Functions - Sector Services

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Sector Services
Functions

Agreement Administration

New Agreements Creation
New Agreements are created by Sector Services on behalf of the Funders and Ministry of Health. These agreements are based on standard templates. Variations to the Standard Terms and Conditions of these templates may be captured in the Provider Specific Terms and Conditions section of the Agreement. The Agreements support the relationship between the Funder and the Provider.

An Agreement Request Form is completed by the funder, with the requirements listed to enable Sector Services to generate the agreement. The form must be signed off by the person with appropriate delegation before Sector Services can action.

An Agreement is created by a member of the Agreement Administration team. All information from the Agreement Request Form is entered into the appropriate databases to ensure consistency of information captured and allow payments to be made.

Once the draft Agreement is completed and signed off by Funder it is sent to the Provider. The Agreement is signed by both parties (Funder and Provider). Once this has been completed and Sector Services have been notified, via the appropriate process, the Agreement is activated.

Agreement Renewal/Agreement Variation
Agreements can be established for a fixed term with the Funder having the right to renew/extend the end date. This is classed as variation to the Agreement and will require an Agreement Request form to be completed, which will be followed with appropriate documentation for both parties to sign off as agreement. A variation may also be used to add/amend services within the current active agreement.

A variation can only be actioned on an active agreement (ie original/previous version has been signed by both parties)

Performance Reporting
As part of the Agreement between Funder and Provider, there is usually a requirement for the Provider to report on the services being provided within the Agreement. The Performance Reporting Team (part of the Agreement Administration Team) is responsible for collecting Performance Reporting data from Providers. This includes sending out templates for Providers to complete with their reporting data, receiving and processing reporting data from Providers, and following up on overdue or incomplete reports.

Entitlement Management

Entitlement Management
An Entitlement is the right for a Health Care User to obtain specific health care services, or to claim for refunds or subsidised costs for a defined period.
The level of Entitlement (types of services or amount of subsidy) is established between a Funder and a Health Care User based on criteria such as health care needs and usage, income, travel and accommodation needs, and other legislated criteria.
In some cases assessments, which may include determining health care and financial needs, are performed by external agencies on the Funders behalf. Results of these assessments may be provided in electronic or paper form.
For certain entitlements, the rate the Funder pays is the contract rate less personal or benefit contributions from other sources. Therefore, the Entitlements Management process is required to record external contributions.

The Entitlement Management process supports:

Pharmaceutical, health care service and health care product entitlements
Mapping entitlements to National Health Index numbers
Definition of total service or product quantity, or total amount payable per period
Calculation of entitlement payments based on defined rules
The capture and tracking of usage in both volume, amounts paid and remaining balance
Expiring (renewable and non-renewable) and non-expiring entitlements
Recording of the interval for which the provision of services is valid (start and end date)
Recording events that terminate the entitlement (e.g. birth, age, death)
Capping of total entitlement by service for the recipient per period
Capping of services to the recipient by individual Providers per period
Different entitlement rates by District or Funder
Customisation of entitlement rates for individual recipients
Multiple entitlements per recipient
Capture of associated documents (e.g. Special Authority and Needs Assessment Forms)
Capture of individual contributions towards care and contributions made separately by other Funders (e.g. Ministry of Social Development).

Entitlement Types
A number of entitlement types are supported:

Adolescent Oral Health Enrolment – Dental patients between the ages of 13 and 18 are eligible for adolescent oral health services. In order to claim for these services, Dentists register the adolescents with Sector Services, and subsequent claims are approved against this register
Artificial Aids – Individuals that meet the criteria for subsidised artificial aids are entitled to receive an annual subsidy. Suppliers are reimbursed for the provision of these aids, funding of which is capped to an annual amount
Carer Support – The primary carer of an individual with special needs or disability is entitled to funding to employ a support carer to relieve them. The relief entitlement is typically funding for a capped number of days per year. General Practitioners and Needs Assessment Service Coordinators assess the level of support required.
Community Services Card or SuperGold Card – The Community Services Card or SuperGold Card are cards issued by the Ministry of Social Development, which provides card holders with subsidised health services. Providers indicate whether the patient holds a Community Services Card or SuperGold Card when claiming for additional subsidies.
High Use Health Card – is applied for by the Practitioner on behalf of health care users with high health care needs. The card entitles the user to subsidised health care services. Sector Services assess the applications to confirm they meet the required criteria, namely that the number of consultation visits exceeds a set amount for the condition. An extract is then sent to a bureau service, who issues the card. Capitation Based Funding processes use the register to validate the High Use Health Card number and calculate payments
Maternity Services – pregnant women are entitled to receive certain medical services which are currently funded by the Ministry
National Travel Assistance – individuals who need to travel frequently or long distances to receive public treatment may be eligible for travel assistance subsidies
Oral Health Services – Under an Oral Health Services Agreement, fully subsidised Oral Health Services are provided to (i) all adolescents between 13 and 18 years of age; and (ii) all children under the age of 13, who have been referred or officially released early from the school dental service as not being able to be treated by them due to medical or management reasons
Pharmaceutical Entitlement (Special Authority) – practitioners request access to and/or government subsidy on certain pharmaceuticals by submitting a Special Authority application to Sector Services on behalf of their patient for approval. On approval, a Special Authority number is created, which is subsequently used by pharmacies in the dispensing of the pharmaceutical
Primary Health Organisation entitlements - Primary Health Organisations are entitled to payments, such as Service Improvement Access and Rural payment entitlements. These entitlements may vary, depending on the type, location or stage of development of the Primary Health Organisation
Residential Care Assessments – assessments are performed to determine the level of residential care individuals require and the financial subsidy for which they are eligible. This may include individuals under 65 with intellectual or physical disabilities. Services may include home care services, rest home or frail care accommodation, and non 24 hour services such as day care and respiratory care
Rural Subsidies – to encourage practitioners to practise in remote areas a Rural Subsidy may be used to subsidise their income
Special Dental Services – Under a Special Dental Services Agreement, fully subsidised Oral Health Services are provided to, a) all children from birth until the end of school Year 8 enrolled with the school dental service; and, b) adolescents from and including school Year 9 up to their 18th birthday, who otherwise would not have access to their regular oral health services provider.

Entitlement rates may differ due to geographical location, patient need or defined criteria.

Entitlement Creation and Maintenance
Entitlement creation involves identifying the individual, establishing the list of services to which they are entitled, and the level of subsidy that will be provided by the Funder.
Many of the entitlements are reviewed periodically in order to retain eligibility and notification of expiry to the relevant parties is required. Certain clinical events, such as mortality, trigger the immediate expiry of certain entitlements. Data for this type of notification may be received by external systems.
In some cases new entitlements with new effective dates are generated from existing entitlements.

Entitlement Reporting
Entitlement reporting includes reporting on the following aspects:

Registration processing volumes – for process performance reporting
Balances of entitlement – for health care users.
Outstanding liabilities (including forecasting) – for Funders
List of registered members – for Providers and Funders.

In addition regular and ad hoc reports are provided to various requestors. These requests may include information such as registration, entitlement and claim volumes by demographic category.

For example:

Adolescent Oral Health Enrolments – The enrolment register maintains a list of current patients but does not record any balance information. Dentists periodically request their current patient list. Enrolment processing volumes are also included in HealthPAC’s monthly reporting
Artificial Aids – Balances are maintained and checked upon claiming or prior to provision of the aid
Carer Support – A new claim form with the remaining balance is generated and sent to the carer once a claim is paid
Community Services Card – HealthPAC’s monthly reporting includes the current number of active Community Services Cards and Community Services Card endorsed SuperGold cards
High Use Health Cards – HealthPAC’s monthly reporting includes the current number of active High Use Health Cards
Maternity Services – Reporting on pregnancy registrations, events and associated costs is required
Pharmaceutical Entitlement (Special Authority) – Patient and pharmaceutical lists are provided for registered Providers
Residential Care Assessments – Home care entitlement balances are provided on claim forms to health care users.

Entitlement Queries
Queries relating to entitlements and entitlement balances are handled by the contact centre or respective processing teams.

Member Registration
The registration process for each entitlement type varies but is intended to ensure correct identification and tracking of the details of the member’s entitlement. A brief description of each is provided below.

Adolescent Oral Health Enrolments – Dentists submit a dental enrolment form to Sector Services, who maintains the Dental Enrolment Register
Artificial Aids – Customers are required to provide Sector Services with medical certificates as stipulated in legislation in order to register for the subsidy
Carer Support – General Practioners and Needs Assessment Service Coordinators submit a registration form for Carer Support subsidies to Sector Services who enter the details in the Health Payment System. A pro forma claim form is sent to the carer containing details of the entitlement
Community Services Card – The Ministry of Social Development provide an electronic file containing a list of card holders, which is loaded in to the Health Payment systems. Subsequently, it is used to validate the Providers claims and calculate the payment amount
High Use Health Card – A register is maintained by Sector Services and applications are recorded in this register
Maternity Services – A New Registration (maternity) claim is submitted by a practitioner and is subsequently used to validate maternity services claims for each pregnancy episode
National Travel Assistance – Individuals apply to Sector Services to determine eligibility. If they are eligible for travel and accommodation subsidies they are registered in the Health Payment System and can claim for subsequent travel and accommodation expenses
Pharmaceutical Entitlement (known as Special Authority) – Practitioners request a Special Authority for individuals who require restricted pharmaceuticals or meet the criteria for higher subsidies on certain pharmaceuticals from Sector Services. Sector Services maintain a register of approvals and subsequent claims for the pharmaceuticals are validated against the register
Residential Care Assessments – Needs Assessment Service Coordinators provide electronic or paper forms which are entered into the Health Payment System. These forms include details of the service entitlements.

Registration Management

Practitioner Registration and Maintenance
In order to provide and be compensated for certain services, a Provider is required to have a valid Annual Practicing Certificate. Annual Practicing Certificates are provided by professional registration bodies, such as the New Zealand Medical Council, or the New Zealand Nursing Council, and these details are submitted to Sector Services.
Reference data containing Provider and Annual Practicing Certificate status information is submitted to Sector Services on a regular basis. This information is used to confirm the active registration of health Providers before approving and paying their claims.
Currently, the registration and maintenance functions are performed by Sector Service’s Agreement Administration team.

Provider Registration and Maintenance
A Provider can be either an individual (with a valid Annual Practicing Certificate) or an organisation employing one or more individuals (with valid Annual Practicing Certificates).
Details of these Providers are supplied by the Funder (usually a District Health Board) wishing to establish an Agreement with the Provider. The Provider details are captured in the Health Payment System.
Provider registrations and agreements are currently established and maintained by the Sector Services agreements management team on the Funders’ behalf.

Facility Registration and Maintenance
Certain agreements cover services provided at specific facilities, for example, the services provided at an Aged Care facility. Details about these facilities are captured and maintained to support the creation of payment schedules. These schedules list the patients being cared for at the facility and their services and subsidy entitlements.
Facilities may provide different levels of care for which different Goods and Services Tax rates may apply.

Funder Creation and Maintenance
Funder details, including contact names, address, bank account details and other required information such as company code for tracking payments in the financial system are setup and maintained in the Health Payment System.

Primary Health Organisation Registers
The registration of Health Users with a Primary Health Organisation is captured within a Primary Health Organisation Register. The Primary Health Organisation Registers are maintained by Providers online or directly via their Practice Management System, and contain clinical, geo-code and demographic information of their Primary Health Organisation Health Care User members. This information is used to calculate the amount of funding that Primary Health Organisations will receive through Capitation Based Funding.

Registration of Online Application Access
Providers are required to request access to online applications, for example Special Authority, by calling the Contact Centre and requesting an information pack and an application form. The completed forms are returned to the Contact Centre, which manages the end-to-end registration and setup process. The process includes arranging approval and access with:

The Registration Authority
Health Secure Network Providers
New Zealand Health Information Services.

Claims and Invoice Processing

Providers, suppliers and health care users submit claims, invoices and refund requests to Sector Services. For example:

Providers claim for health services and medication provided to health care users
Suppliers claim for products, generally artificial aids, that have been provided to health care users
Members of the public claim for refunds for health related costs, such as travel or accommodation expenses
Primary Health Organisations submit patient registers, which form the basis for population based funding calculations.

Sector Services process registers, claims, invoices and refund requests by:

Capturing and validating them against the Providers Agreement or against the health care users Entitlement, and against the business rules specified for each claim type
Generating Buyer Created Tax Invoices or Remittance Advices
Making payments on the Funder’s behalf.

Pro forma invoices for some scheduled payments are automatically created and sent to Providers for completion or correction prior to being submitted for payment. Residential Care pro forma invoices include a list of the residents in a rest home and their subsidy entitlement.

Claim Submission, Capture and Correction
Submission can be via:

Paper or paper based forms
Electronic files on diskette or Compact Disc
HL7
Electronic messages
Browser based or other file uploads.

Capture by Sector Services staff may involve the following:

Entering data from forms
Loading files from diskette or Compact Disc by selecting the file from the application file load menus or dialogs and setting load parameters.

Claim Validation
Claims and claim data are validated against:

Registers - such as National Health Index, Health Practitioner Index, Special Authority or Dental Enrolment
Entitlements – such as remaining balance for artificial aids
Historic claims – such as Pharmacy partial dispensing claims
Other criteria specific to each claim type.

Validation is performed for a variety of reasons, including the prevention of duplicate claiming and to ensure the accuracy of clinical data.

Customer Servicing Overview
Sector Services provides enquiry and request management services to support Health Payment processing. These services include:

A District Health Board Support Desk located in Wellington that manages specific informational requests from the sector and the associated delivery and billing
Contact Centres for handling telephone calls, email, postal and fax enquiries from the sector and the public relating predominantly to entitlements, registrations, claims and payments.

For additional information on the Contact Centres click the link below
Teams – this link will take you directly to the Teams pages

Payment Processing

Invoices captured in or generated by the claims processing system are scheduled for payment on a specific day depending on the Agreement terms.
Payments processing is performed daily by loading the scheduled invoices from the claims processing system and generating a payment instruction output file. The payment instructions are then uploaded to the Ministry’s bank for payment.
Payments are reconciled against the due invoices and exception reports are generated to support identification and correction of payment errors.

Financial reporting is provided to the Funders, including:

Short term cash flow forecasting to assist Funders with managing their funding accounts
Journal files for uploading to the Funders financial system
Standard general ledger financial reports to assist Funders with managing their budgets
Ad hoc reporting and data extracts for additional analysis purposes.

Page last updated: 8 October 2009