Claim Response

If an Electronic Claims response file (*.xml) has been obtained from HealthPAC, RxOne will read the XML file and load that information into three tables: Complete Report, Variance Report and Errored Item.

At the same time, appropriate information will be saved into the Database for display on the Claim Response Tab on each script. 

• Claim Errors Reports – It is important you check the report after getting the claim response for your claim.

• It’s much easier to keep up-to-date Remind your staff of errored scripts on these reports every time you get one..

• When accessing SmartClaim, RxOne will check  if the LAST Claim Errors Report has been reviewed. If the claim errors on your last report have not been marked as reviewed, then a message will come up with an alert. If this alert comes up, please do not ignore it.

Example of the message that may come up:  "There are 4 Errors in the last claim. 0 have been fixed. Please mark the remaining scripts as 'Reviewed' once you have corrected any problems."

• It is important that the Claim errors are checked before you do the next claim.  

• When you tick the buttons on the 'Claim' tab in the Script screen to send the script back into the claim, RxOne will automatically mark any associated claim responses as being reviewed and will show which claim they will be sent in.

Additional Notes

There is a column named Script/Service Type which shows the HPac Pricing Category for the script e.g. LTC, ARRC.

Initial claims where the amount paid is less than the amount claimed will show in red so can be easier to spot.  Check your Variance Reports regularly.

For a  ‘close control not ticked’ claim error, highlight the script and right mouse click to bring up a list of options and then select ‘Mark as Close Control’.

To process the Claim Response.

From the RxOne Start Menu, 'SmartClaim', 'Claim Response Tab', then 'Claim Response' button to process (if it is not automatically processed as below).

When accessing SmartClaim on the claim machine, RxOne will check if the last 8 claim responses have been received.  If not, it will then request a claim response from MoH Sector Services starting with the latest claim period.  Note that you can only request one claim response at a time. RxOne will request the latest claim response first and then will request the others when you go back into the claim again later.

To sort data by any column in three reports, Right Click on any column. Click once to sort by Ascending or Descending depending on the column. Clicking again will sort by different order from the previous click.

To Edit Double click any line on 'Errored Items' or click 'File' 'Edit Script' will go to RxOne Disp and open the Script so you can look, edit and reclaim if you wish.

To examine anytime

The "Claim Response" panel on each script displays brief information of the script about claimed.