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TRANSCRIPT
INFORMATION GUIDE
FOR
PRIVATE HOSPITALS
AND
PRIVATE MENTAL HEALTH
HOSPITALS
January 2018
Table of Contents
1.Overview1
2.Patient Eligibility2
2.1Seeking Prior Financial Authorisation3
2.2Department of Defence Arrangements3
3.Hospital Services Agreement4
4.Admission, Transfer and Discharge4
4.1Hospital Admission Voucher5
4.2Death Certification arrangements for a deceased veteran5
5.Contract Managers6
5.1Additional Information6
6.Quality Standards6
Advice to DVA on existing Accreditation Status:7
Advice to DVA on future Accreditation Outcome Results:7
Private Hospital Quality Reporting:7
Mental Health Standards7
Mental Health Quality Reporting8
7.Patient Satisfaction8
8.Information Management Submitting HCP data8
8.1HCP date format requirements8
9.In Hospital Claims (IHC) Release 69
9.1What are the advantages for facilities that move to DVA IHC?9
9.2What types of services are able to be claimed via IHC for DVA?10
9.3What types of services cannot be claimed via IHC for DVA?10
9.4Is EFT mandatory for claims lodged through IHC?10
9.5Are remittance advices available electronically through IHC?10
9.6What happens to paperwork when claiming via IHC?10
9.7Can a claim be submitted if IHC is unable to identify a veteran?11
9.8Will a claim be paid if IHC identifies a veteran patient?11
9.9Do facilities need to check a veterans accepted conditions?11
9.10Are DVA prior approvals required for IHC?11
9.11How do facilities get access to IHC?11
9.12How do facilities using in-house software get access to IHC?11
9.13Who does my software vendor contact for information on IHC?11
10.Billing Arrangements12
10.1Where to send non-electronic claims12
10.2Prompt Payment12
10.3Account Enquiries12
11.Discharge Advice and Hospital Claim D653A Form13
12.How to Fill in the Discharge Advice and Hospital Claim (D653A) Form14
13.How to complete your claim16
Claiming a complete episode16
How to claim a Continuation claim17
How to claim a Continuation claim with leave day:17
How to claim theatre fees for multiple procedures:17
How to claim a case payment for Short Stay MBS Packages17
How to claim per Diem (unbundling) for Short Stay MBS Procedures18
How to claim for Dual Banded items18
How to claim an ECT as a day Patient18
Certain MBS Coronary Angiography items18
How to claim Overnight Dental19
Admitted Same Day Rehabilitation Services19
Non-admitted Sessional Rehabilitation Services19
Accident and Emergency20
High Cost Medical Devices20
High Cost Robotic Consumables20
Calculating the day count20
14.Certificates and Certification21
Acute Care Certificates21
Rehabilitation Program Certificate:22
Day Only Procedure Certification and Overnight Stay Certification:22
15.Claims Stationery and Hospital Forms22
16.Advertising23
ATTACHMENT 1 Contact details for the Department of Defence Joint Health Command24
ATTACHMENT 2 DVA Quick Contact List25
Overview
The Repatriation Commission and the Military Rehabilitation and Compensation Commission (the Commissions) have entered into a Hospital Services Agreement (the Agreement) with your organisation to provide private hospital services to Entitled Persons. The Department of Veterans Affairs (DVA), on behalf of the Commissions, will work with you during the life of this Agreement to ensure the best outcomes for Entitled Persons, with minimal administrative impediments.
The provision of Hospital Services under your Agreement is to be in accordance with the following legislative frameworks:
a) the Treatment Principles and Private Patient Principles made under the Veterans Entitlements Act 1986 (VEA), or under the Military Rehabilitation and Compensation Act 2004 (MRCA), or under the Australian Participants in British Nuclear Tests (Treatment) Act 2006; and
b) the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 (DRCA)
In addition to its arrangements with private (including private mental health) hospitals, DVA has arrangements in place with Day Procedure Centres, and all public hospitals in every State and Territory. These arrangements ensure that Entitled Persons have access to hospital services when and where they are needed.
While the Deed of Agreement defines the term Entitled Persons, throughout this document the terms veteran, veteran community or patient are used, but the same broader meaning is intended.
DVA entered into new contractual arrangements with a range of private hospitals during 2016. This document has been updated to reflect the changes to the Agreement. Hospitals should note that this document is a guide only and that where questions arise, the Hospital Services Agreement has precedence over this document.
Patient Eligibility
DVA advises Entitled Persons to present their Repatriation Health Cards or their written letter of authorisation to hospital admission staff in order to access treatment under DVA arrangements.
Patients who are Repatriation Card holders may also elect to be treated outside DVA arrangements, however, in those circumstances, DVA is unable to accept financial responsibility for any part of the admission.
Private Room
Charges for inpatient treatment are based on Entitled Persons receiving private room hospital accommodation where available, and doctor of choice, in accordance with the Repatriation Private Patient Principles (See Hospital Services Agreement Section 4.4).
At admission, when determining access to a private room, DVA acknowledges that the hospital will take into account the competing clinical needs of a veteran and non-veteran patient if there are not two private rooms available. In the Hospital Services Agreement, Hospitals agree not to levy additional charges against DVA patients for accommodation in a private room. (See Section 4.12.6 of the Hospital Services Agreement).
All Entitled Persons are, at the time of admission, to be provided with a copy of DVAs fact sheet HSV74 - Hospital Admission & Discharge available from the DVA website www.dva.gov.au.
Gold Cardholders are entitled to treatment of most conditions, however, prior financial authorisation must be sought for some services and treatment types.
White Cardholders continue to be eligible for treatment only for those conditions for which DVA has specifically accepted financial responsibility. DVA will not be responsible for payment for the treatment of any person admitted to the Hospital who, at the time of admission, was not an entitled veteran with eligibility for the treatment provided.
Ascertaining the eligibility for White Card Holders:
If a veteran presents with a White Card and eligibility for treatment is uncertain, you should confirm eligibility with DVA to ensure treatment costs will be met by DVA. For emergency treatment outside business hours, financial authorisation should be sought from DVA on the first business day after the treatment.
Holders of Letters of Authorisation may have treatment authorised under either the Veterans Entitlements Act 1986 (VEA), the Military Rehabilitation and Compensation Act 2004 (MRCA), the Australian Participants in British Nuclear Tests (Treatment) Act 2006, or the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 (DRCA). As provision of services may vary amongst all four Acts, hospitals should phone the contact officers on the letters to clarify entitlements and billing arrangements.
2.1Seeking Prior Financial Authorisation
Prior Financial authorisation is required in the following circumstances:
Where there is a doubt about a patients eligibility for treatment;
Respite or convalescent care in a residential care facility;
Surgical/Medical procedures not listed on the MBS;
Prostheses not listed on the Department of Health Prostheses List;
Non-admitted sessional rehabilitation services for treatment in excess of four weeks, or where the treatment is not otherwise covered by a program agreed between the parties;
Pharmaceuticals not listed on the Pharmaceutical Benefits Scheme or Repatriation Pharmaceutical Benefits Scheme; and
Specific treatments nominated in writing by DVA from time to time (e.g. cosmetic surgery).
To seek prior financial authorisation you should:
contact DVA during business hours by telephoning 1800 550 457 (Option 3)
or
download, complete and email the DVA prescribed Prior Approval form D1328TreatmentPrior Financial Approval Request (available from the DVA website) and include any required supporting documentation and email to [email protected]
or
provide a written request that contains all the elements from the D1328 Treatment Prior Financial Approval Request form from a doctor and email it to the DVA Health Approvals mailbox at [email protected].
2.2Department of Defence Arrangements
All ADF Personnel admissions require prior financial authorisation from the Department of Defence local Joint Health Command. The contact details for the Joint Health Command are shown at Attachment 1 Contact details for the Department of Defence Joint Health Command. Claims for payment should be sent to the relevant Joint Health Command. Claims should not be sent to the Department of Human Services (DHS).
Hospital Services Agreement
The Hospital Services Agreement between DVA and your organisation defines how the arrangements will work. You should familiarise yourself with the aspects of the Agreement relevant to your position. Hospitals should note that DVA entered into a new Hospital Services Agreement in 2016. This Information Package reflects the updated arrangements, however it is to be noted that where questions arise, the Hospital Services Agreement takes precedence over these information notes.
Your DVA Contract Manager (see Clause 12.1 of your Hospital Services Agreement) is available to discuss any of the conditions of the Agreement, including:
Treatment of Entitled Persons;
Provision of Services;
Admission, Transfer and Discharge Procedures;
Charges, Fees and Billing
Guidelines for Programs; and
Quality and Performance Management.
The commencement of a new Hospital Services Agreement in 2016 included a shift to a new procurement model. DVA responded to industry and government requests to reduce red tape by developing a simplified method of engagement. It involved a standard contract and an ability for providers to commence service delivery simply by accepting DVAs terms and conditions, with the only negotiation being around prices.
A key aspect of the new model is that there is no necessary end date in the Hospital Services Agreement. This avoids a cumbersome tender process at set intervals, regardless of whether an approach to market adds value at that time. Commensurate with the concept of an ongoing agreement is the need for regular adjustment, to ensure that the arrangements reflect current legislation and government policy and broader industry trends. The Hospital Services Agreement therefore provides for the unilateral variation of the Agreement by DVA with three months written notice (clause 12.7 of the Agreement). The clause requires DVA to act in good faith, consistent with the requirement, as a Commonwealth agency, to act as a model contractor.
It is DVAs intention that clause 12.7 will be used in the following circumstances:
Where DVA is obliged by the Government or other Commonwealth agencies to reference and incorporate new legislation or policy into the Agreement;
To correct typographical errors and to update references to other documents, and to websites and contact information; and
Where DVA wishes to change policy or standards for all contracted private hospital providers, and does so following an appropriate period of industry-wide consultation.
It is DVAs intention that amendments would occur no more frequently than annually, bar exceptional circumstances. Separate to this, DVA will continue to enter into deeds of variation with hospital providers to reflect the changes to fees and charges that are agreed through the annual fee review process under clause 7.1 of the Agreement.
Admission, Transfer and Discharge
The Hospital Services Agreement (see Section 6) also outlines admission, transfer and discharge requirements that apply to Entitled Persons. Detailed information is available in your Agreement on:
Admission procedures and notification;
Prior Financial Authorisation requirements;
Pre-discharge assessments;
Transfer requirements;
Discharge Planning protocols;
Discharge documentation;
Medication Review;
Discharge medications;
Discharge advice to Local Medical Officers or General Practitioners;
Arranging post-discharge services; and
Supply of Hospital Episode Data.
To assist staff involved in discharge planning, DVA publishes a Discharge Planning Checklist which identifies important aspects to consider in the discharge process. The checklist is available at: https://www.dva.gov.au/sites/default/files/files/providers/hospitals/Discharge%20Planning%20Checklist.pdf.
DVA also publishes a Discharge Planning Resource Guide which provides information on DVA and community based services available to entitled persons and which may be of assistance in planning an effective discharge. The Discharge Planning Resource Guide is available at:
https://www.dva.gov.au/sites/default/files/files/providers/hospitals/discharge_planning_resource_guide.pdf
Additional information on admission and discharge can be found within DVA Fact Sheet HSV74 - Hospital Services at http://factsheets.dva.gov.au/factsheets/documents/HSV74 Hospital Services
4.1Hospital Admission Voucher
A DVA Hospital Admission Voucher (form D652B) (or a hospitals own admission form which includes all data elements required by the DVA Hospital Admission Voucher) must be completed for each veteran patient. This is a requirement of the Hospital Services Agreement. The admission voucher must be completed within two (2) business days of admission. These must be kept with the patients clinical record to confirm patient identity and eligibility when required for audit and investigation of claims, and to document the Entitled Persons authorisation for disclosure of Clinical Information as shown by their signature.
Hospitals are reminded that they should not include the Hospital Admission Voucher with the claim sent to the Department of Human Services (DHS). The Hospital Admission Voucher (pdf version) can be located on the DVA website in the forms section at: http://www.dva.gov.au/sites/default/files/dvaforms/D0652B.pdf
4.2Death Certification arrangements for a deceased veteran
Hospitals are reminded that they must use their best endeavours to educate attending doctors that, when an Entitled Person dies in the Hospital, the attending doctor should consult the Entitled Persons Local Medical Officer to obtain a full and complete medical history to inform the wording of the cause of death noted in the Death Certificate. This is important to provide clarity in relation to the cause of death and to simplify subsequent claims by the Entitled Persons dependents for benefits potentially available through DVA which can be affected by the recorded cause of death.
Contract Managers
Your organisation and DVA have both appointed Contract Managers (Clause 12.1 of the Agreement) to ensure that services provided are consistent with the spirit of the arrangements. The respective Contract Managers will work together to establish and maintain a productive working relationship.
The Contract managers role is to:
a) Monitor the quality and review the outcomes of the Hospital Services provided at and from the Hospital to Entitled Persons;
b) Investigate any complaints by or on behalf of Entitled Persons;
c) Monitor the submission of invoices to DVA for the Hospital Services provided to the Entitled Persons and DVAs payment for those Hospital Services;
d) Initiate negotiations in accordance with clauses 7.1 and 7.2 of the Hospital Services Agreement;
e) Provide such information as is reasonably agreed, to meetings at the State based Consultative Forum if requested by that body (see clause 3.2 of the Hospital Services Agreement);
f) Promptly meet to attempt to resolve any disputes arising under the terms of this agreement;
g) Facilitate the electronic transfer of invoices, statistical information or other data specified in this Agreement; and
h) Ensure the timely exchange of information, as agreed.
5.1Additional Information
General information is available on the DVA Hospitals Webpage at: https://www.dva.gov.au/providers/hospitals-day-procedure-centres-and-mental-health-private-hospitals
The Hospitals Webpage contains information to assist Contract Managers and hospital staff and includes:
The Group Accommodation and Theatre Banding (GATB) table;
Coronary Care Certificates;
Intensive Care Certificates;
A list of contracted hospitals
Quality Reporting templates
Useful contact information included in Attachments 1 and 2.
Quality Standards
Quality management under the arrangement between the hospital and DVA is aimed at continuously improving the effectiveness of veterans hospital care and health care in terms of accessibility, appropriateness, efficiency, continuity, and satisfaction.
As outlined in Section 5 of the Hospital Services Agreement, Hospitals must comply with the accreditation requirements specified in the Australian Health Services Safety and Quality Accreditation (AHSSQA) Scheme, including any Commonwealth or State laws or policies introduced as part of the implementation of the Scheme. The AHSSQA Scheme requires hospitals to be assessed to the National Safety and Quality Health Services (NSQHS) Standards (and where applicable, the National Standards for Mental Health Services 2010).
Advice to DVA on existing Accreditation Status:
Hospitals will provide DVA with the details of their accreditation status and agree to advise DVA in relation to any changes in their accreditation status as they arise. DVA may seek to confirm the hospitals accreditation status at any time. Hospitals either:
a) agree to DVA obtaining data relating to Accreditation Outcome Results from the Australian Commission on Safety and Quality in Health Care; or
b) agree to provide DVA with a report detailing their most recent Accreditation Outcome Results before 31 October each year using the report format on the DVA website.
Advice to DVA on future Accreditation Outcome Results:
Accreditation Outcome Results beyond 1 July 2017 must be provided to DVA in a report no more than 3 months after the results are received by the hospital. The report will identify the actions that have been met and actions which are not met. For actions which are not met the report will identify whether these are core or developmental. The report template will be available from the DVA website and will provide hospitals with the required format to be followed in producing the Accreditation Outcome Results report.
Private Hospital Quality Reporting:
Section 5.6 of the Hospital Services Agreement sets out the requirement for hospitals to submit a report within four months of the end of each twelve month period of July to June. The Quality Reporting Template has now been streamlined to reduce duplication of quality reporting processes and is now in an EXCEL based format. Mental Health and Better Discharge Planning quality measures have been incorporated into a single template which means that hospitals now only need to provide one report to cover Private Hospital, Mental Health, Better Discharge Planning quality measures.
The new streamlined report which came into effect for the reporting period 1 July 2016-30 June 2017 (and due 31 October, 2017) is available at:
https://www.dva.gov.au/sites/default/files/files/providers/hospitals/phqrt.xlsx
Mental Health Standards
Mental Health Services provided to Entitled Persons under this Agreement must be in accordance with the principles contained in the Guidelines for Determining Benefits for Private Health Insurance Purposes for Private Mental Health Care (2015 Edition).
Hospitals delivering mental health services to Entitled Persons must:
comply with the Commonwealth of Australia 2012 Mental Health Statement of Rights and Responsibilities;
meet the National Standards for Mental Health Services 2010;
provide a summary report on the Hospital results as provided by the Private Mental Health Alliance (PMHA) Centralised Data Management Service in its monthly standard reports. The report will include an analysis of variance from national outcomes;
for each Entitled Person episode, collect industry agreed and validated outcome measures. The data to be collected is that which complies with the PMHA Minimum Data Set with Outcome Measures for private, hospital-based psychiatric services. This data is to be provided to the PMHA Centralised Data Management Service for incorporation in its quarterly standard reports;
For Trauma Recovery Programmes PTSD, hospitals must:
comply with the DVA accreditation requirements as detailed at clause 4.40 of the Hospital Services Agreement; and
collect additional outcome measures as directed by DVA.
The elements of the TRPPTSD dataset are detailed in the 2015 National Accreditation Standards for Trauma Recovery Programmes posttraumatic stress disorder available online at:
at-ease.dva.gov.au/professionals/files/2015/08/Trauma-Accreditation-Standards-2015.pdf
The outcome data is to be submitted to the organisation responsible for Program data monitoring, for each Entitled Person who participates in an agreed Program.
DVA will evaluate the clinical effectiveness of the TRPs by collecting outcome data from veterans through Phoenix Australia Centre for Posttraumatic Mental Health, under contract arrangements, at the following time points:
assessment
intake
discharge
3 months post-discharge (relapse prevention)
9 months post-discharge.
Mental Health Quality Reporting
Hospital staff responsible for Quality Reporting should check the DVA website from time to time to ensure that the correct version of the Quality Reporting template is used. As the Mental Health Quality measures are now included in the excel-based Private Hospitals Quality Report, providers should access the new template at: https://www.dva.gov.au/sites/default/files/files/providers/hospitals/phqrt.xlsx
Patient Satisfaction
The Patient Satisfaction survey was part of DVAs Pay for Performance (P4P) Program. While the P4P Program was discontinued on 30 June 2016, the DVA Patient Satisfaction Survey continues to be a source of important information for DVA in relation to patient satisfaction, experience and hospital quality as reported by patients. The Patient Satisfaction Survey is distributed to all clients who have an overnight admission in an acute care, mental health, sub-acute or non-acute contracted Hospital.
For information on the DVA Patient Satisfaction Survey, refer to your Hospital Services Agreement - Part B, Appendix 2: DVA Patient Satisfaction Survey.
Information Management Submitting HCP data
Each month you must provide to DVA in electronic medium and without charge, information in respect of each veteran separation during the preceding month.
8.1HCP date format requirements
The data must be supplied using the Hospital Casemix Protocol (HCP) format, as specified by the Department of Health (DoH), and split into monthly periods.
The HCP data provided will be
based on the current HCP version, or any future revisions as specified by DoH
supplied using DVAs Secure File Transfer facility.
It is critical that the HCP data specification complies with the current DoH header and episode record, hospital-to-fund layout.
From time to time the specification of HCP data is altered and these changes will be advised by DoH and made available via the DoH website:
http://www.health.gov.au/internet/main/publishing.nsf/Content/health-casemix-data-collections-about-HCP
Hospitals seeking to submit HCP data electronically will need to nominate a staff member within the hospital and contact DVA to obtain a copy of the Secure File Transfer Registration Form and Confidentiality Deed. The nominated staff member should complete these and return them by post to your DVA Contract Manager for registration.
Once the nominated staff member has been registered, a secure file transfer logon and passphrase will be issued and the nominated staff member will be contacted with the details and will also be provided with assistance in accessing the HCP data transfer website.
For this and further information please contact the DVA Secure Services Desk on 1300 301 575 or email:
For Qld and NSW/ACT facilities [email protected] or
For Vic, SA/NT, WA and Tas facilities [email protected]
In Hospital Claims (IHC) Release 6
Your organisation has agreed to implement and/or maintain effective electronic billing and payment arrangements during the period of the Agreement. The In Hospital Claims (IHC) system is an electronic billing system available to Private Hospitals and Day Procedure Centres (DPCs). It was developed by the Department of Human Services (DHS) in collaboration with DVA, the health care industry and the medical software industry. The IHC system is an extension of the DHS online claiming solutions which:
enables Private Hospitals and DPCs to submit electronic claims for processing without the requirement to send additional paperwork to DHS;
offers a secure connection between private hospitals, DHS and DVA and health funds; and
incorporates direct communication for providers with DHS and health funds, all in the one transaction.
9.1What are the advantages for facilities that move to DVA IHC?
Facilities are able to submit DVA claims electronically for processing and payment. This may reduce administration and management costs.
DVAs IHC component is consistent with the system used for health funds.
IHC contains an inbuilt automated veteran verification system that confirms whether a veteran patients details are correct.
Electronic remittance advice statements detailing DVAs payment of claims allows automated account reconciliation on request.
Facilities can check the status of their hospital claim assessments and request processing and payment reports relating to claims through their claiming software.
Certificate information (such as an Acute Care Certificate) can be submitted electronically.
The future ability to transmit Hospital Casemix Protocol (HCP) data via IHC eliminating the need to supply separately.
9.2What types of services are able to be claimed via IHC for DVA?
The following private hospital and DPC DVA claim types can be claimed electronically using IHC:
Accommodation
Acute Care*
Critical care
In patient
Interim claims
Miscellaneous charges
Overnight
Prosthesis
Psychiatry
Rehabilitation
Same day
Theatre
*Including certificates
9.3What types of services cannot be claimed via IHC for DVA?
Public hospital claims - existing payment arrangements for public hospital services will continue.
Australian Defence Force personnel claims - claims should continue to be sent to the relevant Defence Area Health Service for payment.
Adjustments to previous claims these claims should be manually submitted to DHS for payment.
Some claims where Letters of Authority indicate other specific billing arrangements.
9.4Is EFT mandatory for claims lodged through IHC?
Yes, Electronic Funds Transfer (EFT) is a mandatory part of the IHC registration process. Facilities are required to provide their EFT details as part of the IHC registration process. For further information on EFT, contact DHS on 1800 700 199.
9.5Are remittance advices available electronically through IHC?
Yes, a facility can retrieve a remittance advice through their software for up to six months from the date of payment. After six months have lapsed the facility will need to contact DHS Processing Centres on 1300 550 017 to request duplicate statements.
9.6What happens to paperwork when claiming via IHC?
Facilities are required to retain auditable records, these may be in paper or electronic form. DHS does not require paperwork to process the claims. You no longer need to complete the Discharge Advice and Hospital Claim Form (D653A) when claiming via IHC. However, you must retain all the data elements required by this form, and any accompanying certification, with the Entitled Persons Clinical Record. You must complete a Hospital Admission Voucher (D652B) and retain a copy with the Entitled Persons Clinical Record.
Paperwork that would normally be submitted with a claim for payment, such as Critical Care Certificates, no longer needs to be submitted. An electronic/paper record should be kept by you with the Entitled Persons Clinical Record for audit purposes.
9.7Can a claim be submitted if IHC is unable to identify a veteran?
No, if a veteran verification request does not identify the veteran, the facility should either:
check the details with the Veteran, or
contact DVA on 1800 550 457 to confirm the veterans details, and
correct the details before submitting the claim.
Where the process does not verify a veterans details, the claim will be rejected.
9.8Will a claim be paid if IHC identifies a veteran patient?
In most cases yes, however the claim must meet all DVAs business rules. The process does not check a veterans accepted conditions, and therefore a claim could still be rejected for reasons relating to the accepted condition.
9.9Do facilities need to check a veterans accepted conditions?
Yes, under DVA contracting arrangements it is the facilitys responsibility to ensure that a veteran has eligibility for the requested treatment before admitting a patient at the expense of DVA. If a facility is unsure of a veterans eligibility, they should contact DVA on 1800 550 457 (select Option 3) for confirmation.
9.10Are DVA prior approvals required for IHC?
Prior approval requirements are specified within contractual agreements for certain items. IHC has not changed any of DVAs prior approval requirements. Please check your contract for these requirements.
9.11How do facilities get access to IHC?
The facility should contact the software vendor that currently supplies the billing software. The software vendor should call DHS Online Technical Support on 1300 550 115 for advice and assistance. Each private hospital and DPC must be registered to use IHC. The DHS eBusiness Service Centre can assist your facility with registering for IHC and can be contacted by:
Phone: 1800700199
Fax: 0396057981 or
Email: [email protected]
All sites submitting claims electronically through IHC require a digital certificate that ensures the security of claims lodged online. The DHS eBusiness Service Centre will also assist with registering for digital certificates.
9.12How do facilities using in-house software get access to IHC?
Private Hospitals or DPCs using in-house software or facilities who do not have a software vendor should contact DHS Online Technical Support via email on [email protected] or via phone on 1300 550 115 for advice and assistance on the steps required to incorporate IHC functions into their software.
9.13Who does my software vendor contact for information on IHC?
If your software vendor is unaware of IHC and requires further information they should contact DHS Online Technical Support (OTS) via email in the first instance at [email protected] or via phone on 1300 550 115 for advice and assistance on the steps needed to incorporate IHC functions into their existing software products. OTS Liaison officers are the first point of contact for software vendors.
Billing Arrangements
10.1 Where to send non-electronic claims
The Department of Human Services (DHS) is an agent for DVA and processes all Gold and White card DVA admissions and payments in accordance with DVAs policies and procedures. Amounts are paid in accordance with contracted or negotiated rates. Accounts for hospital accommodation, theatre fees, day only accommodation, fixed price items, case payments and prostheses supplies should be mailed to:
Hospitals in SA - NT - WA - NSW - ACT send claims to:
Veterans Affairs Processing - Hospital Provider ClaimsDHS-Medicare ProgramsPO Box 9917PERTH WA 6848
Hospitals in VIC - TAS - QLD send claims to:
Veterans Affairs Processing Hospital Provider ClaimsDHS-Medicare ProgramsPO Box 9917MELBOURNE VIC 3001
Please refer to Section 2 Patient Eligibility for details of billing arrangements for non-DVA Card holders and for information regarding Department of Defence arrangements.
10.2 Prompt Payment
Claims submitted to DHS must be on the DVA Discharge Advice and Hospital Claim Form (D653A). Incomplete, inaccurate or illegible information can cause delays in payment. Please include sufficient information with your claim to ensure prompt and accurate processing. Claims must be itemised using the item numbers that apply at the date of service. Claims which are incorrectly completed, e.g. without item numbers, admission date or principal diagnosis code, will be rejected and returned to hospitals.
10.3 Account Enquiries
Hospital account enquires should be directed to DHS on: 1300550017 (local call cost)
Where hospitals have issues with the timeliness of payment of correctly rendered invoices, this should be raised with their DVA Contract Manager.
Discharge Advice and Hospital Claim D653A Form
How to Fill in the Discharge Advice and Hospital Claim (D653A) Form
The DVA Discharge Advice and Hospital Claim form should be used for all hospital and prostheses claims. It is comprised of two copies:
1. Departmental Claim Copy; and
2. Hospital Copy.
Please forward the Departmental Claim Copy to DHS for claiming purposes, and retain the Hospital Copy for your records.
Hospital Details:Contains the hospital name, address and provider number
Patient Details:The details required for each patient are:
DVA File Number
Patient Surname
Given names
Date of Birth
Dates of Service:Insert the date of service FROM (i.e. the admission date or continuation claim date) and the date of service TO (i.e. the day prior to discharge or continuation claim date TO).
Date of Service
From
To
Admission date
Day prior to discharge
Dates of service must not overlap. In cases where there is more than one accommodation line (e.g. because of a change in rate or patient classification) the FROM date will be the first day of the new classification or rate. Examples of a correct and incorrect claim is shown below:
Correct claim
Date of Service
No of Days
Item No
Total Claimed
From
To
29 /01/17
30 /01/17
$
31 /01/17
04 /02/17
$
Incorrect claim
Date of Service
No of Days
Item No
Total Claimed
From
To
29 /01/17
30 /01/17
$
30 /01/17
04 /02/17
$
Number of days:Insert the number of occupied bed days being claimed. The first and last day of an inpatient stay are counted as one day in total.
Item Numbers:Insert the item numbers from your Agreement. Item numbers not within your Agreement cannot be claimed.
Total Claimed:Insert the accommodation amount claimed in accordance with contracted or negotiated rates.
Theatre Date:Insert the date the operation or procedure was performed.
Total Claimed:Insert the theatre amount claimed for each MBS item. Payment will be made in accordance with contracted or negotiated rates.
Procedure Item
No:Insert the appropriate MBS procedure item number and procedure fee item that are relevant to the service provided.
Prostheses:Use the Item Numbers issued by DoH in the Prostheses List. Prostheses should be charged at the DoH list price. The DoH Prostheses List can be found on the Department of Health website:
http://www.health.gov.au/internet/main/publishing.nsf/Content/health-privatehealth-prostheseslist.htm
Miscellaneous:This section is used for DVA miscellaneous items e.g. all M items. Do not include items of a personal nature such as newspapers, personal laundry, phone calls and television charges. These are not paid by DVA.
Principal ICD-10
Code:The Principal Diagnosis code describes non-surgical treatment and is always required where the Medical patient classification applies. This information is required to validate the group accommodation claimed within the Medical patient classification. This section should contain ICD-10 codes only (not DRGs).
Interim accounts:Tick Interim if this is part of a continuation claim. Tick Final if this is the only claim for the patients admission.
Separation code:Include the relevant code from the following list:
ADischarge by Hospital
BDischarge own risk
CTransferred to nursing home
DTransfer to psychiatric hospital
ETransfer to other hospital
FDeath with autopsy
GDeath without autopsy
HTransferred to other accommodation
IType change separation
RDeceased
SStill an in-patient
WNursing home
XOther hospital
ZHome
Admitted for treatment of:Insert the condition treated. Where additional space is required, please put details in miscellaneous box.
Name of treating doctor:Insert the name of the doctor providing treatment.
Place to which discharged:Indicate the place to which the person was discharged, e.g. home, aged care facility, family care.
Admission date:Insert the date the person was admitted. This information is also required for interim accounts.
Discharge date:Insert the date of discharge. If this is an interim account, leave the section blank.
Reference/invoice no: This information is optional, but will appear on the cheque statement if provided.
Patient Declaration:The patient must sign to certify services claimed have been received. If the patient is unable to sign, the patients agent or Authorised Officer must sign.
Claimant Declaration:The form must be signed by an Authorised Officer.
How to complete your claim
Disclaimer - The scenarios and rates included below are examples only and contain fictitious information developed to provide examples.
Claiming a complete episode
Example 1 - In the example below, a veteran was admitted on 1 March, 2017 for surgery for Intracranial Haemorrhage (MBS 39603). The veteran was discharged on the 20th day.
Date of Service
No of Days
Item No
Total Claimed
Theatre Date
Total Claimed
Procedure Item No
From
To
01/03/17
14/03/17
14
H255
$7,000.00
01/03/17
$500.00
39603
15/03/17
18/03/17
4
H255
$1,600.00
19/03/17
20/03/17
1
H255
$ 300.00
For this example item number H255 is an Advanced Surgery Group 5 accommodation band which has a step-downs on days 15 and 19. Consequently, the primary rate would be billed for the first 14 days (row 1 01/03/17 to 14/03/17), the first step-down rate would be billed for the next 4 days (days 15-18, row 2 15/03/17 to 18/03/17) and the final day, day 19, would be billed at the second step-down rate (row 3 19/03/17 to 20/03/17). The day of discharge is not payable.
Example 2 In the example below, a veteran was admitted on 1 March, 2017 for an acute Mental Health Episode of Care. The veteran was discharged on the 28th day.
Date of Service
No of Days
Item No
Total Claimed
Theatre Date
Total Claimed
Procedure Item No
From
To
01/03/17
21/03/17
21
H300
$9,000.00
22/3/2017
28/3/2017
6
H300
$1,800.00
In example 2 item number H300 is an acute psychiatric accommodation item with step-downs on days 22 and 43. Consequently, the primary rate would be billed for the first 21 days (row 1 01/03/2017 to 21/3/2017). The stepdown rate would be billed for the next 6 days (days 22-27, row 2 22/3/2017 to 28/3/2017). The day of discharge is not payable.
How to claim a Continuation claim
In the example below, a veteran was admitted on 1 March, 2017 for surgery for Intracranial Haemorrhage.
Date of Service
No of Days
Item No
Total Claimed
Theatre Date
Total Claimed
Procedure Item No
From
To
01/03/17
14/03/17
14
H255
$7,000.00
01/03/17
$500.00
39603
In the continuation claim example, the person has not been discharged on the 14th day. Therefore, the FROM date in the subsequent claim would be 15/03/17. In this instance the box should be ticked to indicate an interim account and S placed in the separation code box.
Is this account interim or final? Interim Final
Is this a readmission within 7 days? Yes No
Separation Code: S
How to claim a Continuation claim with leave day:
In the example below, a veteran was admitted on 1 March, 2017 for surgery and on the 6 March had a leave day returning to hospital on the 7 March 2017.
Date of Service
No of Days
Item No
Total Claimed
Theatre Date
Total Claimed
Procedure Item No
From
To
01/03/17
05/03/17
5
H266
$1250.00
06/03/17
06/03/17
1
H999
07/03/17
12/03/17
5
H266
$1250.00
In this example, the hospital is required to show the leave period by entering item H999.
How to claim theatre fees for multiple procedures:
DVA will pay theatre fees which include the cost of pre-operative purgative preparations, imprest medications and pharmaceutical products, dressings and consumable items in Table 4 of Part C, Schedule G: Hospital Services Fee Tables.
When multiple procedures are involved in an operation, the theatre fee will be payable as follows:
I. the first procedure will be paid at 100% of the applicable fee; and
II. the second, third and subsequent procedures will be paid at the percentages indicated in Table 4 of Part C, Schedule G: Hospital Services Fee Tables.
How to claim a case payment for Short Stay MBS Packages
Case payments for Short Stay MBS packages include all theatre fees and expenses, including consumables, together with same day or overnight accommodation not exceeding two days. For 3 nights or longer, or where critical care is administered, the package does not apply and the provider must claim per Diem (unbundling) and the relevant procedure fee.
In the example below, a veteran undergoes a Colonoscopy (MBS item 32090) on 1 March, 2017.
Date of Service
No. of Days
Item No
Total Claimed
Theatre Date
Item No
Total Claimed
Procedure Item No
From
To
01/03/17
02/03/17
1
H292
$1500
01/03/17
32090
In this example H292 is the DVA item number for the complete case payment as per Table 1 in Schedule 1 of your Agreement. The procedure item number should still be noted in the Theatre section. Additional theatre fees for multiple procedures can be billed at the relevant multiple discount rate according to your Agreement, if a case payment is claimed.
How to claim per Diem (unbundling) for Short Stay MBS Procedures
Date of Service
No. of Days
Item No
Total Claimed
Theatre Date
Total Claimed
Procedure Item No
From
To
01/03/17
02/03/17
1
H257
$800.00
01/03/17
$800.00
32090
03/03/17
05/03/17
3
H257
$1500.00
In the above example, a patient undergoes a Colonoscopy (MBS item 32090) however ultimately is an inpatient for four days. As the total admission exceeds two days this episode needs to be ignored and the accommodation according to the principal procedure applies together with the theatre fee as banded in the Group Accommodation and Theatre Banding (GATB) Schedule. To determine the appropriate accommodation and theatre rate payable refer to the GATB schedule and search for the relevant MBS item number. In this example, the accommodation banding for item 32090 is Surgical Group 1 and the theatre band is Band 2. Consequently, the prime accommodation rate at Surgical Group 1 (H257) is claimed for one day, the second stepdown claimed for 3 days plus the agreed rate for Theatre Band 2.
How to claim for Dual Banded items
MBS items numbers involved in the dual banding 40300, 40301, 40303 and 40306, 40309 and 40312. The dual banding means that a basic laminectomy is a band 6. However, if the procedure involves one or more of the indicators of high cost or complexity listed on the complexity certificate then a band 9 benefit is payable. Where payment for the higher band is claimed, complexity certificates should be completed and kept with the patients medical record.
How to claim an ECT as a day Patient
In the example below, a veteran was admitted 01/03/2017 as a Day Patient for ECT.
Date of Service
No. of Days
Item No
Total Claimed
Theatre Date
Total Claimed
Procedure Item No
From
To
01/03/17
02/03/17
1
H468
$500.00
For this example, item H468 is the item number for ECT as a Day Patient. No theatre is claimed because the H468 includes both Accommodation and Theatre.
Certain MBS Coronary Angiography items
When the (6) coronary angiography items (in the grey-shaded column below) were added to the MBS schedule, the National Theatre Banding Committee (NPBC) was unable to assign appropriate theatre bands to them and the items were not added to the GATB schedule. As these items were rollups/combinations of other existing MBS items, they could only be successfully processed by claiming the combinations of items which they were replacing. At that time the NPBC recommended that the accommodation group for each of the 6 items would be S2. Subsequently, a workaround has been agreed and implemented; these same 6 items have been added to the GATB schedule and should be claimed directly, but for full payment to occur ALL the items must be claimed from the relevant row of the 2nd column in the table. (The multiple procedure discount rules will then apply as per clause 17.11.2 of your Agreement.)
Rolled-up MBS Item No.
MBS/Theatre Band combination to be claimed by hospitals
(multiple procedure rules apply)
Surgical Accommodation Group
38225
38225 + 38220
S2
38228
38228 + 38222
S2
38231
38231 + 38222 + 38220
S2
38234
38234 + 38220
S2
38237
38237 + 38222
S2
38240
38240 + 38222 + 38220
S2
How to claim Overnight Dental
Date of Service
No. of Days
Item No
Total Claimed
Theatre Date
Total Claimed
Procedure Item No
From
To
01/03/16
02/03/16
1
H257
$400.00
Miscellaneous
M036
Where a patient is admitted for a dental procedure requiring an overnight admission item M036 is payable in relation to the theatre fees and item H257 (Surgical Group 1 accommodation) is payable in relation to the accommodation component of the admission. Package fees in Table 10 of your Agreement are not relevant. You should not include ICD or MBS on your claim for overnight dental admissions.
Admitted Same Day Rehabilitation Services
Admitted Same Day Rehabilitation Services must comply with the Guidelines for Recognition of Private HospitalBased Rehabilitation Services, as amended from time to time. Programmes for the delivery of same day rehabilitation services must be approved by DVA, and should be billed using the item numbers in Table 13 of the Agreement.
Any changes to an admitted same day rehabilitation programme must be approved by DVA, for example change to the length and frequency of the programme, the number of treatment hours, or the admission criteria.
Non-admitted Sessional Rehabilitation Services
Where a hospital has agreed non-admitted Sessional Rehabilitation Services (under Clause 4.26 of the Hospital Services Agreement) Hospitals should use the item numbers outlined in the table below:
DESCRIPTION
Item No.
Aquatic Physiotherapy (hydrotherapy) session supervised individual
HX021
Aquatic Physiotherapy (hydrotherapy) session supervised group
HX022
Outpatient Exercise Physiology
HX058
Outpatient Physiotherapy
HX027
Outpatient Occupational Therapy
HX028
Outpatient Dietetics
HX029
Outpatient Psychology
HX030
Outpatient Speech therapy
HX031
Outpatient Diabetes educator
HX065
Lymphoedema treatment inclusive of measurement and fitting of garments 1 set bandages First Session (exclusive of the supply of the garments)
HX001
Lymphoedema Maintenance (Subsequent session)
HX002
Non-admitted Sessional Rehabilitation Services may only be delivered to Entitled Persons who have previously undertaken an inpatient rehabilitation programme or same day rehabilitation programme as part of the treatment of that condition or the same episode of care.
Prior approval for the delivery of non-admitted sessional rehabilitation services is not required, except for treatment in excess of four weeks, or where the treatment is not otherwise covered by a programme agreed between the parties.
Accident and Emergency
Accident and Emergency item HX013 may be included in The Agreement where fees for these items have been negotiated with DVA. Item HX013 cannot be claimed if the patient is subsequently admitted to the Hospital for a related condition within the next 24 hours.
High Cost Medical Devices
DVA will meet the costs associated with the use of High Cost Medical Devices (HCMD) where it is considered not reasonably included in the theatre fees. As a guide, items valued at $250 or less would generally not be considered high cost. As all disposable and consumable items are considered to be included in the theatre fee payable for the procedure, the item should only be used in exceptional circumstances.
HCMD claims should only be used when a theatre or surgical package item is claimed. Claims for HCMD do not require prior approval. Claims are to be itemised (i.e. multiple items are not to be added together) and based on invoice price from the supplier. No handling charge is payable for the items. DVA has implemented a post payment monitoring regime to examine the nature and type of items claimed and reserves the right to view the relevant supplier invoices.
High Cost Robotic Consumables
DVA will meet the cost of the specific consumables associated with the use of robotic technology, on the basis of invoice fee from the supplier, with a pro-rata amount for multi-use items. When raising a charge for the robotic consumables the Contracting Entity must quote DVA Item number M201 for each item claimed. No additional high cost medical consumable claims under M152 will be paid when M201 is claimed. As a guide, items valued at $250 or less would generally not be considered high costs.
Calculating the day count
During some admissions there are circumstances where a patient might need to be reclassified, and as a result, the day count needs to be restarted. For example:
If an Entitled Person in the same hospital
Then
is discharged and readmitted within 7 days for a condition that continues to be described by the ICD describing the first condition
the day count continues
is discharged and readmitted within 7 days for a condition that is not described by the ICD describing the first condition
the day count starts again
has a second more complex procedure
the day count starts again at the higher classification
has a second less complex procedure
the day count continues at the previous classification
is interrupted during a rehabilitation program for either surgical or medical treatment and then returns to the rehabilitation program
the day count starts again for the continuation of the rehabilitation program
If an Entitled Person in a different hospital is
Then
transferred to another hospital for a more complex procedure
the day count starts again at the receiving hospital
transferred to another hospital for the same condition
the day count continues at the receiving hospital
transferred to another hospital where classification has changed e.g. to rehabilitation
the day count starts again at the receiving hospital
Certificates and Certification
There are a range of certificates available for hospitals to use:
D9076 Acute Care Certificate (PDF 212 KB)
D6345 Coronary Care Patient Certificate (PDF 169 KB)
D6346 Intensive Care Patient Certificate (PDF 174 KB)
Rehabilitation Program Certificate
Acute Care Certificates
These certificates are required for acute care patients once they have been admitted for 35 days. Leave days and periods between hospitalisation do not count towards the 35 day period. Hospitals should note:
If claiming an acute rate for a period beyond 35 days, an Acute Care Certificate must be completed by the treating Medical Practitioner and forwarded to DHS with the account for that period of stay.
If hospitals are using electronic billing, the Acute Care Certificate information can be submitted electronically, however, a hard copy must be retained on the Entitled Persons Clinical Record.
Hospitals can either use the DVA Acute Care Certificate or a similar form. Please do not send Acute Care certificates to DVA.
Where DHS receives a claim for an admission longer than 35 days without an accompanying Acute Care Certificate, the period up to 35 days will be paid at the rate claimed by the hospital and the period over 35 days will be rejected. This allows the hospital to either resubmit the claim accompanied with an Acute Care Certificate or alter the claim to indicate the appropriate non-acute NHTP rate.
Please Note: DVA will pay the basic daily care fee patient contribution for ex-Prisoner of War (ex-POWs) and entitled veterans awarded the Victoria Cross who are classified as receiving Nursing Home Type care in hospital.
Critical Care Certificates clinically justify the need for accommodation in a Critical Care Facility and list the required interventions and level of Nursing Care. There are two Critical Care certificates (Coronary Care and Intensive Care) that are available.
Where a patient requires critical care for 10 days or less a critical care certificate is required. Where the length of stay in the Critical Care Unit exceeds 10 days a subsequent critical care certificate is required. Certificates are to be kept on the patient file for audit purposes and should not be sent to either DHS or DVA.
Rehabilitation Program Certificate:
When a patient is admitted for an inpatient rehabilitation, admitted same day or non-admitted Sessional Rehabilitation programme, an appropriate Rehabilitation Programme Certificate must be completed and signed by a rehabilitation physician. At a minimum the Rehabilitation Programme Certificate should contain details of the treatment goals and indicative timeframes for the patients rehabilitation treatment.
The Rehabilitation Program Certificate must be kept with the Entitled Persons Clinical Record for audit purposes. An example of the current Rehabilitation Program Certificate template is available for hospitals to use and is available on the DVA website http://www.dva.gov.au/sites/default/files/files/providers/hospitals/rpc.pdf
Hospitals are reminded not to send the Rehabilitation Certificate to DVA or to DHS.
Day Only Procedure Certification and Overnight Stay Certification:
When a patient undergoes a Type C procedure within an acute facility, Day Only Procedure Certification must accompany an account. Certification must be provided on the Common Claim Form (known as the National Private Patient Hospital Claim Form), or the data elements required by the Common Claim Form may be submitted electronically if electronic billing is used.
Certification is not normally required for Theatre Band 1 admissions (e.g. chemotherapy, dialysis, etc.). On all occasions where a patient is provided with an anaesthetic as a day only patient, the details of the anaesthetic are required. Overnight Stay Certification is also required when a patient undergoing a Type B procedure who then requires an overnight stay in hospital. Both the Day Only Procedure Certificate and Overnight Stay Certificate should be sent with the Discharge Advice and Hospital Claim form (D653A) to DHS for claims processing.
Claims Stationery and Hospital Forms
DVA no longer supplies health care providers with manual Health Care Claim forms, making printable forms available online.
While DVA has moved to electronic claiming solutions, no changes to the claiming process have been made and the department will still accept the use of existing (and printed) manual claiming vouchers. If you would like to continue to use the manual claiming forms please self-print the DVA voucher(s) below:
D0652B - Hospital Admission Voucher
D0653A - Discharge Advice and Hospital Claim Form
Advertising
Advertising requirements are set out in clause 1.5 of your Agreement.
Advertising to Entitled Persons and others in relation to the awarding and operation of this agreement is permitted, subject to prior written approval of DVA. This is to ensure that DVA can consider any information issued with reference to the Arrangements which may be interpreted by DVA stakeholders as having reference to or the endorsement of the Department. It includes (but is not limited to) the following:
Letters to:
Veterans
Ex-Service Organisations
specialists and medical practitioners
allied health providers
Advertising in:
print and electronic media
journals and professional association newsletters
Ex-Service Organisation publications
pamphlets and brochures
You should discuss your advertising needs with your DVA Contract Manager, and provide them with a copy of all material that is published, for DVA records.
ATTACHMENT 1 Contact details for the Department of Defence Joint Health Command
Joint Health Command
Regional Health Service Queensland
Gallipoli Barracks
Lloyd Street
ENOGGERA QLD 4051
Phone: (07) 3332 4900
Point of contact for North & South Queensland
Joint Health Command
Regional Health Service Central & West
Leeuwin Barracks
EAST FREMANTLE WA 6158
Phone: (08) 9311 2832
Point of contact for WA, SA & NT
Joint Health Command
Regional Health Service Northern NSW
Defence Plaza
Level 17, 270 Pitt St
SYDNEY NSW 2000
Phone: (02) 9393 2518
Point of contact for Sydney metro/regional areas and northern NSW
Joint Health Command
Regional Health Service Victoria & Tasmania
Level 1, M Block
Victoria Barracks
256-310 St Kilda Road
SOUTHBANK VIC 3006
Phone: (03) 9282 7070
Point of Contact for Victoria (including Albury/Wodonga military area) and Tasmania
Joint Health Command
Regional Health Service Southern NSW
Duntroon Garrison
Morshead DriveCAMPBELL ACT 2612
Phone: (02) 6265 9413
Point of contact for ACT and southern NSW
ATTACHMENT 2 DVA Quick Contact List
Department of Veterans Affairs General Enquiry Line
1800 555 254
Press 1: Transport bookings and travel claims
Press 2: DVA Provider line
Press 3: For veterans to receive assistance with access to their online account
Press 0: All other enquiries
Department of Veterans Affairs Health Provider Line
1800 550 457 (follow prompts)
Press 1: Rehabilitation Appliances Program
Press 2: Veterans Home Care and Community Nursing
Press 3: Health Prior Approvals and enquiries, Card Eligibility checks, Provider Registration
Press 0 Transport and Pharmaceutical Enquiries
Press 1: Transport Enquiries and bookings
Press 2: Pharmaceutical Enquiries and to request an RPBS authority prescription approval
Prior Financial Authorisation for medical services
Please note: Fax contact is no longer available. Please email your request for prior approval to Health Approvals.
1800 550 457 (follow prompts)
Press 3: Health Prior Approvals
Email: [email protected]
Veterans Transport Services Booked Car With Driver bookings and Travel Cost Reimbursements/Claims
1800 555 254
Press 1: Transport booking and travel cost reimbursements
Pharmaceuticals
Veterans Affairs Pharmaceutical Approvals Centre (VAPAC)
1800 552 580 (24 hours per day)
Veterans and Veterans Families Counselling Service (VVCS)
1800 011 046 (24 hours)
Information Guide for Private and Mental Health Hospitals Page | 6