Provider Payments - Claims, Provider Payments & Entitlements - Sector Services

Sector Services

Claims, Provider Payments & Entitlements

Provider Payments

FAQs

Who are providers?
What services does Sector Services provide for Providers?
What is Practitioner Registration and Maintenance?
What is Provider Registration and Maintenance?
What is Facility Registration and Maintenance?
What is claims and invoice processing?

Who are providers?

Providers include the following:
Individual health care Providers, such as nurses, midwifes, occupational therapists, physiotherapists, general practitioners, radiologists, and specialist doctors such as surgeons, obstetricians, gynecologists, and radiologists
Provider organisations, such as DHB’s, Primary Health Organisations (PHO’s), Community based providers, Non-Government Organisations (NGOs), medical practices, laboratories, pharmacies, home care services and hospitals.

What services does Sector Services provide for Providers?

Sector Services provides the following services for Providers:
Maintenance and distribution of services catalogues
Preparation of payment schedules

• Maintenance and distribution of entitlements payment schedules
• Receipt, capture, validation and processing of entitlements, registers, claims and invoices
• Payment processing
• Query and request management.

What is 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 (APC). APCs 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 APC 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 Services’s Agreement Administration team.

What is Provider Registration and Maintenance?

A Provider can be either an individual (with a valid APC) or an organisation employing one or more individuals (with valid APCs).
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 Systems.
Provider registrations and agreements are currently established and maintained by the Sector Services agreements management team on the Funders’ behalf. In the future, Funders may wish to administer their own agreements using online solutions provided by Sector Services.

What is 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 tax rates may apply.

What is 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 capitation 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 Funders behalf.

Please note: you should not rely solely on the answers provided here; the contracts applicable to each provider and all relevant legislation must be consulted to determine the full rights & liabilities applicable to any service provider or funder.