Patient Claims quality checking processing 111-22090020

Category

Displayed in QCS as…

Error-free

OK

Document status codes

ADM

Processing status codes

PRO

Referred for further attention

REF

Error-free status code

Definition

Processing Tip

001

Error-free

Quality check did not detect errors

Error status codes

Definition

Processing tip

100

Address change not notated, or the address section of the claim form not completed.

Claim form

It is an error when the address section of the claim form is partially complete and there is no notation of a confirmed address.

It is an error when an address change has not been notated.

101

Claim form not attached to supporting documentation or account not endorsed by claimant.

Claim form

It is an error when:

• a claim form is not attached to supporting documents when required
• the claim form does not relate to the supporting documents when required

Telephone claiming

It is an error when the account/receipt for claims received via the telephone are not endorsed by the claimant and no contact was made by the Service Officer.

Note: Access Point (MAAP)

As there is no paperwork to check against any claims selected for quality checking, these are currently being entered 001 (error-free) on the QBBI screen.

102

Agent's authority section of claim form not completed in full.

It is an error when the Agent's Authority Section has not been fully completed and is not detected by the Service Officer.

104

S4B(3) item paid without the delegate's approval.

It is an error when a delegate's approval is not endorsed on the documentation for payment of an item under the S4B(3) rule and it is not detected by Service Officer.

105

Patient's/Claimant's Medicare card number cannot be uniquely identified from details supplied.

It is an error when the source documents do not have sufficient information to uniquely identify the patient's or claimant's Medicare card number and no contact was made by Service Officer.

106

No evidence of confirmation of service or claim details recorded.

It is an error when the Service Officer failed to record details of confirmation to support action taken.

110

Claimant's signature omitted or mismatched to claimant details.

It is an error when:

• there is no claimant signature present
• the claimant's signature does not match the claimant's name

Note: it is not an error if the claimant details have been verified and there is a VG4 form to support action taken.

Claimants can use any type of symbol as their signature, for example, X. Claims should only be returned where there is a difference in names.

111

Inappropriate/insufficient documentation to support payment.

It is an error when:

• the accounts supplied by the claimant are insufficient to process a Medicare claim
• there is no NPOC print in the batch or uploaded to PaNDA to support the payment of a telephone claim
• there is no print in the batch to support the substantiation for an online claim
• rebate paid to patient/claimant when no receipt provided

118

Statement of Benefit not attached to supporting documentation.

It is an error when a:

• Statement of Benefit is not attached to supporting documents
• Statement of Benefit does not relate to the supporting documents

199

More than four document errors.

When four document errors are detected, key all four error codes.

When more than four document errors are detected, key the first three error codes followed by error code 199.

When more than four errors are made and there is a combination of processing and document errors, use 299 as the fourth error code.

Error status codes

Definition

Processing tip

200

Patient keyed or selected incorrectly.

It is an error when the patient details on claims history does not match the supporting documents.

201

Item keyed incorrectly.

Manual

It is an error when the:

• item number keyed does not match supporting documents
• supporting documents do not have a sufficient description to uniquely identify the item number processed

Online

It is an error when a Service Officer has inserted or copied a line and keyed the item number incorrectly.

202

Date of service keyed incorrectly.

Manual

It is an error when the date of service does not match supporting documents.

Online

It is an error when a Service Officer has inserted or copied a line and keyed the date of service incorrectly.

204

Charge keyed incorrectly.

It is an error when:

• the charge keyed does not match supporting documents
• a discount has been applied to an account but the original charge has been keyed

Note: it is not considered a 204 error when an account or receipt indicates that a notional charge should have been keyed. Refer to error code 211.

205

Item paid incorrectly as outpatient.

It is an error when an ‘H’ suffix has not been keyed at the end of the relevant item numbers and there is indication of the service being performed in hospital.

206

Incorrect processing indicator (PI) keyed.

Manual and online

It is an error when the incorrect PI has been keyed.

Note: only the highest PI code used is stored by the system.

207

Reason code not keyed, keyed incorrectly or keyed when not required.

Manual and online

It is an error when a reason code is

• not keyed
• keyed incorrectly
• keyed when not required

Note: it is not an error when the system has automatically inserted a reason code.

208

Medicare card number for claimant or patient keyed incorrectly or consumer ID for claimant keyed incorrectly.

It is an error when the:

• patient's Medicare card number
• claimant’s Medicare card number or consumer ID

has been keyed incorrectly.

Note: when both fields are in error this would be considered one error for quality checking purposes.

209

LSPN keyed incorrectly.

It is an error when the Location Specific Practice Number (LSPN) for a diagnostic or oncology item does not match:

• manual - supporting documents
• online - the transmission or LSPN register

210

Service provider keyed incorrectly.

It is an error when the service provider keyed or selected does not match supporting documents.

211

Notional charge not applied or applied incorrectly.

It is an error when a notional charge has:

• been applied when it should not
• not been applied when it should

Note: when a Service Officer has applied a notional charge, reason code 113 will be displayed on the patient's history in the RSN field.

When a system generated notional charge has been applied reason code 241 or 242 will be displayed on the patient's history in the RSN field.

212

Text transmitted not actioned appropriately.

It is an error when the transmitted text was not acknowledged and the Service Officer did not action the claim appropriately as per the business rules.

213

Telephone claim paid incorrectly.

It is an error when a telephone claim has been paid without following the business rules in Operational Blueprint.

214

Items not keyed.

It is an error when one or more items on supporting documents have not been keyed.

215

SCP keyed incorrectly.

It is an error when the Specimen Collection Point (SCP) for a pathology item does not match:

• manual - supporting documents
• online - the transmission

216

Radiation oncology fields not keyed or keyed incorrectly.

It is an error when:

• fields are not keyed
• fields keyed do not match the number of fields indicated on supporting documents

217

Over 2 year old claim paid incorrectly.

It is an error when:

• an over 2 year old claim with a charge of greater than $100 was paid without checking the patient's culled history, and
• no copy of SAS report attached/uploaded to PaNDA

218

PAYP line not keyed or keyed incorrectly.

It is an error when the:

• PAYP line is omitted
• PAYP details are keyed incorrectly

Note: PAYP line must only be keyed where 'Locum' or 'LT' is indicated on the supporting documents.

220

Miscellaneous line keyed.

It is an error when a miscellaneous line is keyed and the charge is not greater than $9,999.99.

Note: this error code does not apply to online claiming.

221

Incorrect or inappropriate manual calculation of schedule fee.

Manual and online

It is an error when:

• a processing indicator (PI) has been used to amend a schedule fee which has caused an incorrect benefit to be paid
• the fee has been adjusted when a latter day adjustment should have been performed
• a modifier has not been keyed or keyed incorrectly

Error status codes

Definition

Processing tip

224

Provider location keyed or selected incorrectly.

It is an error when the provider location keyed or selected does not match supporting documentation.

228

Address not changed or changed incorrectly.

It is an error when the:

• address keyed does not match supporting documents
• claimant has requested a temporary address change or has not indicated on the claim form, and the address has been changed permanently
• claimant has requested a permanent address change and the address has been changed temporarily

229

Restrictive item paid incorrectly.

Manual and online

It is an error when a restriction has been overridden without supporting documents.

Note: it is not an error when the rooms have transmitted a NNAC override and the system has automatically inserted a PI 44.

232

Cancel and re-issue cheque issue

It is an error when the request for the cancellation of a Medicare cheque was:

• re-issued without a valid request
• not re-issued when requested

233

EFT paid inappropriately.

It is an error when an EFT:

• payment has been made and the claim has not been processed under payee code 9
• payment was made on an unpaid account

235

Cheque paid to provider on paid account.

It is an error when a benefit was paid via cheque to the provider and an account has been paid.

238

Item paid incorrectly as inpatient.

It is an error when an 'H' suffix has been keyed at the end of an item number and there is no indication of the service being performed in hospital.

239

Referral details (SR and AH) keyed incorrectly.

It is an error when the referral details (FST DT, LST DT, Provider number, sub/con) are keyed incorrectly.

It is also an error when referral details keyed when not listed on account/receipt and no comments in PaNDA/CDMS to substantiate this action.

Note:

• when more than one field on the SR line is in error it is considered one error for quality control purposes
• this error code applies to specialist (SR) and allied health (AH) referral lines that appear on history
• it is not an error when the system has generated a referral line with reason code SGN

240

Diagnostic request details (DI) keyed incorrectly.

It is an error when the diagnostic request details keyed do not match supporting documents.

241

Pathology request details (PA) keyed incorrectly.

It is an error when the pathology request details keyed do not match supporting documents.

242

Non-critical

Errors must:

• not be recorded on the QBBI screen
• be recorded on the online Error Explanation Sheet

ACRF details keyed incorrectly.

It is an error when the ACRF details keyed are not identifiable on supporting documents.

Note: when ACRF is requested and there is no information on supporting documents, the Service Officer should key '0' or 'No'.

245

Claimant’s name or claimant's reference number keyed or selected incorrectly.

It is an error when the claimant keyed or claimant selected does not match supporting documents.

247

Service verified inappropriately or has not been verified.

It is an error when:

• services are not verified when they should have been
• services are verified when they should not have been

Note: verified also refers to recording of gaps and partial payments.

248

Verified amount incorrect.

It is an error when the:

• amount verified does not match supporting documents
• provider has accepted less than the balance of the account, indicated that no further payment is required and the Service Officer has not changed the verified amount

Note: verified also refers to recording of gaps and recording of partial payments.

249

Additional item lines keyed without justification.

It is an error if additional lines have been keyed without justification.

Note: it is not an error when additional lines have been keyed in accordance with business rules.

250

Item lines rejected in error.

It is an error when item lines have been rejected when not in accordance with business rules.

253

EFT details keyed or stored incorrectly.

It is an error when the claimant’s EFT details keyed and/or stored do not match supporting documents, this includes:

• Account name
• Account number
• BSB number
• EFT storage indicator (C,T,P,U)

Note:

• if more than one field is incorrect in the same claim this would be considered one error for quality control purposes
• this error code does not apply to online claiming.

299

More than four processing errors.

When four processing errors are detected, key all four error codes in the status value available.

When more than four processing errors are detected, key the first three errors with applicable code followed by error code 299 in the fourth field.

When more than four errors are made, and there is a combination of processing and document errors, use 299 as the fourth error.

310

Two way claim form not transmitted/transmitted incorrectly.

It is an error when the Medicare Two way claim has not been processed or transmitted correctly.

311

Work item not actioned completely.

It is an error if a work item:

• has not been actioned completely as per the business rules
• is closed in PaNDA without being processed and no comments in PaNDA/CDMS to explain the action taken

312

AODR not actioned in patient claim form.

It is an error if AODR claim form is:

• not processed
• processed incorrectly

313

Non critical

Errors must:

• not be recorded on the QBBI screen
• be recorded on the online Error Explanation Sheet

Comments not keyed when appropriate or completed inappropriately.

It is an error when comments are not keyed in PaNDA/CDMS as per the business rules.

314

Claim adjustment completed incorrectly.

It is an error when adjustment:

• processed with incorrect payee code
• processed on a unpresented cheque
• manual Statement of Benefit (SOB) not completed

315

Letter created contains errors.

It is an error when it has customer privacy implications.

Refer the non-critical error code if it does not impact on customer privacy.

316

Non critical

Errors must:

• not be recorded on the QBBI screen
• be recorded on the online Error Explanation Sheet

Letter created contains minor errors.

It is an error when it does not impact on customer privacy.

Error status codes

Definition

Processing tip

301

Photocopied or altered documents not certified.

It is an error when:

• photocopied or altered documents have been processed without appropriate certification or verification
• original documents are returned to the claimant and the photocopies held by Services Australia do not have appropriate certification

Note: this may require referral to National Compliance Operations.

302

No documents to support payment.

It is an error when:

• no evidence in PaNDA or comments in CDMS to support a payment being processed
• photocopied or altered accounts or receipts have been processed without appropriate certification or verification
• original account or receipt is returned to the claimant and the photocopy held by Services Australia does not have appropriate certification

Note: this may require referral to National Compliance Operations.