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 Medicare 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 Medicare activation is provided at: (https://help.medipass.com.au/en/articles/4064976-activating-medicare-and-dva-claiming-in-medipass)

Patients

For Medicare, 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
• accountNumber : unique Medicare issued account number for patient, maps to Medicare number
• reference: unique patient reference with Medicare, Maps to medicareReferenceNumber
• 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.

Medicare 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 Medicare claims. This includes most medical provider items defined in the Medicare Benefits Schedule (MBS). Multiple service items with different dates of service can be included in a single claim.

Item codes are updated dynamically by Medicare and new codes will be automatically integrated into the Tyro Health platform. Current Medicare 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

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

If you choose to use the patient claim , you can set the applicable fee your practice charges for this item. The patient will pay in full for the full cost of the consultation and we will raise the patient claim with DHS/Medicare on their behalf, except as provided in partial or Pay Doctor via Cheque Scheme (PDVC) requests. The benefit is typically paid into the nominated bank account by the next business day.

Approved claims will return a "benefit paid", and the remaining amount will appear as a "gap" on the invoice. The service provider is permitted to charge the injured worker additional gap fees for amounts not covered by Medicare.

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 Medicare units of measure include:

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

• serviceText
• selfDeemedCode
• serviceTimeString
• patientContributionAmount
• scpId
• rule3ExemptIndicator
• s4b3ExemptIndicator
• accessionDate
• accessionTime
• collectionDate
• collectionTime