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:
|patient verification||an appointment||
|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.
|Functions||Type of verification||Response timeframe||Release|
|Online Patient Verification (OPV)||Confirms the accuracy of a patient's details with:
||These checks can be done in real time, you will receive an immediate response.||
|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.||
|Enterprise Patient Verification (EPV)||Allows you to submit up to 1000 patient verifications per transmission in batch mode.
||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.||
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.
|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:
|Patient's eligibility for a selected presenting illness or condition on the admission date based on:
|Eligibility Check Fund (ECF)||Hospital only checks||Patient's eligibility for a selected presenting illness or condition on the admission date based on:
|Eligibility Check Medicare (ECM)||Medicare only checks||If Medicare covers the patient and what Medicare benefits are payable for in-patient medical services.||
Understanding patient verification and eligibility check responses
Refer to the ECLIPSE Medical Eligibility and User Guide available at Simplified Billing and ECLIPSE.
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.
|Get Participants report||
||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.||
||The response provided depends on the state and type of transmission:
Where Medicare only patient verification is performed for In-patient Medical Claims, there will be no private health insurer responses provided.
|Claim processing report||
||You can only retrieve the claim processing report after the private health insurer has paid their benefit to the billing agents.||
|Eligibility processing report||
||Reports are only available for 7 days, after the report is made available.||
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
- 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
|Software vendors offering online claiming||
Contact us for Online Technical Support (OTS) for Software Vendors
||Online: Register for online business
Contact us at the eBusiness Service Centre for help in completing the online claiming registration and enquiries, including:
||Online: Simplified Billing and ECLIPSE
Contact us at the eBusiness Service Centre for help in completing the forms
|Billing Agent Registration Kit||Online: Simplified Billing and ECLIPSE|
||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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