Dealing with rejected or part paid ECLIPSE claims can be daunting, particularly since the process varies depending on the nature and circumstances of the claim. This guide outlines some basic steps to follow that will make this process easier, as well as how to fix some of the more common exceptions.
Before you begin
This article assumes a working knowledge of ECLIPSE. If you aren’t familiar with how to process these claims, including retrieving reports and receipting, you may like to have a look at the ECLIPSE manual, particularly the Reporting and Receipting sections.
1. Find out what caused the exception
Open the IMC Claims Control window (through File > Maintenance and Reports > Daily tab, ECLIPSE IMC Transmission).
In the ‘Exceptions to Review’ category, highlight the claim and click ‘Review Exceptions’ to open the Processing Report:
This window is broken down as follows:
- Claim-level messages: these are messages from either the fund or Medicare about the whole claim. If an entire claim has been rejected, the cause may be listed here. Claim-level errors often relate to the patient’s health fund membership or Medicare card.
- Service-level messages: these messages are specific to the item currently highlighted in the window. In the above screenshot, item 51300 has a ‘fee invalid’ error.
(For a more detailed explanation of this window, please refer to the ECLIPSE manual.)
You can usually determine from the exception(s) why an item was rejected or underpaid. If the reason isn’t clear, however, contact Medicare or the fund (whichever organisation rejected the item) and ask them to clarify.
Before dealing with the claim in ECLIPSE, you will usually need to fix whatever issue was identified by the exception (e.g. invalid Medicare number, or issues with the provider number or referral details).
If you need to edit the patient (e.g. Medicare number, referral details), highlight the claim in IMC Claims Control, click Review Exceptions, then click Edit Patient to open their demographics window.
To edit the item (e.g. service text, Medicare Online Over-rides), you can do this through the Sales window, which is opened by double clicking on the item in the Processing Report.
To edit the invoice (e.g. site of service, referral), highlight the claim in IMC Claims Control and click Show in Acct Hx, then double click on the invoice on the left.
To edit the provider number, go to File > All User Preferences, double click on the provider’s name and go to the Practice Sites tab. Double click on a practice to edit it.
Following are examples of the more common exceptions and how to fix them:
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Exception |
What to do |
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Incorrect charge – benefit paid per schedule of fees |
The fund paid more (or less) than was claimed, usually only a few dollars’ difference. You don’t need to do anything outside of ECLIPSE, so go to step 3. If all claims for a particular fund are receiving this exception, you may need to update your fees for that fund.
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Referral/request details not supplied |
Open the invoice through the patient’s account history and check the referral is selected in the ‘Referring Doctor’ drop down menu. If this looks correct, open the patient’s demographics window, double click on the referral and check the details here.
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Service possibly aftercare |
If the service is not aftercare, check the Not Normal Aftercare Medicare Online override is ticked in the Sales window.
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Fee invalid – no provider registration |
This usually indicates the provider number is not registered (or was not registered on the item’s service date). If the number was registered, check it is entered correctly in the provider’s user preferences.
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Service is within the required waiting period |
The patient has not waited the required length of time since they last received this service. You don’t need to change any patient or invoice details, but the item will need to be removed from the batch and paid by the patient (or credited off).
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A benefit is not payable for this service under this level of cover |
Patient is not eligible for this item, so you will not be able to claim for it.
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Health Fund Membership cover suspended or cancelled |
(Usually a claim-level exception.) Patient is not eligible for any of these items. |
Once you have determined the cause of the rejected item/s, you will need to deal with the ECLIPSE claim by either correcting the issue and resubmitting the item/s, removing them from the claim (and crediting them or charging the patient), or applying to the fund for a ‘top-up’.
When dealing with a claim, keep in mind that all items fall into one of two categories:
Paid: either fully paid, underpaid, or only paid by Medicare. These items must remain in the batch and be receipted off, regardless of what you would like to do with the remaining balance.
Rejected: no payment was received from either Medicare or the fund. These items must be removed from the claim before receipting. (Or, if all items were rejected, the entire claim should be deleted. When doing this, Genie will ask what you want to do with the invoice - you would usually choose to keep it.)
You should never delete a claim or remove an item from the batch where a payment has been made against it (unless you are refunding the health fund for some reason).
You can deal with the claim as follows:
If all items were unpaid:
If no payment was received for the claim, it will need to be deleted as there is nothing to receipt. Highlight the claim in the list and click Delete Claim, then accept the prompt. Genie will ask what you would like to do with the invoice – you would usually choose to Keep it.
You then have three options:
- Resend: if you were able to fix the exception, you can resend it by highlighting the invoice in the account history, then highlighting all items on the right (click on the first item, then press Ctrl/Cmd + A to highlight them all). Click Resend IMC Exceptions, enter the appropriate information in the window that opens, and click OK.
- Re-address the invoice to the patient: if you would like the patient to pay the remainder of the invoice, highlight it in the account history and click the green arrow icon in the top left corner. Click he Change Account Holder icon, search for the patient, then double click on their name in the list. You can then print the invoice for the patient and receipt it off as usual when you receive payment.
- Credit the invoice: if you do not want or are unable to charge the patient, you will need to credit off the remaining balance. For each of the items on the invoice, slow double click on the Credit amount and enter the balance of the item. When prompted, enter a reason for the credit.
If some items were unpaid:
The unpaid items will need to be removed from the batch before you can receipt off the paid items. To do this, open the Processing Report for the claim, highlight the first rejected item and double check that the ‘Total Benefit’ is $0.00 for this item. Click Remove Item from Claim, then repeat this process with the remaining unpaid items. The removed items will be shown in italics.
After dealing with the exceptions, the claim should move to ‘Awaiting Remittance Advice’ or ‘Ready to Receipt’, where you can receipt it off as usual. If the claim does not move, and the claimed and paid amounts are not equal, there may be other exceptions or issues you need to deal with.
After receipting off the paid items, you again have three options for the remaining, unpaid items on this invoice:
- Resend: Highlight the invoice on the left of the account history, then Ctrl/Cmd + click on each item you want to resend. Click Resend IMC Exceptions, enter the appropriate information in the window that opens and click OK.
- Readdress the invoice to the patient: if you would like the patient to pay for the remaining items, you will need to readdress the whole invoice to them (see above steps).
- Credit the outstanding items: if you will not be paid for these items, credit them off (see above steps).
If item/s were paid a different amount to claimed:
If the difference is only a few dollars, you just need to update the claimed amount to match the paid amount. To do this, highlight the item in the Processing Report window and click Update Item. The item will turn blue, indicating the fee has changed.
Once the claimed and paid amounts on the claim are equal, the claim should move to ‘Awaiting Remittance Advice’ or ‘Ready to Receipt’. If it doesn’t move, you may have other exceptions to deal with.
If the difference in the paid and claimed amounts is large and you would like to apply for a top up, do not click Update Item. Instead, receipt off the claim for the amount you have received.
When the claim has been receipted, it will move to the ‘Part Paid’ category in the IMC Claims Control window. You will then need to apply to the fund for a top up manually, outside of Genie. Or, if the patient is not eligible for further payment, you may like to readdress the invoice to the patient and ask them to pay the difference.
Once the balance of the invoice has gone to $0.00 (either by receipting a payment or crediting off the remainder of the invoice) the claim will move from ‘Part Paid’ to ‘Finalised’.
Note: If you find a significant number of your claims come back with exceptions, you may like to organise an onsite visit with one of our trainers to help you with ECLIPSE. A better understanding of how to create and process claims will minimise the number of exceptions you have to deal with, making life easier and ensuring you are paid as soon as possible.