Submitting claims

Provider and location details

Provider and practice location details can be set with a single providerNumber attribute. Importantly, this provider number must be defined and active in Tyro Health and for the given business API Key. Provider numbers which are not registered in Tyro Health or for the given business API key will error. Only one provider can claim per invoice.

Provider number formats can vary by type of professional category and issuing organisation. In general, the provider number will be defined as follows:

For the SDK, if a provider number is not sent in the claim payload, the the user will be prompted to manually select:

• The practice location
• Individual provider
• Provider profession type and/or specialist category
  

If only one of each category has been defined, that will be automatically selected.

Registration of provider numbers

Providers must first register with Tyro Health prior to submitting a DVA claim. We do not currently offer an API for partners to self-register providers.

This registration process is self-service.If providers deliver services from multiple locations or businesses, each unique provider number must be registered. Details on provider registration and DVA activation is provided at: (https://help.medipass.com.au/en/articles/4064976-activating-medicare-and-dva-claiming-in-medipass)

Patients

For DVA, a claim requires one valid patient. Multiple patients are not supported - each must be submitted as a separate claim.

A claim requires:

• firstName :which can be up to 40 characters, and only contain alpha (A-Z and a-z), numeric (0- 9), space ( ), apostrophe ( ' ) and hyphen (- ) characters. Spaces must not appear before or after apostrophes, hyphens, other spaces or the supplied value. At least one alpha or numeric character required. If the patient has only one name, set that in the lastName field and set firstName to " onlyname " .
• lastName: which can be up to 40 characters, and only contain alpha (A-Z and a-z), numeric (0- 9), space ( ), apostrophe ( ' ) and hyphen (- ) characters. Spaces must not appear before or after apostrophes, hyphens, other spaces or the supplied value. At least one alpha or numeric character required.
• dob : Date of birth in YYYY-MM-DD format, must be a valid date,must not be date in the future, must not be after each serviceDate,if Patient is < 15 years old as at each serviceDate, an adult > 18 years old claimant is required, must not be > 130 years in the past
• membershipNumber :3 to 9 alphanumeric characters,unique DVA issued veterans number as shown on card.
• acceptedDisability :Up to100 characters, UPPERCASE, • The value supplied must be alpha (A-Z), numeric (0-9), space ( ), and special characters : ; , . -.• First character must be alpha or numeric and spaces must not appear before or after other spaces or the supplied value.• Alpha characters must be UPPERCASE
• refId (optional): An optional but highly recommended patient unique reference as set by you, such as a UUID/GUID. This value is used to uniquely identify a patient in the Tyro Health platform. Omitting refId will cause duplicate patient records to be created in Tyro Health and could make patient searches more difficult for providers who also use the Tyro Health portal to check on status of a claim and remittance. If supplied and valid, this value will pre-populate patient details from the patient record in the business as set in any prior claim. Any patient details set for an existing patient record will update those values and override what was previously stored.

DVA card number and patient details are validated at claim submission and invalid details will be flagged with corresponding error details.

Items

Over 10,000 unique item codes - also referred to as service items, item numbers, material numbers or pay codes - are supported by Tyro Health for DVA claims. This includes most medical provider items defined in the DVA Benefits Schedule (MBS). Multiple service items with different dates of service can be included in a single claim.

Item codes are updated dynamically by DVA and new codes will be automatically integrated into the Tyro Health platform. Current DVA rates for for medical and allied health treatment can be obtained via : http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home

Item code Pricing

When you raise a claim, we will pre-fill the items you add with the associated MBS scheduled fee for a given service date.

A valid claim will contain the following item attributes:

• serviceDateString : date of service in YYYY-MM-DD format. Past service dates are supported.
• itemCode : up to 12 characters. The item code must be applicable for a given service date and provider registered professional category. For MBS items, leading zeros are permitted or may be omitted. Items which are not known or invalid for a given service date or profession will be flagged with an error at the item level.
• price : net (excluding GST) price each unit in $XX.XX format.

Units of measure vary depending on item code. The current supported DVA units of measure include:

There are many additional optional attributes that can be set with each claimed item. These include:

• accessionDate
• accessionTime
• accountReferenceNumber
• afterCareOverride
• collectionDate
• collectionTime
• duplicateServiceOverride
• duration
• fieldQuantity
• jawCode
• multipleProcedureOverride
• numberOfPatientsSeen
• numberOfTeeth
• opticalScript
• reference
• restrictiveOverride
• rule3ExemptIndicator
• s4b3ExemptIndicator
• scpId
• selfDeemedCode
• secondDevice
• serviceText
• serviceTime
• toothNumber

Additional information on optional attributes

Number of patients seen - is required for group attendance items or home/hospital/institution visits.

Item overrides

• Restrictive override : Service that is not restrictive with another service either within the same claim or on the patient history.
• Aftercare override : Indicates if service is part of normal aftercare for the patient. Select “not normal aftercare” to override.
• Multiple procedure override : Select “Not multiple” to override.
• Duplicate service override : Indicates if practitioner attended patient on more than one occasion on same day. Select “Not duplicate” to override.
• Self Deemed Code : A Self Deemed (SD) service is a service provided by a consultant physician or specialist as an additional service to a valid request. Or a substituted service (SS) is a service provided that has replaced the original service requested. When set to SD, a referral is not required for a service that would otherwise require such a referral.

  Pathology settings

  Specialist settings for Pathology services can be set under Optional Attributes. This includes:

• SCP ID : The Specimen Collection Point is used to identify the site where the pathology specimen was collected.
• ** Collection Date & Time**: This is the date/time the pathology sample was taken/extracted from the patient
• Accession Date & Time : This is the date/time the pathology test was performed.
• Rule 3 Exempt : Indicates if the pathology service is exempt from Rule 3 in the Medicare Benefits Schedule (MBS).
• S4B3 Exempt : Indicates if the pathology service is exempt from assessing in accordance with the S4b3 requirements in the Medicare Benefits Schedule (MBS).

Treatment location

• Treatment location is required in order to claim travel costs. For more information on treatment location and travel costs, see the Claiming travel section of this document.