1. Simplified Billing/ECLIPSE An overview

2. Simplified Billing
First introduced in May 1995 as part of the Private Health Insurance Reforms.
Reduces the number of accounts a private patient receives after being in hospital by streamlining the claims procedures by removing the need for patients to submit claims to Medicare and their private health fund themselves.
Allows un-paid in-hospital services to be submitted to Medicare Australia and a private health fund.
Provides for informed financial consent to ensure the patient is aware of any out-of-pocket expenses.
These claims can be submitted manually or electronically.
Electronic claims can be transmitted either via the ECLIPSE or SMTP (ED) channels.

3. Claiming Arrangements
There are four options available to use Simplified Billing:
Approved Billing Agents
Medical Purchaser Provider Agreement (MPPA)
Hospital Purchaser Provider Agreement/Practitioner Agreement (HPPA/PA)
Gap Cover Scheme

4. Approved Billing Agents
Allows Simplified Billing claiming to occur without the need for any form of agreement.
Billing agents can be a private health fund, hospital, an individual or an organisation.
Billing agents act on behalf of the patient to claim Medicare benefits and private health fund medical benefits.
Billing agent must obtain a patient signature for the assignment of benefit.

5. Medical Purchaser Provider Agreement (MPPA)
Allows a private health fund to claim Medicare benefits on behalf of their members when they have a MPPA in place with the medical provider.
The private health fund can make an agreement with the medical provider to pay benefits above the Medical Benefits Schedule Fee.
Agreements between the private health fund and the medical provider may be expressed orally or in writing.

6. Hospital Purchaser Provider Agreement/Practitioner Agreement (HPPA/PA)
A medical provider does not need to deal with a private health fund directly when submitting claims.
This agreement is a combination of agreements between the medical practitioner and the hospital, and between the hospital and a private health fund.
Agreements between the private health fund and the medical provider may be expressed orally or in writing.

7. Gap Cover Scheme
Private health funds can offer insurance for the cost of a particular hospital treatment for a person where the cost of the treatment is greater than the schedule fee.
The medical provider must not have a medical purchaser-provider agreement or a practitioner agreement or a hospital purchaser-provider agreement in place with the private health fund.
The insured person pays a specified amount or percentage under a known gap policy or the full cost of the treatment is covered under a no gap policy.
The scheme must provide for the insured person to be informed in writing, where circumstances make it appropriate, of any amounts that the person can reasonable be expected to pay for treatment and the insured person acknowledges receipt of this advice.

8. Introduction
ECLIPSE is one of a number of electronic claiming solutions offered by Medicare Australia
Today’s presentation will cover:
What ECLIPSE is and how it works
Features of ECLIPSE
The ECLIPSE Network
Online security
Connecting to ECLIPSE
Where to find out more

9. Electronic claiming solutions
Medicare Australia offers a range of electronic claiming solutions:
Medicare Easyclaim: Standalone and Integrated
Medicare Online
ECLIPSE
Medicare Australia offers a range of electronic claiming solutions which allow quicker, more convenient claiming which benefits both providers and the public. The various channels, devices and software utilised for online claiming have different functionality and benefits.
There are currently four claiming channels which enable electronic lodgement of claims:
Easyclaim, which uses an EFTPOS device to lodge claims
Medicare Online, which requires a computer (PC could imply not Mac compatible) and internet access
Integrated solutions, which use elements of both Easyclaim and Medicare Online
and ECLIPSE, an ‘online solution’ which is the focus of today’s presentation.

10. What is ECLIPSE? ECLIPSE - Electronic Claim Lodgement and Information
Processing Service Environment
Enables private patients seeking treatment in hospital to
claim rebates from Medicare, their private health fund and
the Department of Veterans’ Affairs, (DVA) in one online
transaction.
What is ECLIPSE?
ECLIPSE is an acronym for Electronic Claim Lodgement and Information Processing Service Environment.
ECLIPSE allows private patients who are treated in hospital to claim rebates from Medicare, their private health fund and the Department of Veterans’ Affair (DVA) in one easy online transaction.
ECLIPSE enabled software is offered by a number of different vendors – and while there are common features, the functionality varies from software to software.

11. Benefits of ECLIPSE
Benefits:
Paperless business transactions between Medicare Australia, private health funds and DVA in one software product
Patients pay only the gap
Quicker processing times
Faster resolution of complex claims
Improved data quality
Electronic remittance advice
Informed financial consent
ECLIPSE offers many benefits to providers and patients.
As well as providing a fast, secure and paperless means of communication between Medicare Australia, private health funds and DVA, ECLIPSE allows patients seeking treatment in hospital to get an estimate of their out-of pocket expenses at the time of service.
This results in quicker processing times, faster resolution of complex claims and improved data quality, leading to fewer errors and speedier resolution of claims.
ECLIPSE also provides electronic remittance advice from private health funds, resulting in quicker and more accurate reconciliation of accounts and is an easy way to obtain informed financial consent from patients.

12. How does ECLIPSE work?
ECLIPSE is an extension of Medicare Online which connects medical practitioners, hospitals, billing agents, private health funds, DVA and Medicare Australia via a secure internet connection.
ECLIPSE is an extension of Medicare online which allows direct communication between medical practices, public and private hospitals, private health funds, billing agents, the Department of Veterans’ Affairs and Medicare Australia via a secure internet connection.
ECLIPSE uses the same platform as Medicare Online. A Client Adaptor is used to interface between other parties’ software systems and the Medicare Australia ECLIPSE ‘hub’.

13. The ECLIPSE Network The ECLIPSE Network 2 1 3 4 ECLIPSE HUB Medicare
Site
Private Health Fund
ECLIPSE
HUB 4

14. Features of ECLIPSE Features In-patient Medical Claims
In-hospital Claims
Online Patient Verification
Online Eligibility Check
Status requests
Retrieve reports
Overseas Claims
Online security
Today we are going to talk about the features offered by most software with ECLIPSE functionality. ECLIPSE functionality varies – remember it’s important to contact your software vendor to find out what their software can offer.
The key functionality of ECLIPSE includes
The facility to transmit Inpatient Medical Claims and In-Hospital claims
Online Patient Verification
Online eligibility checking
Status requests
Retrieve reports
The ability to transmit overseas claims
and Online security.

15. Online Patient Verification
Online Patient Verification (OPV)
Medicare Australia (PVM)
Private Health Fund (PVF)
Enterprise Patient Verification (EPV)
Multiple patient verifications per transmission
A very valuable feature of ECLIPSE is Online Patient Verification. Sites can verify the accuracy of patient details with Medicare Australia and the relevant private health fund while the patient is present at the point of service. This reduces mismatches and the need for resubmissions.
The Enterprise Patient Verification feature enables sites to submit batches of up to 1000 patient details for verification at any one time.

16. Online Patient Verification (OPV)
Medicare 2 1
Private Health Fund
Site
ECLIPSE
HUB 4 3
1 - Patient Verification is submitted from the site.
2 - The ECLIPSE HUB submits the Medicare patient information to Medicare for assessment, Medicare passes the assessment
information back to the ECLIPSE HUB (PVM).
3 - If successful, the private health fund patient information is submitted to the private health fund for assessment, the private health
fund passes the assessment information back to the ECLIPSE HUB (PVF).
4 - The ECLIPSE HUB submits both the Medicare and private health fund assessments back to the transmitting site.

17. Inpatient Medical Claims
Inpatient Medical Claims (IMC) are submitted to Medicare Australia and private health funds:
IMC Schemes (SC) – Un-paid claims that are submitted where a private health fund offers does not have a medical purchaser-provider agreement or a practitioner agreement or a hospital purchaser-provider agreement in place and the insured person pays a specified amount or percentage under a known gap policy or the full cost of the treatment is covered under a no gap policy
IMC Agreements (AG) – Un-paid claims that are submitted where a provider or hospital have an agreement with the specified private health fund. The private health fund can make an agreement to pay the provider benefits above the Medical Benefits Schedule Fee
IMC Medical Benefits (MB) – Un-paid claims that are submitted from a Billing Agent (contains a ‘Billing Agent ID’) to Medicare and a specified private health fund
IMC Medicare Only (MO) – Un-paid claims that are submitted from a Billing Agent (contains a ‘Billing Agent ID’) but only invokes Medicare Australia
IMC Two-Way (TW) – Paid or Un-paid claims that are submitted from a Medicare Branch to a specified private health fund
IMC Patient Claims (PC) – Claims that are submitted where a patient has the option of having paid, part-paid or not-paid claims, to a specified private health fund
First inpatient medical claims.
Different types of inpatient medical claims can be submitted to Medicare Australia and private health funds simultaneously.
Inpatient medical claims can be submitted via ECLIPSE where a provider has an agreement or scheme in place with a private health fund. Payment is made via the health fund or billing agent.
Medical Benefits (MB) claims attract a 75% Medicare and 25% private health fund payment. Claims are submitted via billing agents using ECLIPSE.
ECLIPSE can also be used to submit IMC Medicare Only (MO) claims - this is where patients do not have private health cover. Claims and payments are made via billing agents.
IMC two-way claims can be submitted manually, or via ECLIPSE where the private health fund has this functionality
And finally IMC patient claims are similar to two way claims, except these can be submitted at the point of service, and no manual process is involved. Where claims have been paid, the Medicare and health fund payments are sent to the patient or claimant. For unpaid claims, the Medicare and health fund payments are sent to the patient as a cheque made out to the provider. These are then forwarded to the provider by the patient.

18. In-Patient Medical Claim (IMC)
Medicare 2 3 1
Private Health Fund
Site
ECLIPSE
HUB 4 5
1 - In-Patient Medical Claim is submitted from the site, an acknowledgement from the ECLIPSE HUB is sent to the site (IMC).
2 - The ECLIPSE HUB initiates a patient verification at Medicare (PVM) and, if successful, a patient verification at the private
health fund (PVF). All assessment information is passed back to the ECLIPSE HUB.
3 - If successful, the ECLIPSE HUB submits the claim information to Medicare for assessment, the assessment can be returned in
real-time or pended for further assessment. The information is then sent back to the ECLIPSE HUB.
4 - The ECLIPSE HUB submits the claim information, along with the Medicare assessment, to the private health fund for assessment
(IMH). The private health fund will acknowledge that they have received the claim.
5 - The private health fund will send their assessment details back to the ECLIPSE HUB (IMX), the ECLIPSE HUB will acknowledge
their assessment. The completed claim information is ready for retrieval by the transmitting site.

19. In-Patient Medical Claim (IMC) payments
Medicare 2
Provider 1 2
Private Health Fund
Site
ECLIPSE
HUB 4
1 - Medicare sends the Medicare benefit to the private health fund
2 - The private health fund passes the Medicare benefit and the private health fund benefit to the provider or billing agent.

20. Online Eligibility Check
Online Eligibility Checking (OEC)
Checks eligibility for both Medicare and private health fund benefits
Estimates out-of-pocket expenses
Enables informed financial consent before the episode of care
Online eligibility checking is just as it sounds - this feature checks the patient’s eligibility for both Medicare and private health fund benefits before the episode of care and estimates the patient’s out-of pocket expenses for hospital services by providing the likely rebate payable by Medicare Australia and the health fund.
Because of this, the patient can give informed financial consent before the episode of care occurs.

21. In –Hospital Claims In-Hospital Claims (IHC)
Lodgement of claims for a hospital stay directly with private health fund or DVA
Processing reports
Electronic remittance advice
Using the In-hospital claims feature, public and private hospitals and day facilities can lodge claims for a patient’s hospital stay (that is, claims for accommodation, theatre, transfers, prosthetics and miscellaneous services) directly with their private health fund or with DVA.
Processing reports (an indication of which claims have been paid) and electronic remittance advice - or payment reconciliation for health fund payments – can also be obtained using the IHC feature

22. In-Hospital Claim (IHC)
Medicare 2 2 1
Private Health Fund
Hospital
ECLIPSE
HUB 3 4
1 - In-Hospital Claim is submitted from the hospital, an acknowledgement from the ECLIPSE HUB is sent to the hospital (IHC).
2 - The ECLIPSE HUB initiates a patient verification at the private health fund (PVF). All assessment information is passed back to the
ECLIPSE HUB.
3 - The ECLIPSE HUB submits the claim information to the private health fund for assessment (IHH). The private health fund will
knowledge that they have received the claim.
4 - The private health fund will send their assessment details back to the ECLIPSE HUB (IHX), ready for retrieval by the transmitting
hospital.

23. Status Request Status Requests (STS)
Checks the status of an in-patient medical claim at any time
Retrieve Reports (RTV)
Checks the processing report for up to 50 In-patient Medical Claims at a time
Provides assessment of claims details including Medicare and private health fund status
Provides assessment codes for each service within a claim
ECLIPSE functionality includes the ability to provide status requests and retrieve reports.
Using the Status Request function, ECLIPSE allows you to check the status of an in-patient medical claim or in-hospital claim at any time, allowing users to determine the point at which the claim has proceeded to date. For example, whether the claim is currently being assessed by Medicare, whether the Medicare benefit has been paid and whether the claim has progressed to the health fund.
With the Retrieve Report function, ECLIPSE can also be used to access details regarding the assessment of claims, including Medicare and private health fund status and assessment codes for each service included in a claim. This can be used for up to 50 In-patient medical claims at a time.

24. Overseas Claims Overseas Claims (OVS) OVS Agreement (AG)
OVS Scheme (SC)
OVS Patient Claims (PC)
OVS Medical Benefits (MB)
For definitions please see the ‘Inpatient Medical Claims (IMC)’ section.
Overseas claims
Claims from students/visitors holding overseas cover with a registered Australian health fund or where there are reciprocal agreements, can be lodged directly with a participating private health fund. Claims can be made for both in-hospital and out-of hospital services.
In-patient medical claims including those made under a scheme or agreement
Remember!
Not all ECLIPSE enabled software provides the full range of features that I have just described. The functionality is dependent on your practice management software and the Private Health Fund involved. Contact your software vendor for more information.

25. eBusiness Service Centre 1800 700 199
Online security
Online security
Public Key Infrastructure (PKI) used to encrypt and secure all information electronically transmitted to and from Medicare Australia and private health funds.
PKI provides the highest level of confidentiality, privacy and authentication available for transmitting medical data.
eBusiness Service Centre
Medicare Australia uses Public Key Infrastructure (PKI) to encrypt and secure all information electronically transmitted to and from Medicare Australia and the Health Funds.
PKI provides the highest level of confidentially, privacy and authentication available for transmitting medical data.
More information on PKI and digital certificates is available on the Medicare Australia website,
Application forms can be downloaded from the website or you can call our eBusiness Service Centre on for more information.

26. Connecting to ECLIPSE Connecting to ECLIPSE The site must:
contact their software vendor to see if they offer ECLIPSE
register for, and receive a digital certificate
liaise with private health funds where they may have agreements or schemes in place
contact the Medicare Australia eBusiness Service Centre or request a visit from a Business Development Officer
Connecting to ECLIPSE
If you are interested in transmitting claims using ECLIPSE and you are using practice software you should first contact your software vendor to see if they offer ECLIPSE functionality.
You will need to register for your digital certificate – remember, you can download the form from the Medicare Australia website or call our eBusiness Service Centre.
You should also contact any health funds with which you have agreements or schemes and advise that you will be lodging their members’ claims via ECLIPSE.
You may request a visit from a Medicare Australia Business Development Officer via the eBusiness Service Centre if you need additional information or assistance.

27. eBusiness Service Centre 1800 700 199
More information
For health professionals
eBusiness Service Centre
There is lots of information about electronic claiming on the Medicare Australia website
You can find background information about ECLIPSE, find out more about digital certificates and how to get them, access details of the software vendors with ECLIPSE functionality and also the health funds with ECLIPSE functionality
under the For health professionals>doing business online
It’s well worth a visit!

28. Questions? ?