Claims processing
Claims processing flows
icare claims - also called invoices - will have both synchronous and asynchronous outcomes. Approximately 75% of claims are adjudicated in real-time with a synchronous response provided within 30 seconds. The remainder of claims are asynchronous, with adjudication responses ranging from hours to typically two business days from submission. Partners will need to accommodate for asynchronous responses which can be pushed from Tyro Health via webhooks or periodically polled by partners via an invoice status API.
Once a claim is submitted, the status can change as follows:
-
Outstanding : claim is under review by icare -
Approved : claim is approved for settlement -
Declined : claim was declined and will not be paid -
Cancelled : claim was canceled by the provider prior to settlement -
Completed : approved claim paid/settled to provider
If multiple service items are claimed and one item is rejected the whole invoice will be marked as Declined.
Once a claim is approved, payment is issued the next business day. icare utilises a 5pm AET end of day cut off. Claims approved after 5pm AET will be included in the following business day settlement period. If multiple claims are settled for the same provider, a single aggregate payment will be made. A remittance report is issued to providers on settlement which details each claim paid. If a provider has multiple claims - even from different insurers - or card payments issued by Tyro Health in the same settlement period, those claims will be included in the same aggregated settlement.
Claim structure
In icare, patients are referred to as “employees”. However, the details required to claim are similar to other compensatory funders. To issue a successful claim, the following details are required in each invoice:
-
Provider, profession and practice Location
: Usually set with a single provider number attribute. These details must be registered with Tyro Health in advance of a claim. Only one provider can claim per invoice.
- Patient details : including first and last name, icare-issued claim number and scheme.
- Service items : including service date, item number and fees are required.
Multiple service items from multiple service dates can be claimed per invoice.
icare supports invoice level attachments. Providers can attach up to four documents with the limit of 25MB per document.Documents must be uploaded from within the Tyro Health SDK.
The list of supported icare document types are as follows:
- Allied health recovery request
- Clinical notes
- Certificates of capacity
- Medical reports
- Radiology reports
- Surgery requests
- Treatment/Service Request
Tyro health recommends that you keep a copy of all the documents you attach as you will not be able to access these once the claim has been submitted.
Supported providers and patients
Professions and geographies
icare currently supports electronic claims from:
- Aboriginal and Torres Strait Islander Health Practice
- Acupuncture
- Ambulance
- Audiology- Chinese Medicine
- Chiropractic
- Counselling
- Dental- Diagnostic Imaging
- Dietetics - Exercise Physiology
- General Health Equipment
- General Practice
- Genetic Counselling
- Home Care service and Aids
- Hospital - Mental Health
- Myotherapy
- Naturopathy
- Nursing and Midwifery
- Occupational Therapy
- Optometry
- Orthoptics
- Orthotics/Prosthetics
- Osteopathy
- Pathology
- Perfusion (Medical)
- Pharmacy
- Physiotherapy
- Podiatry
- Psychology
- Radiology
- Remedial Massage
- Social Work
- Specialist Physician
- Specialist Treatment centres
- Speech Pathology
icare provides insurance and care services to the businesses, people and communities of NSW.
Providers must first register with Tyro Health prior to submitting a icare claim. This registration process is self-service and can be completed within a few minutes.
If providers deliver services from multiple locations or businesses, each unique provider number must be registered. Details on provider registration and icare activation is provided at: https://help.medipass.com.au/en/articles/3800285-how-to-activate-icare-invoicing-in-medipass
Patients
Any injured employee with a valid claim number can use this service.
Though rare, patients may have more than one active case. In this event, the patient will have a unique claim number for each active case.
Eligibility checks and quotes
The icare integration does not currently support patient quotes for services to be rendered. Tyro Health plans to introduce these capabilities in a future update. However, the Claim number will be checked and validated prior to invoice submission.
Processing and Settlement periods and Payment of invoices
Providers can lodge icare claims 24/7.
Most claims are processed instantly by icare using their straight-through adjudication method. Those claims will return an approved or declined status within 30 seconds and the SDK will return that status via a callback.
Claims that cannot be instantly processed will require manual review by case managers. As icare has a pharmacy review panel, all pharmacy related claims will go into the under review status when submitted. Other claims which contain miscellaneous, general catch-all and special items will also go into under review status for manual review when submitted.
Invoices that are placed Under Review at the time of submission will be handled manually by a icare claims manager. This typically occurs during business hours Monday-Friday.
Once the provider's invoice has been approved by icare within Tyro Health, funds will be deposited to your nominated bank account the following business day by Tyro Health.
icare utilises a 5pm AET end of day cut off. Claims approved after 5pm AET will be included in the following business day settlement period. If multiple claims are settled for the same provider, a single aggregate payment will be made. A remittance report is issued to providers on settlement which details each claim paid. If a provider has multiple claims - even from different insurers - or card payments issued by Tyro Health in the same settlement period, those claims will be included in the same aggregated settlement.
Reporting, statements and receipts
Tyro Health automatically generates patient reports, statements and receipts on behalf of the partner/providers. These reports and receipts can be obtained from Tyro Health Online provider portal or via API calls.
Invoices are automatically generated by Tyro Health Online for each employee and the treatments delivered. These invoices are directly sent to icare's for approval. Providers can print copies of the invoice from the Tyro Health Online provider portal or invoice details can be generated by a partner PMS for print or email to patients.
Remittance reports
Remittance reports are available on the Connect Portal when the payment has been made. Remittance reports will include all payments to a provider for the given settlement period which can include payments for other funding sources such as icare, icare and payment cards.