HealthPoint transactions

Healthpoint supports both private health insurance and overseas visitor/health cover transactions.

The following five Healthpoint transaction types are supported on machines:

• Rebate estimates
• Claims
• Cancellations
• Reporting
• Reconciliation and Settlement

However, the Transaction SDK currently only supports integrated Rebate estimates and Claims transactions. Other functions can be accessed directly on the machine.

To process Healthpoint transactions, set:

• The platform attribute to funder , and
• The funder attribute to phi .

Rebate estimates (Quotes)

Healthpoint transactions can be submitted as claims or rebate estimates - otherwise known as quotes.

Successful claims result in a transfer of funds from a private health fund to a provider, whilst a rebate estimate will be a point in time assessment of fund member benefits and will not transfer funds.

The request payloads for Rebate estimates and Claims are the same except for one flag. By default, a HealthPoint transaction will be a claim. To run the transaction as a rebate estimate you will need to set isRebateEstimate to true.

Claims

The process to complete a claim is as follows:

Set the following details in the PMS and send to the SDK:

• Provider number
• Patient details
• Item details

Swipe the patient health fund card. The claim is processed by the fund and a response is returned within 45 seconds. The claim summary is shown in the SDK and the machine will print a receipt with item level details, which might list a gap for each item. For Approved "00" responses, you will need to ask the patient if they Accept or Reject the claim which is actioned in the SDK.             A. On Accept,
                          i. The claim is finalised.
                         ii. A second claim receipt is printed as the patient copy.
                         iii. The patient should sign the receipt which must be retained by the provider for 2 years
                         iv. If one or more gap amounts were returned, the aggregated gap amount can be sent to the terminal as an EFTPOS purchase transaction via an                         interactive method, like cash.
            B. On Reject,
                         i. A Void transaction is sent to the Health Fund to invalidate the Claim.
                         ii. A Void receipt is printed by the machine.
The Transaction SDK will return a response to the PMS with the claim outcome and if applicable, the EFTPOS payment outcome.

Providers and locations

A claim requires one valid provider. Multiple providers are not supported - each must be submitted as a separate claim.

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 must also be registered and active with HealthPoint which will be arranged by the Tyro Health team. 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 professional category and issuing organisation. In general, the provider number will be defined as follows:

Patient details

A claim requires one valid patient. Multiple patients are not supported - each must be submitted as a separate claim. A claim requires:

• firstName (optional): 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.
• lastName (optional): 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 (optional): date of birth in YYYY-MM-DD format.
• reference : the unique patient indicator/reference or card rank as shown on the private health fund card. Usually two digits which can be set a leading zero and for some funds, the reference can be 00.
• 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.
• mobile (optional): patient mobile number either in international or national notation and used for uniquely searching for patients in the Tyro Health provider portal.

Items

A claim requires at least one claimableItem. Up to 16 claimableItems with different dates of service can be included in a single claim.

Several thousand unique item codes - also referred to as service items, item numbers, material numbers or pay codes - are supported by Tyro Health for HealthPoint claims. This includes those defined by private health funds and for GP/Specialist overseas claims, a subset of Medicare Benefits Schedule (MBS). Lists of valid item codes for each profession are posted under "modality item codes": (https://healthpointclaims.com.au/)

Private and overseas insurers allow providers to determine their own fees for services. However, payment will only be made up to a maximum benefit amount for each service. Approved claims will return a "benefit paid", and the remaining amount will appear as a gap on the invoice. The provider is expected to charge the patient gap fees for amounts not covered by the fund.

A valid claim will contain the following item attributes:

• reference (optional): optional but recommended, a line item unique reference as nominated by you such as a UUID/GUID. Assists with reconciliation where multiple of the same item code and service date are set in a claim. Up to 128 alphanumeric characters are permitted which must be unique for each service item in a claim.
• serviceDate : date of service in YYYY-MM-DD format. Past service dates are supported but most private health insurers expect services to be claimed on the date of service and may decline claims for past service dates.
• itemCode : up to 5 characters. The item code must be applicable for a given service date and provider registered professional category. For PHI and 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 : gross - including GST if applicable - price each in $XX.XX format. This amount will be sent to the health fund. HealthPoint and funds have no way to differentiate GST taxable from non-taxable supply items.
• clinicalCode (optional): usually a two digit number which can designate: These may be required by some private health funds. Only applicable for:
  • Dentistry: as two digit Tooth ID
  • Psychology: as two digit Primary Condition code
  • Occupational therapy:
  • digit one as Primary Condition indicator
  • digit two as Diagnostic Intervention indicator
  • For HCF only: the ICD short code used in the " More for " program which can be three alphanumeric characters.

If the provider claims multiple items with the same item code, those should be listed as separate items. There is no support for quantity with HealthPoint claim items.

Claim flows and states

Once successfully submitted, a claim will be categorised into one of the following status:

Claims will be processed instantly by the health insurer using their straight-through adjudication method. Those claims will return an approved or declined status within 45 seconds and the SDK will return that status via a callback.

Additionally, for each claim, a partner can optionally nominate one or more webhooks which fire depending on the claim status. Each successfully submitted claim will also return, via SDK callback, a Tyro Health unique transaction Id which can be used to periodically poll for current status.

Cancellation

Claim cancellation is supported on the same day as claim approval prior to settlement. For HealthPoint claims, this is usually 23:55 AET but can be as early as 20:55 for select funds.

For example:

• A successful HealthPoint claim processed at 09:00 can be cancelled the same day at 21:00.
• A successful HealthPoint claim processed at 09:00 cannot be cancelled the following day.

Yomani terminal same day cancellations via the SDK:

Claim cancellation can be done via the View Transaction call with the added optional attributes in payload

{
	transactionId: the transaction id of the claim you would like to cancel
	cancelClaim: <true/false optional>
}

Refunds

Yomani terminal same day refunds via the SDK:

Claim refunds can be done via the View Transaction call with the added optional attributes in payload

{
	transactionId: the transaction id of the claim you would like to cancel
 refundPayment: <true/false optional>
}

Receipt and statement requirements

For claims, the Tyro machine will automatically generate a printed statement for the patient to sign . If the claim is approved, the provider should ask the patient to sign the statement and retain the paper copy for 2 years. A 2nd copy will be printed on approval for the patient.

If a gap EFTPOS payment transaction was completed, that will be printed as a separate payment receipt for the cardholder.

Integrated receipts - where the machine omits printing of claim statements and EFTPOS receipts - is currently only available in the Tyro iClient or TTA integration method.