Our ECLIPSE service offers two claim options with various claim types, including 'Agreement' and 'Scheme' for No Gap and Known Gap programs.
Schemes and Agreements are separate claim processing classes and submitting a claim using the incorrect processing class may result in a declined eligibility check or claim. If in doubt, check with the PHI and your contract for the correct claim processing class.
For individual providers, the following typically applies:
AHSA funds except HBF use Schemes
ARHG funds use Schemes
Bupa only uses Agreements
Medibank and AHM use Schemes
HBF use Agreements
HCF uses both schemes and agreements*
NIB uses Schemes
*Depends on the enrolment, please consider the sections below.
Schemes
Used for most No Gap and Known Gap programs where a provider has directly enrolled with a PHI. This can include:
No Gap cover: where the patient doesn’t have any out of pocket expense.
Known Gap cover: where the patient has an out of pocket expense and the provider must provide written Informed Financial Consent.
Agreements
Usually where an organisation – a hospital or medical group - has signed an agreement with a fund. This includes:
Hospital Purchaser Provider Agreement/Practitioner Agreements (HPPA/PA): the combination of agreements between the practitioner and the hospital, and between the hospital and a PHI.
Medical Purchaser Provider Agreements (MPPA): an agreement between the practitioner and the PHI. Normally reserved for No Gap diagnostic services providers, hospitals and billing agents who represent pathology and radiology services.
Agreements may also permit No Gap and Known Gap billing arrangements.
If you have any questions, click on the pink chat bubble on our website or email our Customer Support team. Tyro Health also offers an extensive User Guide for ECLIPSE - you can also request this from our support team.