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Billing New Born / Unregistered Babies

The problem is

When claims are submitted via EDI before the baby has been registered as a dependant with the medical aid, then there are 2 possible outcomes.

Type A. If the medaid is one that requires the claim to be verified before it is submitted (eg Discovery) then Datamax will reject the claim. This will cause a problem in that if you wait too long before getting the info and resubmitting it then the medaid will say that they never received the claim and now it is too old.

Type B. If the mediad does its own verification of the claim (eg Hosmed) then Datamax will allow the claim through. The medaid will reject it but at least they will have a record of it so that when you resubmit it later it will not be old.

New Datamax functions

The new Dcomm v 403 interactive software has functionality that helps with this problem. Call them on 0860 515125 or get it from their website http://files.datamax.co.za/DCSetup.exe

Solution

  1. Set up a 'medical aid' with a code of BABY and a description of 'Baby unregistered' This medaid is obviously not switched on for EDI.
  2. Put all the unregistered babies on this mediad with the medaid name and number both in the number box. (These accounts will be printed at monthend (and will not be sent via edi) with any other non-edi accounts)
  3. Do a query on Dcomm for the claim. If the medical aid is on their list then this is a type A, Otherwise it is a type B.
  4. If it is a type A then check the check box on the "New Query" window that says "Notify me when this patient is registered with the medical aid". The support staff at Datamax will help you to set on the verify option that keeps looking for verification and/ show you how to check the results of your queries.
  5. If it is a type B you can immediately put the account to the correct medaid eg Hosmed and submit it but if the dependant is not registered the medaid will reject the claim. At this time you can either get the correct info from the parents and resubmit immediately, or put the account back onto the BABY medaid so that is treated as private like the other unregistereds.
  6. In the meantime you can monitor that your BABY accounts are not getting too old by running an ageanalysis for one medaid (BABY) and contacting the parents if neccessary.
  7. You should produce printed accounts for these slow registerers to remind them to do it. You can make a private msg esp for them too saying pse register your baby
  8. When datamax notifies you via a message that the Type A baby is registered, go into account details and change the acct onto the real medical aid (which you typed next to the number) and put in the baby name and dependant no
  9. Now this account will be included in the next batch