Best Practice Guidelines: Healthcare Practice Management & POPIA Compliance Framework

Best Practice Guidelines: Healthcare Practice Management

POPIA Compliance Framework

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12. Claim Administration: Roles, Purpose & Business Diagram

12.1. Claim Administration Business Processes

Import Data directly from medical aids

  • Import data from medical aids is an important step in any claim administration. This ensures the correct demographic information as it is coming straight from the medical aid of the patient.
  • The information will differ from medical aid to medical aid, depending on the information the medical aid share with the system.

Validation against medical aid data
  • Validations can be used every time when a patient visits the practice, to ensure the information on the system is still correct and that the membership is still valid and active on the medical aid.
  • The information must be correct to ensure the claim will go through to the medical aid with the correct demographic information for both the patient and the main member.

Benefit Check
  • Assists in checking if there are available funds for the claim that must be processed. The Practice can do up to 3 benefit checks on a patient per day. The system allows the practitioner, billing expert or receptionist to check for a certain amount, the system will give an indication of the required amount is available or not. 
  • Please take note that this is only an indication, and any other practice can submit their claims. The medical aid will then process that claim first, so your practice’s claim can still be rejected for insufficient funds. 
  • Important rule submits the claim as soon as the patient is done with treatment to ensure the correct outcome.

Real-time submission through GoodX Switch
  • After the consultation, and preferably before the patient leaves the practice, the claim needs to be submitted to the relevant medical aid. 
  • An immediate response from the medical aid would indicate if the claim was processed successfully or with short payment. The patient should then settle the short payment before leaving the practice.
  • Most of the medical aids have a real-time submission, but some smaller medical aids will only indicate that the claim was received, and not if the medical aid is going to pay the claim in full or not.
  • Always follow up on all medical aid claims. A claim that was 100% processed successfully and accepted by the medical aid, full payment is not guaranteed until the money reflects in the practice’s bank account. 

Manage claims
  • View responses from the medical aid daily, preferably immediately after the claim was submitted to prevent stale or rejected claims not getting resolved.
  • Follow up on rejections and resolve issues on the rejected claims, for example, if the patient or medical aid details were incorrect. These issues must be rectified daily. Resubmit the claims after they were resolved.
  • If the claim was rejected due to insufficient funds an Invoice can be printed out for the patient to ensure immediate payment.
  • Different claim responses will assist you in managing the outcome of the claim for example if the claim status is "To Send" the claim still needs to be submitted.
  • The rejected claims must be corrected and resend on a daily basis, and not left stale and unresolved.
  • Make sure all rejected or unsent claim responses have been resolved.
  • When a medical aid says that the claim was not received a proof of submission with the transmission number can be sent through the system to the medical aid.

Reverse, Redo & Resubmit

If any mistakes were made on a Claim, you can amend the mistake by doing a Reversal of the claim, Redo the Invoice and Resubmit it.

Ensure the correct steps are taken to ensure the correct information is sent to the medical aid and no duplicate claims errors are received. 

Claim Response
  • The claim response will give an indication if the claim was processed with or without any rejections and whether the claim will be paid in full by the medical aid.
  • The claim response must be checked on every claim after it was submitted to prevent non-payment and rejections.
  • The response will also show the line items that were rejected, with a reason why the line item will not be paid. This can be corrected and the claim can be resubmitted. 
  • This is only an indication and not a guaranteed payment - anything can still happen from the time the claim was submitted to the medical aid processing it for payment.

Claim History Screen
  • The claim history screen is the most important screen in the Claim Administration process. 
  • Claim history has all the information about when the claim was sent to the medical aid, the response from the medical aid, rejections and reversals.
  • The Claim history screen must be checked daily to follow up and resolve the claims that were submitted to the medical aid.
  • Some of the Functions on the Claim History screen is:
    • Send claim
    • Reverse claim
    • Response
    • Patient Validation
    • Resolve claim
    • Move outstanding amount to Patient or Medical Aid
    • SMS and Viewing the account
  • The Claim History screen is also a worklist to resolve all the claims and to ensure that the claims do not go stale.

    Resolve claims
    • To resolve a claim is to mark the claim resolved. This will indicate that the claim has been sorted out and every possible solution was done on the claim to ensure payment or that the payment was received from the medical aid. Claims can be marked resolved:
      • If they have been accepted by the medical aid
      • If they have been accepted but marked that they will not be paid. The claim should be moved to the patient liable.
      • If they were paid in full.
    • The claim history screen should not be used for collection purposes. The credit-control assistant was specifically designed to assist practices in following up on outstanding debt.
    • The process must be agreed on by the practice when a claim will be marked as resolved: 
      • when the claim is fully processed and all rejections were dealt with or 
      • when the payment was received from the medical aid
    • Remember that there are Debt collecting processes in the system to ensure the debt management process runs smoothly.
    • The main focus is to have only the claims that need to be followed up on as unresolved claims. This allows the credit controller to focus only on the unresolved claims and try to resolve them with medical aid.
    • Important functions that will be used to ensure correct claim administration

    • The report will assist the practice to manage the claims. The report reflects all the claim statuses that must be checked or filtered on.
    • The following statuses will assist the practice to check on claims:
      • Rejections - will enable the practice to rectify errors and resubmit claims.
      • Not sent claims or To Send - these claims have been marked as cancelled or sent later. If these claims are not followed up, it can lead to stale claims. It is vital that this report is drawn daily to ensure that all claims were submitted to medical aid.
      • Warnings - warnings can be on the claim or line item and will enable the practice to follow up on these claims.
      • Processed but not paid claims - the claims will indicate that it was processed by the medical aid but no payment was received after approximately 2 weeks, depending on the medical aid. This will assist the practice to follow up the claims with the medical aids.
      • Patient liable - indicate all the amounts that are patient liable and will assist the practice to do timeous debt collection.

    Electronic Remittance Advice (ERA)
    • The electronic remittance advice is part of the receipting and will be explained under the Receipting in detail. For successful and accurate Claim administration, electronic remittance advice must be posted.
    • If the Practice makes use of the ERA function it will save time and post accurate payments to patients accounts.