Medicare eligibility quality checking processing 111-22090030
Expand allThis document outlines the process for checking a random sample of Medicare eligibility transactions to ensure business rules have been correctly applied. The quality checking process for Medicare eligibility transactions must be conducted in the Consumer Directory Maintenance System (CDMS) environment. Enrolment data is captured from CDMS through the overnight log file of Medicare details for the Quality Control System (QCS).
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Health Service Delivery Division (HSDD) daily quality checking work items through digitally enabled processing (DEP)
Table 1: This table outlines how staff in HSDD quality checks the Medicare Eligibility QBBI work items for HSDD staff from PaNDA for post checking.
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Receive new work itemServices 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. | |
Work item detailsWhen 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:
When staff receive their own work item for checking:
When staff do not have the skills to check the work item:
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Access the Quality Control System (QCS)Log into Medicare Mainframe (CICS) using the Source Office Code (SOC) included in the PaNDA document for completing the quality check.
CDMS transactions selected for quality checking show in the QCS using the legacy (CICS) transaction IDs. The following relationships with the legacy transaction ID and the Medicare eligibility processing activities show:
Note: for more information on how to interpret information on the QBBI screen, see the Quality Control System (QCS) for Medicare in Resources. | |
Select transaction to checkTo select the transaction to quality check:
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Source DocumentsQuality checkers must check the transaction against the supporting source documents, which may be located in:
Note: source documents may not be available for CDMS updates that have resulted from a verbal request. | |
Perform checkCompare the source documents with details in the CDMS history using the CDMS quality control quick reference guide. If more than one consumer ID needs checking, select the radio button for each individual. When updates are completed in CDMS as a result from a verbal request, quality check to be completed according to the relevant business rules. See Resources for link to CDMS reference guide. | |
Record outcomeAfter examining the transaction and source documents, return to the QCS. QCS 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, in the STATUS field record the status code as 001. Where errors are identified in the STATUS fields for the transaction selected, key all status code (critical and non-critical) and press [Enter]. Where more than 4 errors are found, refer to error status E39. Where a My Health Record error is identified, complete the MHR Registration email template and send to Digital Health Support. See Resources for the template. QCS returns a lower case u in the S field to advise that the selection has been updated with an error status code. If several updates have been done 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 action the first transaction line related to the same Medicare number with a valid status code. Leave additional duplicate transaction lines unactioned. They will automatically be removed from QBBI after 21 days. | |
Provide outcomeEach time a quality check is completed, the quality checker must:
Press [F3] to exit the QBBI screen. | |
Complete work item in PaNDAOn completion of quality checking, update the status to Complete on the Work Item and Document Details screen:
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. |
Face to face and non-HSDD staff daily quality checks for Medicare eligibility transactions - get source documents
Table 2: This table outlines daily processes for Medicare eligibility quality checking that quality checkers in Face to face and non-HSDD staff must follow.
Face to face and non-HSDD staff daily quality checks for Medicare eligibility transactions - perform check
Table 3: This table outlines daily quality checks for Medicare Eligibility transactions-perform check that quality checkers in Face to face and non-HSDD staff must follow.
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Entitlement Details Inquiry screen
After checking Medicare details on the Entitlement Details Inquiry screen, do a consumer search to make sure no duplicate records have been created. Complete a Mandatory detailed search in CDMS. | |
Perform checkCompare the source documents with details in the CDMS history using the CDMS quality control quick reference guide. If more than one consumer ID needs checking, select the radio button for each individual. When updates are completed in CDMS as a result from a verbal request, quality check to be completed according to the relevant business rules. See Resources for link to CDMS reference guide. | |
Record check resultsAfter checking the transaction and source documents, return to the QCS. QCS shows b (browse) in the S field and is now ready to accept status codes in the STATUS field to indicate whether the transaction had been processed correctly or incorrectly. See Resources for status codes. Where no errors are detected, in the STATUS field record the status code as 001. Where error are identified, in the STATUS fields 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 E39. Where a My Health Record error is identified complete the MHR Registration email template and send to Digital Health Support if a My Health Record error is identified. See Resources for the template. QCS returns a lower case u in the S field to advise that the selection has been updated with an error status code. If several updates have been done 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 action the first transaction line related to the same Medicare number with a valid status code. Leave additional duplicate transaction lines unactioned. They will automatically be removed from QBBI after 21 days. | |
All transactions checkedAfter actioning all the appropriate transactions, press [PF3] to exit QCS. Each time a quality check is completed, the quality checker must:
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PaperworkManual - (completed by Face to Face Service Officers only) Endorse the source documents and batch envelope with:
Do not write on the front of source documents. This helps to make sure details do not get covered which allows for reviewing in the future if required. |