Streamlining electronic claims processes

By focusing on the following you will effectively streamline the electronic claims process at your practice.

To ensure an efficient claim submission process:

• Capture the following information from the membership card of the patient:
1. Membership number
2. Member and Patient's full names
3. Patient's dependant number
4. Patient's date of birth
• The place of service indicator should be stated on all claims:
  

 ICD10 code(s) for each claim line
 Dispensing providers must provide their dispensing License Number
 Dosage Duration and Daily Dosage on all medicine and consumable claims:



Example:
D5 indicates that the medicine was prescribed for a period of 5 days DD3 indicates that 3 tablets per day was prescribed.

Please contact your PMA consultant to obtain further details of how this information should be captured.


Submission of Online Claims via SwítchOn

Understand how it works:

The SwítchOn™ interface which is fully integrated into accredited PMA’s, will enable you to get immediate responses to all claims submitted via MediSwitch thereby reducing the risk associated with rejected claims.

The up-front validation of the IAC (instantly assessed claim) process allows you to correct and resubmit rejected and failed claims without the concern of any additional costs thus making the SwítchOn™ service an effective management tool.

The claim validation process assures medical schemes that claims received from customers can automatically be uploaded into their claim assessing and adjudication systems.

Streamline your electronic claiming process:

Obtain maximum benefit from the SwítchOn process by using the following transaction types and services:

• The SwítchOn Now or Later™ methodology of online claiming. Claims can be sent immediately or you can select to send them later.
• The Instantly Assessed Claims™ (IAC) process. Upon receipt of a claim for an off-line destination, MediSwitch will apply the MediSwitch validations to the claim as well as any destination specific business rules. Once the claim has successfully passed this process, the claim will be delivered to the medical scheme. Should the claim fail this process, an immediate response will be returned detailing the reason for rejection or failure. An online response is therefore returned for every claim submitted.
• SwitchNavigator™ which is a single access point within the PMA to all the SwitchClaim™ information. This allows you to manage your entire claiming process from within your PMA.
• Membership Status Validation™ (MSV) checks the medical scheme membership status of your patients from within your PMA. Responses from participating schemes include patient detail updates.
• electronic Remittance Advices (eRA's) from participating medical schemes which are automatically uploaded into your PMA. Payments can be auto-allocated against the original claims or manually allocated from exception reports.

Please contact your PMA to see if you can sign-up for online claiming via SwítchOn™.

Submitting Claims via QEDI

Understand how it works:

If your system is configured to use QEDI your PMA will automatically flag claim lines that meet certain criteria for electronic submission. (This is dependent on how your PMA is configured.)  After being captured, claims that meet the following criteria are generally flagged to be included with the next batch of claims that is submitted via MediSwitch:

• The claim is linked to a medical  scheme that is MediSwitch active
• The claim is linked to a patient that is charged at medical scheme rates
• The claim is linked to an account flagged for MediSwitch submission
• The claim is linked to an account type that is configured for MediSwitch submission
• The amount on the claim to be claimed is reflected under the medical scheme liable column
  

To create a batch of claims for electronic submission, select the relevant option from the MediSwitch sub-menu within your PMA.  Your PMA will then select all the claim lines flagged for EDI submission and compile these into an export batch file.  While creating the export file, your PMA will assign a sequential batch number to the file and will calculate the total monetary value of the claim lines.

After creating a batch of claims, an audit trail should be printed prior to submitting the batch.  (This report will provide you with a detailed list of the claim lines included in the batch.)  After receiving a batch of claims, MediSwitch will validate each claim within the batch according to each medical schemes validation criteria.  MediSwitch will provide a feedback report back to the practice, indicating accepted and rejected claims.

MediSwitch Rejected Claims:  Lists the claims that were rejected with the reason for rejection.  As rejected claims did not meet the medical scheme validation criteria, these claims should be corrected and then flagged for resubmission in the next batch of claims submitted to MediSwitch.

Accepted Claims:  Lists the claims that were successfully delivered to the medical aid schemes and administrators.  Accepted claim lines are listed together with their respective MFBatch numbers.  These numbers can be used for claim tracking purposes.

Streamline your electronic claiming process:
To obtain maximum benefit from the QEDI electronic claiming process:

• Claims should be submitted on a daily basis. This will help to reduce your claim-payment cycles and increase your cash flow.
• Reconcile your electronic submissions as listed on your audit trail of electronic submissions against the MediSwitch feedback reports as this will provide you with information for future claims tracking.
• Use the WEBDesk to track and manage your claims.
• When submitting claims electronically to medical schemes, refrain from submitting paper claims as well as this may cause a delay in the processing of claims and increase the possibility of claims being rejected as duplicates. Unless accompanied by a motivation letter, the schemes will most likely ignore these claims.
• Claims that have not been paid within 21 days of submission should be resubmitted. In this case they will not be rejected as “duplicates” or with the “resubmission occurred to soon” message.  To do so, you can either:
• Flag the claim for re-submission after 21 days.
• Use the option within your PMA to automatically resubmit all unpaid claims before a specified date.

When prompted to do so - upgrade to the latest SwítchComm Plus application from MediSwitch.  For more information, contact our Call Centre on 0800 111 703.

- Yolandi de Mon