Claims Processing System

The Claims Processing System processes approximately 98.9% of all claims within 30 days, with the majority being paid within 14 days. Processing times depend on the timing of the submissions and the complexity of the claims.

Payments are made at the middle and end of each month, either by electronic funds transfer or by cheque.

Claims processing involves four major sequential components.

Step 1: Pre-Edit

This component, which runs nightly against approximately 250,000 electronic (TelePlan) claims, performs the following tasks for each claim:

  • Verifies the billing number to ensure it is approved for that site.
  • Checks all fields to ensure the values have been submitted in the correct format and with valid codes (e.g., valid PHN, valid fee items).
  • Checks mandatory fields to ensure they contain data.
  • Rejects the claim if it does not meet these data requirements.
  • Codes the rejected claim to indicate the rejection reason and returns it to the submitter electronically.

Step 2: Eligibility Edit

This component, which runs nightly against both electronic (TelePlan) and online form submission claims, performs the following tasks for each claim:

  • Verifies the match between the PHN and the patient name.
  • Verifies that the amount billed is consistent with the fee item.
  • Verifies that the physician is authorized to bill for the service.
  • Rejects the claim if it does not meet these data requirements.
  • Returns erroneous electronic (TelePlan) claims to the submitter for re-submission.
  • Identifies rejected online form submission claims for manual review.

Step 3: Adjudication

This component, which runs twice monthly, uses approximately 5,000 automated payment rules in assessing claims:

  • Verifies billings of physicians that are dependent on other physician claims (e.g., surgical billing matches for anaesthetic and/or surgical assistant claims).
  • Provides electronic explanatory codes for adjusted or refused claims.
  • Fewer than 3% of claims are adjudicated manually.

Step 4: Payment and Remittance

This component, which runs twice monthly, performs the following tasks with each run:

  • Processes over 2.5 million claims from 10,000 practitioners.
  • Processes all third-party and audit-recovery items.
  • Handles adjustments that may be applied to gross payments, including retroactive payments, interest, carrying changes and GST charges.
  • Approximately four days prior to remittance date, sends electronic remittance statements to submitters, advising of payments to be made on the remittance date (this does not occur for forms sent through online submission.)

This component also contains the Broadcast Message program.

Zapping Claims Submitted in Error

If you discover that your Teleplan submission contains incorrect billings, you can arrange to have the submission returned to you for correction before it is processed if you notify the Teleplan Support Centre by 5:00 pm on the same business day that you made the submission.

The entire submission will be "zapped" and returned the next day with the explanatory code FC. You can correct and re-submit the claims immediately.

If you discover an incorrect submission after the transmission day but before MSP closes off a claims period to process payments, you may still contact the Teleplan Support Centre for assistance. You will be asked to identify the specific claims by Data Centre, Payee Number and Sequence Number. These records will then be rejected, but will not be returned until after MSP has issued your next remittance statement. Again, the explanatory code FC will be used for the returned claims.