HICAPS transactions

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

The following three HICAPS transaction types are supported:

• Claims
• Cancellations (Same day)
• Rebate estimates

To process HICAPS transactions, set:

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

Rebate estimates (Quotes)

HICAPS transactions only be submitted as claims.

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.

To simulate a quote partners will need to submit a claim and cancel the claim within a 15 minute window. When they submit the claim they will be able to see what benefit will be given.

Claims

The process to complete a claim is as follows:

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

• Provider details
• Patient details
• Item details

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 HICAPS. 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 : 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 : 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.
• membershipNumber (optional): membership number or policy number, typically 8 digits.
• 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.

Items

A claim requires at least one claimableItem. 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:

For claimable items:

• 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. HICAPS and funds have no way to differentiate GST taxable from non-taxable supply items.
• clinicalCode :Code used to identify the specific details of the health item.

For non-claimable items:

• price : gross - including GST if applicable - price each in $XX.XX format. This amount will be sent to the health fund. HICAPS and funds have no way to differentiate GST taxable from non-taxable supply items.
• Description : Description of non-claimable item.

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 within the Connect Portal. For HICAPS claims, this is usually 23:55 AET but can be as early as 20:55.

Cancellation will also be triggered automatically if a patient approval is not put through within 15 minutes.

Refunds

Refunds are supported for the payment portion in the Connect portal however there is currently no option to refund the HICAPS health fund benefit. Claims that have been settled require the providers and business to contact the member health fund and initiate a manual refund with that fund.

Receipt and statement requirements

Receipts and invoices are available within the Connect Portal.