedure is to:

• give quality checkers the tools to identify strengths and areas of development in the processing of Medicare eligibility transactions
• highlight opportunities for continuous business improvement, using effective quality checking processes
• ensure Quality Checkers:
• have a consistent level of understanding about the process
• complete checks in a consistent manner, by documenting the quality checking process

Managers/Team Leaders are responsible for making sure:

• quality checking is performed daily for every processing day available on QBBI
• quality checkers have completed the relevant training
• quality checks are undertaken as outlined in this procedure
• results of quality checks are recorded appropriately
• issues are addressed and corrections made immediately (see the Feedback section below)
• error feedback is discussed with the Service Officer as part of the coaching conversation. This supports any learning and development needs
• positive quality checking results are discussed with the Service Officer
• lodgement of quality checking disputes (where applicable)

When source documents are hard copies, they must be held on site until the quality check is finalised. If the documents have been archived, it is the responsibility of the Manager/Team Leader to recall the documents.

Quality Checkers must make sure that:

• Medicare eligibility processing business rules have been applied correctly
• quality checking is performed on the specified sample size, randomly selected by the Quality Control System (QCS)
• update and maintain technical knowledge, procedures and policies
• give constructive and non-judgemental feedback. Include reference materials such as Operational Blueprint
• explain the impact of errors and action to be taken to correct the error (where applicable) when giving feedback
• feedback is given to the processing Service Officer
• quality checking errors are recorded and reported using the online Error Explanation Sheet

Note: at the end of each month, quality checks (post-checking) must be completed by close of business (COB) on the first working day of the new month.

Quality checking of own work

Quality Checkers must not quality check their own work. The quality checker’s own work will not appear on the QBBI Mainframe screen.

Before undertaking quality checking, Service Officers must:

• successfully complete the training:
• MCA00802 - Claims and Eligibility Quality Checker and the assessment, and
• MCA00835 - Claims and Eligibility QC
• have knowledge of relevant policies and procedures and/or know where to find them
• have reviewed the quality checking procedures relevant to their program and emailed the Manager/Team Leader advising they have been reviewed and understood

Only accredited quality checkers can undertake quality checking.

Pre-checks

Pre-checks are used while Service Officers complete training to help with determining proficiency requirements.

Post-checks

Post-checks (QBBI) involve checking a random selection of work processed the previous day. The results are reported to executives and relevant stakeholders each month.

Targeted checks

As well as the pre and post-checks, targeted checks (manual checking) provide an opportunity to look at other areas of the process.

Targeted checks for Medicare eligibility processing may include:

• checks on Service Officers with identified quality issues
• Aim for Accuracy (separate procedure)

Post-checks

The QCS in the CICS mainframe randomly selects eligibility transactions for quality checking (QBBI). These transactions:

• are work items processed the day before
• are a selection of Service Officers from different source office codes
• appear under the legacy (CICS) transaction IDs

Multiple Medicare eligibility processing activities selected for quality checking

When quality checking, all Medicare eligibility processing updates on the date of processing must be checked for accuracy and compliance.

If several updates have been performed in CDMS on the same Medicare card, QCS may select the same card multiple times on the same day.

In these cases, quality checkers must only populate one QCS transaction line with a valid status code.

All other selections should remain unactioned. They will no longer appear on QBBI after 21 days.

Time frames

If quality checking for QBBI is not performed the day after the transaction was processed, the work must be checked within 2 working days. Outstanding transactions must be completed before selecting another day's processed work.

At the end of each month, quality checks (post-checking) must be completed by close of business (COB) on the first working day of the new month.

Resources

Medicare eligibility processing updates selected for quality checking may have been actioned from many different types of source documentation. This includes:

• Medicare Enrolment forms
• Medicare Enrolment Copy/Transfer forms
• Digital Medicare Enrolment applications
• Medicare Safety Net forms
• Written correspondence
• Customer contact by phone call
• Family assistance forms including digital images
• Australian Organ Donor Register (AODR) forms
• Australian Immunisation Register (AIR) forms

Recording confirmation of details

Service Officers must not write on family assistance forms or any Medicare forms. They can record additional processing comments in PaNDA and CDMS if required.

Quality, Performance and Technical Support is only responsible for the management of the quality checking procedures.

Quality Checkers requiring clarification on processing business rules must follow the appropriate escalation process for the relevant programme outlined in Operational Blueprint.

Eligibility errors, except My Health Record, must be recorded and any follow-up action sent to the Service Officer for correction.

My Health Record error details, see Recording and reporting results below.

Document and processing errors

For quality checking:

• document error is when a Service Officer has processed the transaction and has not detected that the original paperwork was incomplete or does not hold enough details to support the action taken
• processing error is when a Service Officer has processed or entered details incorrectly which do not match the original paperwork submitted

Errors should be identified during the quality checking process (post-checks) by following the steps in the program quality checking procedure. See Medicare claims and eligibility quality checking.

All quality checking results (post-checks) are reported to executives and relevant stakeholders each month.

Feedback

Each time a quality check is completed, the quality checker must send an email to the Service Officer and their team Leader advising the outcome.

This feedback must:

• be positive for transactions identified as error-free
• be given the same day or as soon as possible after completing the quality check
• describe the error and what was incorrect
• explain the action to take to correct the error
• include any relevant reference material that supports the action, such as Operational Blueprint

Feedback questions and escalations

• If the Service Officer needs clarification or disagrees with the error received, they must first discuss this with their Team Leader
• After discussion with the Team Leader, see Quality checking dispute process for Medicare
• Service Officers must not directly contact the quality checker, or email Health Service Delivery Division Quality
• This escalation process is noted at the bottom of each Processing Feedback email, via a link to the Quality checking dispute process for Medicare

The Quality Checker must:

• Identify any possible areas for development, gaps in business rules, issues about environmental factors and system faults and limitations
• Complete the My Health Record (MHR) registration email template and send to Digital Health Support when a My Health Record error is identified
• Complete an online Error Explanation Sheet (EES)

See Resources for email template and guide to completing EES

If errors have been identified, action must be taken to correct the error. Errors are to be corrected by the original processing Service Officer. Where corrections cannot be made by the original processing Service Officer, the Team Leader will be responsible for ensuring the corrections are undertaken.

Recurring errors must be brought to the attention, by way of feedback, to the:

• Manager/Team Leader of the processing area, and
• Service Officer concerned

Remedial action (such as training) needed to reduce the occurrence of errors should be planned by the Manager/Team Leader and undertaken as a matter of priority.

Respective programs regularly review quality checking procedures in consultation with the Quality, Performance and Technical support team. This incorporates endorsed changes to program business policy and procedures and makes sure error codes are current and appropriate.