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This scenario applies at March 2014 but is subject to change by the Ministry of Health and / or EXACT upgrades. It is advisable to monitor EXACT software updates and MoH notifications.
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A 16 year old teenager at a local school requires treatment.
EXACT configuration requirements:
- A School must be defined for the patient. The school needs to have a valid TFEA (Targeted Funding for Educational Achievement) score, using the decile system of 1 to 10.
Select the school from the list to be sure that EXACT identifies it correctly:
- NHI (National health Index) numbers are required and should be entered in the NHI field to the right of the Ethnicity field in the Patient File.
- The OHSA payor should be set in the Payor field on the patient file (on the right side).
This causes any treatment plans created for this patient to have the OHSA Payor set by default.
Alternatively, the OHSA Payor can be manually set on each Treatment Plan at time of creation if the patient regularly receives a mix of private and public dental care.
NOTE: Such treatment cannot be mixed on any single treatment plan.
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- Create the Treatment Plan by means of
- +1 on the patient Chart in the Treatment Plan area, or
- Chart some treatment with auto-creation of treatment plans and appointments set in Configure > User Settings.
Treatment Plan example:
A common treatment plan is a DBCON1; the basic prerequisite consult for any further treatment.
It requires some other treatment item such as a DBFIL1 (a single-surface amalgam filling).The fee charted for this pair (DBCON1 plus DBFIL1) will show as a price for the DBCON1 and $0.00 for the filling.
IMPORTANT NOTES:
GST:
The amount displayed will include GST, while the amount claimed does not include GST – this often causes confusion.
TFEA:
The amount shown will vary according to the TFEA score (decile) of the relevant school. The higher the score, the lower the fee.
Amalgam work around:
At time of writing (March 2014) the OHSA do not pay for composite fillings; only amalgam fillings. As a workaround it is common for dentists to actually perform composite fillings but claim for amalgam fillings and make a note on the patient file. Then when the patient turns 18, they re-do the base chart to reflect that the fillings are actually composites. This is a work-around resulting from many dentists not doing amalgam fillings at all, but unable to claim for composite fillings from the OHSA.
- Perform the treatment.
The dentist / clinician performs the treatment and then ticks it as complete.
However, to be able to claim this treatment (via File > Payors (OHSA) > Claim button), the entire Treatment Plan must be TC’d (click TC button > Treatment Complete).
TIP:
The practice may wish to put just one appointment on a treatment plan and instead chart a series of 1-appointment treatment plans. Advantages: This enables speedy claiming and avoids long delays due to the patient being unavailable for subsequent appointments for completing the remainder of the work (in some cases the patient never returns). Keep in mind though that this may not be appropriate in situations where approval is required for a more complex treatment plan involving several appointments. Check with your local DHB as to the correct procedure in such cases.
- Process a claim for one or more completed (TC’d) Treatment Plans.
Go to the OHSA Payors page in EXACT (via File > Payors OR via the quick-list dropdown on the Payors icon on the Workspace (if this icon has been added to the Workspace).
In the OHSA Payor file, you can see existing claim “bundles” as well as any individual “TC” transactions that are not yet in a claim bundle.
A claim bundle is denoted by an icon with several pages in a stack and the description of the transaction is Oral Health Services Agreement. A single transaction is is a single page icon with a red TC next to it. If you double-click on either of these you will see the details of the records contained there.
- To claim, click the Claim button.
This causes EXACT to gather up any OHSA payor claim transactions into a bundle. You will be asked sequentially to Print, Preview or Close related forms. Click Close to move to the next form:
- Individual Claim Form for each patient in the new bundle. These will be printed sequentially until done, one at a time.
- The OHSA Claim Summary Form. This form summarises the total value and number of patients with the detail of the previous forms.
- Check these forms for accuracy, sign them where required and send to the appropriate address.
- If you need to reprint these forms, list the Payor transactions in the View Payor Transactions window, select the relevant claim bundle and select the Print This Transaction button at lower right.
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Charting and Charging Treatment
When charting OHSA treatment the ‘DB’ codes must be used in order for the Claim forms to print out properly. These codes correspond to the codes used on the OHSA forms, for example "DBCON1" - Consultation.
Entering OHSA Treatment for a Patient
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When the fee is calculated, EXACT looks at previous history to see if any of these services have been claimed in the past 12 months.
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Claims are created and printed from the Payor's Transaction window. EXACT collates invoices for the specified provider within a specified date range into a claim. The claim is then printed and sent in for payment.
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Processing Payments from OHSA
(for MoH payors such as OHSA, SBD, OHSA Exceptional Circumstances)
- Click File > Transactions > Payor Payments
The List Claims for Payment screen displays:
Select a Provider by means of the selectors or select Multiple Providers from the Multiple button :
Select single Provider
Select multiple Providers
- Select a Payor by means of the selectors .
- Select From and To dates:
- Click the View Claims button to List the Payor Claims, from where you can optionally process selected payments:
Checkbox
Use this to instantly fully allocate a claim. For the selected line item, this will change the Unpaid figure to 0.00, and the Received figure will be the same as the Total.
Date
The date the claim was TCed. This is the default sort order for the screen.
[Note]
If there is a claim note for the current claim, an icon displays in this column.
Hover your mouse over the icon to display the note text via a ‘tooltip’.
If more than one note exists, the tooltip displays the most recent note.
To read the note details, or to add or edit a note, click the Note button in the bottom right-hand corner of the List Payor Claims window.
Claim#
The Claim Number displays if the Payor requires Invoices to be sent in Claim Bundles (MoH Payors such as OHSA/SDB/OHSA Exceptional Circumstances).
TP#
The claim’s Treatment Plan number
Edit
If necessary, click this Edit button to open the Edit Payor Payment window, from where you can adjust the Amount Received to be less than what has been claimed for.
- To process a Payment amount that is LESS than what has been claimed for, click the e|d button and enter the amount received in the Amount Received box:
Note the instruction on this screen: If the amount paid is all you expect to receive click the Adjust button so that the Remainder is not left open. If you intend to chase the remaining amount, click the Leave button.
- Check (tick) multiple transactions for the Total to show in the bottom right corner:
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- From the Payor Transactions window, double-click the claim that requires adjusting to display the View Claims window:
Adjust button
Change the value of an invoice in the event that the fee for the treatment was entered incorrectly.
Transfer button
Charge the amount back to the patient.
Details button
Show the details of the current transaction. Double-clicking a transaction or clicking the button also performs the same function.
Insert button
Insert an invoice into a claim. This tool would be used to insert an individual Patient invoice into a claim after the claim has been created. For example, the wrong date range was selected or if an invoice was removed from a previous claim that needs to be reclaimed.
Clicking on the insert button will display any unclaimed patient invoices in the Payor Transactions window. Move through the list and double-click on the required patient invoice to add it to the claim. The balance of the claim will be increased automatically.
Remove button
Remove the selected claim item. This tool would be used when the payor has declined to pay for a patient invoice included in the claim.
Highlight the patient invoice that needs to be removed from the claim and click the Remove button. The patient's invoice will be moved out of the claim and back to the Transactions window where it can either be written off, transferred to the patient or reclaimed. The balance of the claim will automatically be reduced.
Delete button
Delete the selected transaction. In the event that the treatment was entered incorrectly (either the incorrect patient, treatment and/or fees), it should be deleted and re-entered correctly then inserted into the next claim.
- Highlight the patient invoice that needs adjusting.
- Click the Adjust button to display the Create Adjustment window:
- Click in the Adjustment Type field, then on the List button .
- If the Ministry of Health has paid less than the amount, select Invoice Refund and click the OK button.
- If the MOH has paid more, choose Invoice Correction and click the OK button.
- In either case, type the difference in the Amount field, and press the Tab key.
- Ensure the correct invoice is ticked, and click the OK button.
- Select the Close button to close the Payor Transactions window.
Viewing OHSA claim status
- Within EXACT, click Transactions > List Items > List Claims
- To see Patients/Invoices within a claim, double click the claim bundle.
Double-click a claim bundle that has an Open Amount against it (indicating that the claim bundle is still outstanding for payment).
The Patients/Invoices within the bundle display.
- Here you can add claim notes to the patient invoices if required: