Education guide - ECLIPSE claiming and functions

Help with ECLIPSE functions, including lodging in-patient medical claims and in-hospital claims with us and private health insurers, patient verifications and reports.

Claiming and other functions

Electronic Claim Lodgment and Information Processing Service Environment (ECLIPSE) gives a secure channel to connect with:

  • us
  • public and private hospitals
  • billing agents
  • health professionals,
  • private health insurers
  • the Department of Veterans' Affairs (DVA).

ECLIPSE works through your practice management software (PMS).

Use ECLIPSE to:

  • lodge in-patient medical claims (IMCs), billing agent claims and patient claims
  • lodge in-hospital claims from public and private hospitals and day facilities
  • request eligibility and verification checks from private health insurers and us
  • you can also retrieve your reports from us.

ECLIPSE functions may vary between different software products and ECLIPSE release versions. Both your PMS and private health insurer's software must have the same ECLIPSE functions installed. Read more about vendors offering Medicare online claiming and Simplified Billing and ECLIPSE.

Patient verification and eligibility checking

Patient verification functions help you claim successfully. Use these functions in ECLIPSE to verify patient details and eligibility:

  • online patient verification (OPV) to verify Medicare enrolment and private health insurer membership
  • online eligibility checking (OEC) to
    • check the patient's eligibility with their private health insurer and us
    • get an estimate of out-of-pocket expenses.

We recommend you use:

  • OPV before an appointment
  • OEC before an anticipated admission date.

These checks will help you identify anything incorrect about your patient’s Medicare or private health insurer details or eligibility. Knowing this information will reduce the number of rejected claims.

Requirements

Before verifying a patient or checking their eligibility you must:

  • get the patient’s consent or the consent of their legally authorised representative
  • have the patient's Medicare or private health insurer details
  • check the private health insurer is an ECLIPSE participant
  • make sure your PMS has OPV or OEC functions.

Patient verification

Before submitting the claim, patient verification confirms that the patient:

  • is eligible to claim Medicare benefits
  • is known to the private health insurer
  • holds hospital level cover.

The table below gives details about the 3 types of patient verification.

Type of verification What it verifies Response timeframe

Online Patient Verification (OPV)

There are 3 types of OPV:

  • An OPV confirms patient's details are correct with the patient’s private health insurer and us.
  • A Patient Verification Medicare (PVM) verifies the patient’s details are correct with us only.
  • A Patient Verification Fund (PVF) verifies the patient’s details are correct with their private health insurer only.

You will get a response in real time.

Online Veteran Verification (OVV)

An OVV confirms the accuracy of a patient's details with DVA only.

You will get a response in real time.

Enterprise Patient Verification (EPV)

EPVs verify multiple patients. You can use them to request up to 1000 patient verifications in the 1 transmission.

Each transmission can include multiple private health insurers.

An EPV can confirm with us, the private health insurer or both.

You will get a response within 72 hours of submitting the request.

You’ll need to retry the request at a later time if we or the private health insurer:

  • can’t perform the patient verification
  • rejects part of the patient verification
  • rejects the entire request.

Eligibility checking

Using ECLIPSE, you can check a patient’s eligibility for their Medicare and private health insurer status. You can also get an estimate of out-of-pocket expenses for hospital stays, prosthetics and miscellaneous items.

Use the OEC function to give the patient enough information for them to give informed financial consent.

You can submit an eligibility check for:

  • anticipated admission date that is up to 12 months in the future
  • emergency admission that was up to 7 days in the past.

If you submit an eligibility check for an admission date well into the future, you should check again before admitting the patient. This will pick up any changes in benefits that may impact on the patient’s out-of-pocket expenses.

The table below gives details about the 3 types of eligibility checks and who can use them.

Type of eligibility check Used by What it checks

Online Eligibility Check (OEC)

Hospitals, day surgeries and health professionals

An OEC checks a patient's eligibility for treatment of a presenting illness or condition on the admission date. It’s based on:

  • their hospital insurance product, including
    • out-of-pocket expenses for excess
    • exclusions
    • co-payments
  • which medical services are covered by
    • Medicare benefits
    • their private health insurer.

An OEC checks hospital and medical eligibility with both private health insurers and us.

Eligibility Check Fund (ECF)

Hospitals and day surgeries

An ECF checks a patient’s eligibility for treatment of a presenting illness or condition on the admission date. It is based on their hospital insurance product, including:

  • out-of-pocket expenses for excess
  • exclusions
  • co-payments.

An ECF only checks hospital eligibility.

Eligibility Check Medicare (ECM)

Hospitals, day surgeries and health professionals

An EMC checks whether we cover the patient and what Medicare benefits are payable for in-patient medical services.

An ECM only checks Medicare eligibility.

Understanding patient verification and eligibility check responses

For help:

Retrieving reports

You can use ECLIPSE to retrieve reports using the retrieve report function.

The report’s content and format depends on the function and ECLIPSE release installed on your PMS.

The table below gives details about the types of reports you can retrieve using ECLIPSE.

Type of report Contents of the report Notes

Get Participants report

The Get Participants report includes details of all ECLIPSE enabled private health insurers, including their:

  • fund brand ID
  • trading name
  • contact number
  • date record last updated
  • ECLIPSE enabled functions and transactions.

You should request reports regularly so you have access to the latest information and services. New private health insurers come on board regularly. Existing private health insurers upgrade and provide more features in new ECLIPSE releases.

You will get a real-time response.

Status report

A status report provides the status for submitted transactions. It lets you know if the transaction has been validated and assessed, and whether a report is available. The response depends on the state and type of transmission:

  • processing applies to
    • patient verifications
    • claiming
    • eligibility checks
  • ready applies to
    • claiming
    • eligibility checks
    • remittances
  • reported applies to
    • claiming
    • eligibility checks
    • remittances.

You should request a status report before attempting to retrieve a report.

If you try to retrieve a report that isn’t ready you’ll get an empty report.

You can request the report or it can be provided in response to a submitted transaction. It depends on your software.

Claim processing report

A claim processing report tells you about the outcome your completed claims.

You can retrieve these reports at any time. You can request them more than once within 6 months of the claim.  

The presentation and structure of the report depends on the type of software your practice uses.

The status response will indicate a report is available. The response will look different depending on the transmission type.

For billing agent claims, you can only retrieve the report after the private health insurer pays their benefit.

Eligibility processing report

An eligibility processing report (OEC) includes information for any out-of-pocket hospital expenses, prostheses and medical services.

If the system accepts the OEC, we and the private health insurer will assess the claim. You can retrieve results within 20 minutes of OEC receipt.

If results aren't returned to the ECLIPSE hub within 20 minutes, it means the request is cancelled.

Reports are available for 7 days.

ECLIPSE Remittance Advice

report

An ECLIPSE remittance advice (ERA) report includes payment information for unpaid IMCs that were submitted under these claim types:

  • AG - agreements
  • SC - approved gap cover schemes
  • MB - billing agent submitting claims to private health insurers and us
  • MO - billing agent submitting claims to us only.

ERAs aren’t available for IMC patient claims (IMC PC) because the patient or claimant is responsible for the account.

The private health insurer will create an ERA when they deposit the EFT funds into your bank account.

If you have more than 1 payee submitting per location, you’ll get a remittance advice for each payee.

You can retrieve an ERA report at any time. You can request them more than once within six-months of the original request.

ERAs are only available if the private health insurer supports the ERA function.

ECLIPSE Medical and Eligibility User Guide

Read more about ECLIPSE in the ECLIPSE Medical and Eligibility User Guide at Simplified Billing and ECLIPSE.

The user guide includes 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.

More information

Read more about:

Contact us at the eBusiness Service Centre.

Contact us for online technical support for software vendors.

Provide your feedback on our education resources.

Page last updated: 8 January 2019