Health Fund Claiming - AU

How to send Health Fund claims

Shelley Withington avatar
Written by Shelley Withington
Updated over a week ago

Dentally Australia currently supports HICAPS and Tyro options for Health Fund claims. The claim process is the same for both options however practices will need to set up the option they use in Dentally for the claim to be sent to the correct terminal.

Setting up the Health Fund Claim Option

To set up the relevant option the practice uses to process Health Fund Claims go to Settings < Sites and select the relevant site (if you have more than one). Navigate to Health Fund Claiming. Click on the down arrow and select either Tyro or HICAPS.

Select Save.

Note: Ensure that your HICAPS / Tyro terminal is connected. Please contact support if it's not connected yet or if you are unsure if it's connected.

Sending an Electronic Claim

To send an Electronic Claim, ensure the set up covered above has been completed. This process simply involves selecting which item codes to include in the claim and then clicking Send. This will send the procedure codes through to the terminal, swipe the patient's health fund card when prompted, once the claim is successful the completed claim information will be returned to Dentally.

To get started, the user can either click directly onto the New Claim button or click the drop-down arrow and select Electronic.

Electronic claims

Once the claim dialogue box appears, the user needs to tick the claim items that are going to be sent as part of this claim.

Only a single provider or a single payment plan (health fund) can be sent at a time in a single claim - so once the user begins ticking procedure codes, any other codes that don't have the same provider or payment plan will be filtered out from selection (greyed out).

Once all the procedure codes have been selected, the user can simply go ahead and click Send.

Don't forget to check the Health Fund Patient ID is correct before processing the claim.

Once this has been entered, then a prompt to swipe the patient's health fund card on the terminal will appear. Once the claim is successful, this information will be returned to Dentally. There will be a final on-screen dialogue box detailing the key information about the claim and the user will simply need to click Finish.

electronic health fund claim

Upon completion, a payment line will then appear within Dentally to display the amount covered by the claim, deduct this amount from the total balance, and allow the remaining gap balance to be processed via normal methods.

Saving a Manual Claim

A patient will have their claim manually entered (and completed) directly on the HICAPS terminal, and then the receptionist will simply enter the claimed amounts manually into Dentally afterwards so a record of the claim is maintained.

To get started with a manual claim, simply click the drop-down arrow next to the New Claim button on the patient's Account screen:

manual claims

Once the Claim dialogue box appears, the user simply needs to enter in the health fund rebate amount into the Rebate Amount field/s.

manual health fund

Within this dialogue box, you're able to see both the associated Provider and the associated Payment Plan. You are only able to send (or enter) a claim for:

  • A single Provider at a time

  • A single Payment Plan at a time

Once you begin ticking items that you want to save a claim for, Dentally will automatically grey out procedure codes that either has a different provider or payment plan associated so no errors ensue when attempting to save or send a claim.

In the case of having to complete multiple claims, the user will have to first complete a single claim, save it, and then complete the second claim.

managing clains

Once the procedure codes have been selected, simply enter in the Rebate Amounts that have been covered (based on the already completed claim from the terminal) and then click Save.

Once saved, a payment line will be entered into Dentally displaying the amount that was covered by the health fund, and deduct this amount from the total balance. Process the remaining gap payment using the Take Payment button.

payment in claim making

Viewing a Completed Claim

Additional details about any completed claims can be viewed by simply clicking the View hyperlink on the Claim payment line.

oayment claims

Once opened, you will be able to view the Provider associated with the claim, the type of claim (electronic or manual), the Health Fund the claim was completed with, the date and all specific line items within the claim along with their associated rebate/s.

health fund claims

Cancelling a Claim

Claims cannot be deleted in the same process that a payment can be deleted, they must be cancelled first. This is to ensure there is always a clear audit trail for practices to review if required (especially if a patient has a query in regards to their claiming history or benefits).

As a result, the usual bin icon that appears on unexplained payments does not appear on any claim payment lines, instead, this is replaced with a cancel icon.

take payment claims

To cancel a claim, simply click this icon and select Cancel Claim. For Manual Claims, you are only able to complete a Manual Cancellation. For Electronic Claims, you can complete either an Electronic Cancellation or Manual Cancellation.

Claim Cancellation Timing:

Depending on if a claim is cancelled on the day of its creation will determine the claim is cancellation process.

Day of Claim Creation:

When a claim is cancelled on the day of creation, the claim payment will be automatically deleted from the patient's Account tab. Record of the cancelled claim will remain on the Patient's Claim tab as shown below as well as in the Audit log.

After the day of Claim Creation:

To ensure that financial records maintain consistency, if a claim is cancelled after the day of claim creation, the claim payment will not be deleted automatically. Instead, a reversal 'claim cancellation' payment will be created and shown in the patient's Account tab. This payment will show the negative value of the initial claim amount to balance the patient account. This ensures that record keeping is accurate, tracking the incoming and outgoing of the claim rebate.

In the example below a claim with a rebate of $60 was cancelled and a claim cancellation payment of -$60 was created and automatically explained to the patient's invoice to balance the patient account.

Note that the summary text of the two claim payments details which payment is the initial claim amount, which is the claim cancellation amount.

Adjusting Cancelled Claim Payments:

If further corrections are required to adjust a cancelled claim payment, Dentally allows you to un-explain (and re-explain) the payments or to delete the payments altogether if required.

Un-explaining claim payments:

When making changes to an invoice that is locked by a cancelled claim's payment, simply click the unlink icon (shown in red below). This allows you to un-explain (unlink) the claim payment from the invoice, you may then adjust the invoice as required and re-explain the payment.

Deleting claim payments:

To delete the cancelled claim payments altogether, click the trash can icon (shown in red below). Reminder - the claim payment will need to be un-explained (unlinked) first in order to delete the claim amounts. This functionality is only available if Payment Locking is not enabled for your practice.

Note: All cancelled claims are associated to two payments, the initial claim amount and the reversal claim cancellation amount. Deleting one payment will trigger the deletion of both payments associated to the cancelled claim; this is done to keep the patient account and records balanced. This will be confirmed with you as shown below before deletion. Once this is complete, record of the claim will remain on the Patient's Claim tab as shown below as well as in the Audit log.

Claim Cancellation Types:

Manual Cancellations:

A Manual Cancellation involves only cancelling the claim in Dentally. It will reverse the claim amount and display a cancellation line to reflect this change. Reminder - you will need to contact Hicaps/Tyro to arrange cancellation of the claim with the Health Fund.

Electronic Cancellations:

An electronic cancellation involves a message being sent to the terminal and when prompted swiping the patient's health fund card. This method can only be completed if the patient is in the practice with their health fund card available to swipe. Once the cancellation has been approved, this will also be reflected in Dentally.

NOTE: Dentally will only let a user cancel a health fund claim electronically (i.e., through the HICAPS terminal) if it is on the same day of the claim creation. If it is not on the same calendar day, then the user will need to process a manual cancellation instead.

Note: Claims can also be cancelled by clicking on the View hyperlink and then clicking the Cancel Claim button.

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