Medical aids are starting to check the ward rates that have billed on an account against the level of care that has been authorised.

In an effort to prevent claims from being rejected, Clinic Manager now checks all ward rates billed to an account against the level of care that has been entered.

How does the level of care check work?

1. Turn the level of care check on for individual medical aids

The level of care check can be turned on/off for specific medical aids.

It is advisable to keep it turned on for every medical aid, so as to minimise the chances of claims being rejected or short paid.

In order to check that the level of care check is activated for a specific medical aid, or to turn the level of care check on/off, follow the steps below:

• Click on Patient
• Click on Code File Maintenance
• Click on Medical Aids
• Click on Medical Aid Codes

• Select the medical aid from the list of available medical aids
• Click the Change button
• Click the Indicators tab
• Either place a tick or remove a tick from the Check Level of Care on Release box at the bottom of the browse.

2. Insert the level of care when entering authorisation details

When inserting a patient’s authorisation details in the Edit Patient Confirmation browse, the level of care must also be entered.

In order to enter the level of care, follow the steps below:

• Click on Patient
• Click on Patient Administration
• Click on Patient Details
• Click on Enter Patient Confirmation

• Select the patient from the list

The Enter Patient Confirmation browse will appear.

• Click on Insert

• Enter the authorisation details as provided by the medical aid.

Next to the Days Confirmed field, you will notice a Level of Care Detail button.

Click this button.

A new window will appear allowing you to insert individual ward rates based on the level of care.

In order to do so, click the Insert button.

Another window will appear.

Select the Ward Fee Group from the drop-down list and enter the number of days that have been authorised.

If the patient was authorised for a further number of days with a different ward fee (for example, if the patient was authorised to be in ICU and then authorised to stay in a recovery ward), repeat the above to insert another Ward Fee Group and enter the days authorised.

What this does is allow for individual levels of care to be entered for cases where a patient is charged different ward rates.

For example: if a medical aid authorises a patient to spend 1 day in the ICU and 3 days in Surgical, a case manager can enter the total number of days authorised (4) on the current authorisation screen, and can then further enter the 1 day ICU and 3 days Surgical authorisations individually.

3. Check the level of care in Room and Board

The level of care is now displayed in the Room and Board screen.

In order to view the level of care in Room and Board, follow the steps below:

• Click on the Room and Board icon

• Select a patient from the list

The Room and Board screen will appear.

You will notice that the Authorised Level of Care is now displayed, along with the Total Days Confirmed.

The individual ward rates that have been authorised are also displayed.

The user can now match the ward rates that have been authorised with the ward rates that have actually been billed to the account.

4. Release the account

When releasing an account, Clinic Manager will now check the level of care and match it against the ward rates that have been billed.

If the level of care and ward rates do not match, the account will not be able to be released.

The user will have to go to Room and Board (see above) and check the level of care against the ward rates that have been billed.