AS 4705-2003

Sets out guidelines for an EDI implementation that provides business and technical managers with an understanding of the scope of the simplified billing message for medical services and defines the basic data structure of a medical message for simplified billing.

This Standard defines the basic data structure of a medical message for simplified billing and suggests a method for billing agent implementation. The simplified billing message is designed to transmit claims relating to medical services and transmit information about the benefits paid. NOTE: A complete definition of Simplified Billing is given in Clause 3. Data element summaries are provided for: (a) Simplified Billing Medical Claim using MEDRUC (medical resource usage cost message) D.97B version. (b) Response to Simplified Billing Medical Claim using MEDRUC. (c) REDMADV (remittance advice message) D.97B version. MEDRUC and REDMADV are standard messages from UN/EDIFACT Directory D.97B. This Standard does not include claims for those hospital services (including theatre, accommodation, critical care, prostheses, pharmaceuticals, and other non-medical services) currently covered by the NCG hospital claim message. NOTE: Separation of hospital and medical claim data for the purposes of EDI does not preclude a billing agent from providing a single account for hospital and medical services to the patient if they are a hospital billing agent. The EDI data flows are independent of the final paperwork presented to the patient. Other business procedures that are outside the scope of this Standard are : (i) Health fund eligibility information for providers. (ii) Error information provided to the sender if data received is missing or corrupted. NOTE: This will be covered by an application error and acknowledgement message (APERAK) that will be the subject of a separate Standard. (iii) Financial/billing information internal to an organization such as a hospital. The data flows for messages within the scope of this Standard are defined in Figure 1 which shows the flows which may occur for simplified billing depending on what type of process is being followed. It covers the third party billing agent, medical purchase provider agreement (MPPA), HPPAs with Practitioner agreements and Gap Cover Schemes. The flows are self-explanatory and are implemented by utilizing the data formats set out in this Standard. NOTE: It will be necessary to contact the Health Insurance Commission to determine any special requirements that may need to be taken into account.

First published as AS 4705-2003.