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Patient verification functions help you claim successfully in Electronic Claim Lodgement and Information Processing Service Environment (ECLIPSE).
You can use online patient verification (OPV) to verify Medicare enrolment and private health insurer membership.
You can use online eligibility checking (OEC) to check the patient’s eligibility with their private health insurer and us, and get an estimate of out-of-pocket expenses.
We recommend you use:
- OPV before an appointment
- OEC before an anticipated admission date.
These checks will help you identify anything incorrect about your patient’s Medicare or private health insurer details or eligibility. Knowing this information will reduce the number of rejected claims.
Make sure you:
- get your patient’s consent or the consent of their legally authorised representative
- have your patient’s Medicare, Department of Veterans’ Affairs (DVA) or private health insurer details
- check the private health insurer uses ECLIPSE
- make sure your Practice Management Software has OPV or OEC functions.
Patient verification
You can use ECLIPSE to verify your patient:
- is eligible to claim Medicare or DVA benefits
- is known to the private health insurer
- holds hospital level cover.
This table gives details about the 3 types of patient verification.
| Type of verification | What it verifies | Response timeframe |
|---|---|---|
| Online Patient Verification (OPV) | There are 3 types of OPV:
| You’ll get a response in real time. |
| Online Veteran Verification (OVV) | An OVV confirms the accuracy of a patient’s details with DVA only. | You’ll get a response in real time. |
| Enterprise Patient Verification (EPV) | EPVs verify multiple patients. You can use them to request up to 1000 patient verifications in the one transmission. Each transmission can include multiple private health insurers. An EPV can confirm with us, the private health insurer or both. | You’ll get a response within 72 hours of submitting the request. |
You’ll need to retry the request later if we or the private health insurer:
- can’t perform the patient verification
- rejects part of the patient verification
- rejects the entire request.
Eligibility checking
Using ECLIPSE, you can check a patient’s eligibility for their Medicare and private health insurer status. You can also get an estimate of out-of-pocket expenses for hospital stays, prosthetics and miscellaneous items.
Use the OEC function to give the patient enough information for them to give informed financial consent.
You can submit an eligibility check for:
- anticipated admission date that is up to 12 months in the future
- emergency admission that was up to 7 days in the past.
If you submit an eligibility check for an admission date well into the future, you should check again before admitting the patient. This will pick up any changes in benefits that may impact on the patient’s out-of-pocket expenses.
You’re not required to submit an online eligibility check for DVA claims.
This table gives details about the 3 types of eligibility checks and who can use them.
| Type of eligibility check | Used by | What it checks |
|---|---|---|
| Online Eligibility Check (OEC) | Hospitals, day surgeries and health professionals | An OEC checks your patient’s eligibility for treatment of a presenting illness or condition on the admission date. The check includes their hospital insurance product, including:
The check also includes the medical services covered by:
An OEC checks hospital and medical eligibility with both private health insurers and us. |
| Eligibility Check Fund (ECF) | Hospitals and day surgeries | An ECF checks your patient’s eligibility for treatment of a presenting illness or condition on the admission date. An ECF only checks hospital eligibility. It’s based on their hospital insurance product, including:
|
| Eligibility Check Medicare (ECM) | Hospitals, day surgeries and health professionals | An ECM checks if Medicare benefits are payable for in-patient medical services. An ECM only checks Medicare eligibility. |