Process pended claims in Australian Immunisation Register (AIR) 011-10110000

An immunisation encounter or episode is pended when the system assesses the antigen, dose or registration detail and one or more of these do not meet the AIR business rules.

Reason codes and explanations help AIR Service Officers understand why an encounter has pended and how to process it.

Some codes (such as Pend 24: postcode/locality incompatible) are easily resolved. Some need clarification from the provider (such as Pend 103: duplicate antigen codes - different provider). Others need help from an AIR Local Peer Support (LPS) or AIR Program Support.

See Resources for a list of System reason codes and explanations.

AIR Site (WEB), bulk upload (IDI) and Practice Management software (API) claims are online claims assessed automatically by the system. For more information, see the Data transmission methods table.

The last character of a claim ID (!, %, +, @, *, &) provides information about the lodgement channel used, see Step 2 in the Identifying data lodgement methods table for details. Encounters that need to be assessed manually by Service Officers are placed in a pend queue and allocated a pend reason (RSN) code. Service Officers access the queue and process the pended encounters, preferably to an accepted (A) status. See the Action codes used in claims processing table for more information about codes.

All pend processing occurs in AIR Mainframe.

Service Officers can search for an individual or provider using:

• CDMS
• Provider Directory System (PDS)
• Customer First - Front of House (FOH)

The pend (P) status cannot be manually overwritten with an A (accept) status by Service Officers. Only the system can allocate a status of A or P. An antigen or dose status can only move to an A status where a change is made to:

• the encounter or episode
• the individual's registration
• previous immunisation history

Any of the above changes can result in reassessment of an episode. Where no change is made to the record, Service Officers may overwrite the pend status with an appropriate assessment code e.g. C and Y, R and Z, or X. See also: Action codes used in claims processing table.

It is essential that records are accurate. If unsure what to do, or for complicated pends that need processing any of the below codes, always check:

• A - Data is within guidelines (system generated only)
• C and Y - Data is good, provider has clarified
• R and Z - Data should not be included on AIR (e.g. information incorrect)

Service Officers refer any scenarios that fall outside the standard pend processing guidelines to an AIR Local Peer Support (LPS). The AIR LPS can escalate the scenario to AIR Program Support if necessary.

See the Process page for how to reassess an episode.

Reason codes and explanations help Service Officers understand why an episode or encounter has pended and how to process it.

Error messages

Error messages display when a Service Officer accesses a pended encounter or episode. It explains the reason for the pend.

Examples

• When an encounter is pended with RSN code 024, the error message:
  LOCALITY INVALID displays on the Encounter Details (YIAE) screen. This means the postcode (P/C) is not matching the suburb/location (LOC) recorded. Amending the locality or postcode may resolve an episode or encounter to an A status
• When an episode is pended with RSN code 103, the error message:
  SAME OR EQUIVALENT DOSE ALREADY RECORDED BY DIFFERENT PROVIDER displays on the Antigens Details (YIAN) screen. This means the same, or a similar vaccine (or component of the vaccine) with the same dose number has already been reported by another vaccination provider. Amending the vaccine or dose may resolve an incorrectly reported vaccine to an A status

Warning messages

A warning message displays if data needs to be reviewed for the encounter or episode.

The Service Officer presses [F18] - ACK WARN to:

• acknowledge the warning
• assess and if required amend the episode/encounter, or confirm the information with the vaccination provider

Acknowledging the warning continues the assessment of the episode.

Example

When an episode is pended with RSN code 107, the warning message DOSE GIVEN AT > SCHEDULE AGE - [PF18] TO ACK WARNING displays on the YIAN screen. This means the service date recorded indicates that the vaccine and dose given were at an age that is older than is recommended. Correcting the date of the dose and selecting [F18] may resolve the episode to an A status.

Pend 300 and 301 reason codes occur when a vaccination is duplicated on an individual's history. The system automatically resolves them. No further action is required.

If there are other types of pended encounters in the claim (for example, pend 80 - child not identified or pend 24 - postcode/locality incompatible), processing the encounter may result in it being resolved to a pend 300 or 301, or an A status.

See also: View and amend history details on the Process page.

Overseas immunisations recorded for individuals on the AIR may cause future vaccinations given in Australia to pend due to differing immunisation schedules between countries.

Vaccinations given in Australia must take precedence over vaccinations given overseas. Service Officers may need to reject previously recorded overseas vaccinations for:

• valid Australian vaccinations to process to an A status, and
• provider payments to be made

Example

An individual has received dose 1 of generic, single antigen measles vaccine while overseas. The individual then receives a Priorix vaccine (MMR) dose 1 in Australia. The measles component of the Priorix vaccine is a duplicate and is pended.

To bring the individual up to date, Service Officers must reject the generic measles vaccine given overseas. All 3 components of the Priorix vaccine will then resolve to an 'A' status and a provider payment will be made.