User Tips
Duplicate Claims to Medical Schemes & the Validation Process
Medical Aid Administrators have requested that MediSwitch perform an up-front validation, disallowing duplicate claim submissions. MediSwitch understands that healthcare providers want to resubmit claims that haven’t been paid within 21 days from date of service.
In order to accommodate this, the MediSwitch duplicate validation process will only reject claims as duplicates, if such claims are resubmitted through MediSwitch within 21 days from the date of service. Thus, if the service on a resubmitted claim exceeds 21 days, then MediSwitch will accept such claim/s for delivery to the intended destination even if the claims have been submitted through MediSwitch previously.
A claim is regarded as a duplicate when any of the following data on the claim is the same as that on a previous claim received by MediSwitch:
» Practice number
» Membership number
» Patient’s name
» Dependant code
» Account number
» Date of birth
» Service date
» Tariff and Modifier code
» Description
» Invoice / Lab number (where applicable)
» Tooth number
» Service amount
» NAPPI codes (where applicable)
» CPT codes / ICD10 codes
» MediSwitch activation / destination codes
» Quantity
» Referring doctor (where applicable)
Prior to sending your claims through to MediSwitch, if the claim was posted twice in error, delete the duplicate claim from your Practice Management Application and submit the single correct claim.
If you have submitted your claim through MediSwitch and your claim is rejected with the error message ‘Duplicate Transaction Presented’ you are then required to follow these corrective actions:
- If the duplicate is in fact a valid claim due to a patient receiving the same treatment twice on the same day, change the first part of the description on the second claim so as to indicate that it is a valid transaction.
- In the case of a Group Practice, claims received by MediSwitch with the same patient account number will not be rejected as a duplicate if any of the data listed above differs and if the attending / treating doctor’s registered BHF practice number differs.
If the same patient receives the same treatment twice on the same day, the MediSwitch duplicate validation process will reject the second entry as invalid. However, if this is a valid treatment, the description on the second claim must differ from that of the first claim in order to pass the duplicate validation. For example: A patient is charged for a consultation and injection in the morning and is instructed to receive a follow-up injection later that same afternoon. The second claimed item should be entered as follows on the Practice Management Application:
15/04/2011 JOHN 0191 NAUSEA R200.00
15/04/2011 JOHN 0201 STEMETIL INJ 1.25% 2ml R17.11
15/04/2011 JOHN 0201 2nd STEMETIL INJ 1.25% 2ml R17.11
Group Rejections
A group rejection principle has been implemented on all claims via MediSwitch. This means that MediSwitch will only submit your claim if all the claim lines on a specific service date pass our validation test. Therefore, if one claim line is rejected, MediSwitch will reject all the claim lines for that patient for that particular service date. For example: If you submit the following claim:
Date Dep Tariff Description Amount
15/04/2011 JOHN 0191 Allergy R200.0
15/04/2011 JOHN 0210 Stemetil Inj 5ml R26.78
The second line will fail the MediSwitch validation process due to the invalid tariff code of 0210, instead of the correct tariff code 0201 being used. Your feedback report will then read something like this:
15/04/2011 JOHN 0191 Allergy R200.00 Rejection exists for patient
15/04/2011 JOHN 0210 Stemetil Inj 5ml R26.78 Tariff code does not exist
Please note that if a claim is rejected with only the MediSwitch rejection ‘Rejected Transaction Exists for Patient’, then there is nothing wrong with that specific claim, but is part of a group rejection.
Your course of action would be to rectify the error, which caused the group rejection and then flag all such claims for resubmission to MediSwitch. Please ensure that all the claims in that group are included in your next submission to MediSwitch.
Therefore, in the example presented above, you would change the invalid tariff code 0210 to the correct code 0201 and then flag the claim for resubmission to MediSwitch.
Should you need any assistance regarding this or have any other claims submission query, please do not hesitate to call our in-house call centre on 0800 111 703 where our team of professionals will be only too pleased to assist you.
- Yolandi de Mon