Education guide - ECLIPSE - tools to help with claiming

Providing an overview of functions available through ECLIPSE that streamline lodging In-patient Medical Claims (IMC) and In-Hospital Claims (IHC) with us and private health insurers.

Claiming and functionality

ECLIPSE (Electronic Claim Lodgment and Information Processing Service Environment) provides a secure internet connection between us, practices, public and private hospitals, billing agents, health professionals, private health insurers and the Department of Veterans' Affairs (DVA) for medical and hospital claims lodged through ECLIPSE enabled practice management software.

Functionality may vary between different software products and ECLIPSE releases. Access to functions requires practice and private health insurer's software to have implemented the same ECLIPSE functions. For more information on:

Claim processing and payment functions

These functions can help with claim processing and payment.

  • patient verification
  • eligibility checking
  • retrieve report

Patient verification and eligibility checking

Using patient verification and eligibility checking functions in ECLIPSE can help with successful ECLIPSE claim transmissions. It is recommended you perform:

Function Before Requirement
patient verification an appointment
  • you must seek and get patient or legally authorised representative's consent
  • you have the patient's Medicare or private health insurer details
  • private health insurer is an ECLIPSE participant
eligibility checking an anticipated admission date

You or your patient will be made aware of any problems with us or private health insurer details or eligibility.

The following tables provide information on patient verification and eligibility checking functions available in different ECLIPSE releases.

Patient verification

Functions Type of verification Response timeframe Release
Online Patient Verification (OPV) Confirms the accuracy of a patient's details with:
  • Medicare only (Patient Verification Medicare - PVM)
  • Private health insurer only (Patient Verification Fund - PVF)
  • Medicare and private health insurer (Online Patient Verification - OPV)
These checks can be done in real time, you will receive an immediate response.
  • 2.8
  • 3
  • 6
Online Veteran Verification (OVV) DVA patient verification confirms the accuracy of a patient's details with DVA only. This check can be done in real-time, you will receive an immediate response.
  • 5
Enterprise Patient Verification (EPV) Allows you to submit up to 1000 patient verifications per transmission in batch mode.
  • batches can include multiple private health insurers
  • this check may take up to 72 hours
  • EPV functionality available with private health insurers that also have EPV functionality. Check the Get Participants report
This check isn't immediate and not provided in real-time. Responses may not be available for up to 72 hours after you submit the request.
  • 5

If Medicare or the private health insurer cannot perform the patient verification, part of or the entire request is rejected and you will need to re-try at a later time. All functions listed are available in the release stated and above.

Eligibility checking

Function Type of check Used to determine Release
Online Eligibility Check (OEC) Hospital and medical checks with both Medicare and private health insurers to facilitate the patient receiving informed financial consent (IFC).
You must seek and get patient or legally authorised representative's consent before submitting an OEC.
Check can be submitted for an:
  • anticipated admission date up to 12 months in the future
  • emergency admission up to 7 days in the past
Patient's eligibility for a selected presenting illness or condition on the admission date based on:
  • their hospital product:
    • out-of-pocket expenses for excess
    • exclusions
    • co-payments
  • the medical services:
    • Medicare benefits payable
    • private health insurer benefits payable
  • 5
Eligibility Check Fund (ECF) Hospital only checks Patient's eligibility for a selected presenting illness or condition on the admission date based on:
  • their hospital product:
  • out-of-pocket expenses for excess
  • exclusions
  • co-payments
  • 5
Eligibility Check Medicare (ECM) Medicare only checks If Medicare covers the patient and what Medicare benefits are payable for in-patient medical services.
  • 5

Understanding patient verification and eligibility check responses

Refer to the ECLIPSE Medical Eligibility and User Guide available at Simplified Billing and ECLIPSE.

Retrieve reports

Reports can be retrieved using the retrieve report function.

Report availability, format and content

The availability of reports and their format and content depend on the function and ECLIPSE Release installed on your practice management software.

Reports Provides Notes Release
Get Participants report
  • all private health insurers participating in ECLIPSE, including their:
    • fund brand ID
    • trading name
    • contact number
    • date record last updated
    • ECLIPSE enabled functionality and transactions
  • real-time response when report is requested
New private health insurers come on-board regularly and existing private health insurers upgrade to new ECLIPSE releases, giving you access to more types of transactions and functionality.
  • 3
Status report
  • the status for submitted transactions:
    • processing
    • ready
    • reported
  • either an automatic response to a submitted transaction or request a report, depending on your software
  • ECLIPSE Remittance Advice (ERA) status report is only available for release 4 and above
The response provided depends on the state and type of transmission:
  • 'Processing' applies to:
    • patient verifications in claiming
    • claiming
    • eligibility checks
  • 'Ready' applies to:
    • claiming
    • eligibility checks
    • remittances
  • 'Reported' applies to:
    • claiming
    • eligibility checks
    • remittances

Where Medicare only patient verification is performed for In-patient Medical Claims, there will be no private health insurer responses provided.

  • 3
Claim processing report
  • information on the medical services in a claim
  • depending on your software, reports can be retrieved at any time and may be requested more than once within the six-month period, after the claim has been finalised
You can only retrieve the claim processing report after the private health insurer has paid their benefit to the billing agents.
  • 3
Eligibility processing report
  • OEC information requested for any:
    • hospital out-of-pocket expenses
    • prosthesis
    • medical services
  • if the OEC is accepted, Medicare and private health insurer assessing is conducted as required and results are available for retrieval within 20 minutes of OEC receipt
  • if results aren't returned to the ECLIPSE hub within 20 minutes the request is cancelled
Reports are only available for 7 days, after the report is made available.
  • 5
ERA report
  • payment information only for unpaid In-patient Medical Claims submitted under these claim types:
    • AG – Agreements (MPPA, HPPA/PA)
    • SC – Approved gap cover schemes
    • MB – Billing agent submitting claims to Medicare and private health insurer
    • MO – Billing agent submitting claims to Medicare only
  • for patient claims an ERA isn't available as the patient or claimant is responsible for the account
  • remittance advices are only available for AG, SC and MB if the private health insurer also has remittance advice functionality
  • ERA reports can be retrieved at any time, and may be requested more than once in a six-month period, after the original request
  • ERAs available only when ERA functionality is also supported by the private health insurer
  • 4

ECLIPSE Medical and Eligibility User Guide

More details on these functions and ECLIPSE claiming are available in the ECLIPSE Medical and Eligibility User Guide at Simplified Billing and ECLIPSE.

The user guide includes more detailed information on:

  • getting ECLIPSE ready
  • eligibility checking
  • eligibility processing
  • interpreting eligibility responses
  • submitting In-patient Medical Claims
  • reports
  • Medicare services contacts
  • private health insurer contacts
  • field notes for patient information, hospital information, medical information
  • claim processing
  • DVA claiming
  • ECLIPSE Releases and functions
  • patient verification and types
  • In-patient Medical Claiming Latter Day Adjustments

Contact details for services

Service Contact details
Software vendors offering online claiming

Online: Vendors offering Medicare online claiming

Contact us for Online Technical Support (OTS) for Software Vendors

  • Registering for online claiming
  • Enquiries about online claiming
Online: Register for online business

Contact us at the eBusiness Service Centre for help in completing the online claiming registration and enquiries, including:
  • registration
  • business support
  • on-site visits
  • help with the transmission process
  • changed contact and practice details
  • technical problems with missing claims, confirmation of transmissions

Email: ebusiness@humanservices.gov.au

  • ECLIPSE Medical and Eligibility User Guide
  • Private health insurer's functionality and contact details
  • Simplified Billing and ECLIPSE forms
Online: Simplified Billing and ECLIPSE

Contact us at the eBusiness Service Centre for help in completing the forms

Email: simplified.billing@humanservices.gov.au
Billing Agent Registration Kit Online: Simplified Billing and ECLIPSE
ECLIPSE enquiries:
  • policy and procedures
  • complaints and disputes
  • feedback and suggestions
Phone: 02 6143 7557 call charges may apply
Access to the Doing Business with Medicare Electronically eLearning program and other education resources Education services for health professionals

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Page last updated: 15 September 2016

This information was printed Friday 9 December 2016 from humanservices.gov.au/health-professionals/enablers/education-guide-eclipse-tools-help-claiming It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.