AHSA
Stands for Australian Health Service Alliance. The AHSA represents a number of registered Health Funds across Australia and is responsible for facilitating payment arrangements between hospitals, doctors and health service providers on behalf of these funds.
Participating funds
Fund List for AHSA
Access Gap Cover (AGC)
Access Gap Cover is the AHSA Participating Fund Gap Cover arrangement. It:
- enables Health funds to cover the medical gap without the need for a contract with the doctors.
- facilitates payment of the medical gap above the schedule fee (MBS) in a simple manner.
- allows for a Known Gap (limits apply) where written informed financial consent (IFC) has occurred.
- has different fees for each state.
- is reviewed on 1 July each year.
- allows for participation in AGC is on a patient by patient basis - doctors have the ability to 'Opt In' or 'Opt Out'.
Patient Co-payment facility
Access Gap Cover allows the doctor to charge their patients a co-payment if they wish to do so.
The total charge for the operation must be put on the invoice / claim to the fund (inclusive of any co-payment).
The co-payment is not claimable through any other source and the patient must be informed of this.
Calculation of Patient Co-payment:
The patient co-payment can be up to the difference between the AHSA benefit and the AMA fee but no more than $400 per item (scaled).
If the procedure does not have an AMA Fee, a maximum up to $400 may be charged to the patient.
Multiple Procedure Rule (MPR):
Medicare and the Health funds apply a percentage to each item number or service performed during an operation.
| First Service |
100% |
| Second Service |
50% |
| Third Service |
25% |
| Service thereafter |
25% |
The MPR is applied to the calculation of any patient co-payment.
TAC (Transport Accident Commission) is 100% and 75%.
ECLIPSE
Electronic Claim Lodgement and Information Processing Service Environment is an extension of Medicare Online claiming. It offers a secure connection between:
- health professionals
- public and private hospitals
- billing agents
- private health insurers
- the Department of Veterans' Affairs
- Medicare
ECLIPSE can be used for both paid and unpaid patient medical claims.
The Department of Human Services keeps information up to date on their website. You can view all participating health funds at:
https://www.humanservices.gov.au/organisations/health-professionals/services/medicare/simplified-billing-and-eclipse/resources/private-health-insurers-functions-and-contact-details
The section 'Contact details for private health insurers who use ECLIPSE lists the Health fund name and the Fund Brand ID. Use this information to cross check that you have the correct HIC Participant selected in your Health Fund configuration.
IMC PC
Stands for In-patient Medical Claim - Patient Claim.
IMC SC
In-patient Medical Claim - Scheme
IMC AG
In-patient Medical Claim - Agreement
Informed Financial Consent (IFC)
Written informed financial consent is required under Access Gap Cover if you are charging a gap to the patient. The estimate must include the patient and procedure details and details of any patient gaps must be clearly indicated.
GapCover
An arrangement a medical practitioner can participate in to reduce or eliminate a member's out-of-pocket medical expenses. Medical practitioners may choose to participate in GapCover on a case-by-case basis.
MBS
Medicare Benefits Schedule
MBS Online
This contains the Medicare Benefits Schedule (MBS), a listing of the Medicare services subsidised by the Australian government.
The Schedule is part of the wider Medicare Benefits Scheme managed by the Department of Health and administered by the Department of Human Services. MBS Online contains the latest MBS information and is updated as changes to the MBS occur.
Link to download the latest MBS Schedule
Medicare Online
This allows doctors to lodge patient, bulk bill and DVA claims via a secure internet connection.
It allows Online Patient Verification (of Medicare details) and Online Eligibility Verification (for DVA patients).
Patient verification
Confirms the accuracy of a patient's details with:
- Medicare only (Patient Verification Medicare - PVM)
- Private health insurer only (Patient Verification Fund - PVF)
- Medicare and private health insurer (Online Patient Verification - OPV)
These checks are done in real time, you will get back an immediate response.
Using patient verification and eligibility checking functions in ECLIPSE can help with successful ECLIPSE claim transmissions.
Out-of-pocket expense
The difference between the fee charged by a provider and the benefit Medibank will pay for the service, also known as a gap
90 day pay doctor cheque scheme
The scheme allows Medicare to cancel a patient cheque for some Health Professionals when they do not receive it, or it hasn’t been banked after 90 days.
How the scheme works
When a patient’s unpaid or partially paid medical account is lodged for payment, Medicare sends the patient a Pay Doctor Via Claimant (PDVC) cheque. The patient is required to forward the cheque to the doctor for payment of their invoice.
If the doctor does not receive the cheque or it hasn’t been banked after 90 days, Medicare can cancel it. The Health Insurance Act 1973 allows Medicare to pay the doctor the Medicare schedule fee by Electronic Funds Transfer (EFT).
