Welcome to the Easy-claim operating guide

About this guide

The guide provides information to pharmacies who will be using ‘Easy-claim’ with Southern Cross. It includes step-by-step instructions and FAQs.

The information in this guide does not alter or amend the terms of the Southern Cross Health Society Easy-claim Agreement (Agreement) you have signed. Should there be any inconsistency between the terms of the Agreement and this guide, the Agreement will prevail, to the extent of the inconsistency.

Contact the Easy-claim team: Easy-claim Helpdesk: 0800 700 053Open 8am – 5pm, Monday to Friday (except public holidays). Please note that all calls to and from this number will be recorded.Fax: 07 959 7844E-mail: easy-claim@southerncross.co.nzClaims correspondence: Southern Cross Claims Centre, Private Bag 3216, Waikato Mail Centre, Hamilton 3240

1 About this guide
2 Contents
3 Introduction
- 3.1 What are the benefits for my pharmacy?
- 3.2 What are the benefits for Southern Cross members?
4 How does Easy-claim work?
5 Welcome to the world of Easy-claim!
6 Day-to-day Easy-claim processing
7 Enter a Member card number into the dispensary application
8 Easy-claim support Frequently asked questions (FAQs)
- 8.1 Easy-claim support/queries

Introduction

Easy-claim is a claiming process which pharmacies can use to help Southern Cross members claim electronically for eligible prescriptions. It allows members to claim at the time of purchase without having to complete a claim form. When a member presents their Member card for eligible prescriptions, the pharmacy can send an electronic claim to Southern Cross on behalf of the member. Within seconds, pharmacy staff can advise the member of the outcome of their claim.

The refund the member would normally receive from Southern Cross is paid directly to the pharmacy and the member just pays any remaining balance.

The normal claiming process requires members to pay for the prescription, collect their receipt, complete a claim form, and send it to Southern Cross to be processed. This takes much longer than electronic claiming.

Southern Cross Health Society is the first health insurer in New Zealand to provide members with pharmacy-based electronic claiming.

What are the benefits for my pharmacy?

More efficient service for patients who are Southern Cross members.• May improve patient loyalty to your pharmacy because it makes claiming easy.• If the claim is approved, Southern Cross makes a direct electronic payment to the pharmacy (a ‘cash-less’ process).• Positive brand association with Southern Cross.

What are the benefits for Southern Cross members?

Hassle-free electronic claiming at the point of purchase – no need for members to pay the entire amount up front or complete a claim form.• Members will be able to claim more easily for benefits they may not have claimed for previously (resulting in them getting better value from their Southern Cross policy).

How does Easy-claim work?

A Southern Cross Member card is required to make Easy-claim work. These are sent to all Southern Cross members over 16 years old. Some Southern Cross members may have the old blue ‘plus’ card and not the newly branded card as pictured above. Pharmacies may try to use the Member card number from the old card, but we recommend the member contacts Southern Cross to obtain their newly branded card – it is possible that their card number may have changed.

After completing the application form and configuring their dispensary system, the pharmacy will be ready to start using Easy-claim.

Entering the member’s details into the dispensary application along with the member’s 16 digit card number allows a prescription to be processed and then claimed with Southern Cross. It is that easy!

Welcome to the world of Easy-claim!

System configuration

Once Southern Cross has received and processed your completed application form and signed Easy-claim agreement, they will send you a Welcome email containing the following information:

User name.
Password.
Contracted Party number.
Provider number.

This information will need to be entered into your dispensary application to enable it to communicate with the Southern Cross system. Please follow these two easy steps to configure your system:

Enter the required information into the dispensary system

On the RxOne Start Menu, go to Tools, Options
Enter your Staff ID (if required)
Click the tab entitled ‘Disp switchboard’
Under the heading ‘Southern Cross’, enter the information provided in your Welcome email.

Test the connection to Southern Cross

Click Test Southern Cross. This will validate the username and password entered.

Successful test - If the test is successful, a green message will display confirming this. Click the ‘Exit’ button, then click ‘OK’ to close the Options menu and return to the home screen.

Unsuccessful test - If the test is unsuccessful, a red message will display explaining the error encountered.

• ‘Connection To Southern Cross Failed Check User Name And Password’ means the user name and password has been entered incorrectly. Click the ‘Exit’ button, resolve the issue and try again. If you continue to experience issues, call the Easy-claim helpdesk on 0800 700 053.• ‘Error Connecting To Southern Cross Webservice’ means there is an issue preventing your system from connecting to us. Check your computer is connected to the internet, then click Retest to try again. If you continue to experience issues, call HealthSoft on 09 300 7007.

Have you entered the correct Contracted Party and Provider numbers? The test function only validates your user name and password, so it’s imperative that you enter the correct Contracted Party and Provider numbers as per your Welcome email. If these numbers are entered incorrectly this will affect claiming.

Day-to-day Easy-claim processing

This section explains the day-to-day steps to be followed when processing Easy-claims. Easy-claim process overview

On the day of claiming

Counter staff receive the prescription and Member card from the patient and hand it to the pharmacy technician for processing.
The pharmacy technician enters the member card number (Southern_Cross,_Add_card_number.htm) and prescription into the dispensary application and the pharmacist dispenses the medications prescribed.
Counter staff process payment for the prescription in the point-of-sale system. The outcome of the claim will be shown on-screen and the member will pay any balance remaining.

The following day

Payment and a Remittance advice are sent to the pharmacy.
Confirmation (a Claims assessment advice) is sent to the member by Southern Cross.

Each step noted above has its own ‘section’ in this guide. At the end of each section, common questions and answers are listed which will help users understand the processes further.

Enter a Member card number into the dispensary application

Obtain the Member card and prescription

Counter staff will need to establish whether the patient is a Southern Cross member and if they have their Member card with them.
Not a Southern Cross member - Send the prescription for dispensing as normal.
Southern Cross member, no card - If the patient is accompanied by another person who is a member on the same Southern Cross policy (ie; a parent) you can use their card to look up the patient. Obtain their card and send it with the prescription for dispensing. - Otherwise, you will need to see the Member card for the first Easy-claim. Advise the member to bring their card next time or to contact Southern Cross if they need a replacement card, then send the prescription for dispensing.
Southern Cross member, with card - Obtain the Member card and send it with the prescription for dispensing.

Locate and edit the patient in the dispensary application

Open the dispensary application and search for the patient’s details.
Existing patient - Select the patient then click the Patient’s Dispensary Information tab.
New patient - Add the new patient then click the Patient’s Dispensary Information tab.

Add the Member card number

Click Edit > Card Information > Add Card details or simply right-click in the grey area below ‘Card Number’ and click Add Card details.
Enter the 16-digit Member card number into the field supplied then click OK.
If you have a Magnetic strip or barcode reader, you can either swipe the card or scan the barcode on the back of the card instead.
The Member card number will be populated into the Patient’s Dispensary Information as below.
As you click the options to the right of the screen i.e. Script, the dispensary system will connect to Southern Cross to validate the card number.
The details of all members on the same policy will be displayed, and the member matching the card number you entered will be highlighted.
Find your patient’s name in the list, click to highlight it, then click OK. If you used another person’s Member card number to locate your patient, the card number will be automatically updated to the correct card number for your patient.
If the name of the member you select is different to your patient, the dispensary application will prompt you to double-check and confirm. Using the wrong member’s card number will mean the claim is processed for the wrong patient and will delay the process.
Once the correct member has been selected, their card number will be retained in the Patient’s Dispensary Information tab for future claims until it is removed.

I receive an error message on validating the card number.

The Southern Cross system will validate card numbers for current active policies only – suspended or cancelled policies will not validate for Easy-claim.

Also, when a Member card has been reissued, the card number will change – so if the member is using an old Member card, but has been reissued with a new card, they will need to contact Southern Cross.

If neither of these situations apply, there may be a technical issue with either the dispensary application or the Southern Cross system. Refer to the technical support section at the back of this guide.

The member has presented a ‘plus’ card.

Some members may present an old blue ‘plus’ card and not the newly branded card. You can try to use the card number from the old card, but it is possible that their card number may have changed. We recommend the member contacts Southern Cross to obtain their newly branded card.

What if the member doesn't have a card?

If the member doesn't have their card, Easy-claiming is not possible. Advise the member to bring their card next time or to contact Southern Cross if they need a replacement card, then process the prescription normally.

Processing an Easy-claim prescription

Once the Member card number has been recorded, Easy-claim prescriptions can be processed.

Enter the prescription details.

Enter all of the appropriate details into the ‘Script’ screen as per normal procedure. (See also: Preventing a medicine from claiming at the end of this section.)
Click Finish. The dispensary application will then submit the Easy-claim to Southern Cross.

Interpret the claim outcome

Labels will print, along with two receipts.
The first receipt advises that the prescription is being claimed from Southern Cross and can be entered into the point-of-sale system in the absence of the second receipt.
The second receipt will print shortly after, and confirms one of four claim outcomes:
Southern Cross Pay in full
Southern Cross Part pay
Southern Cross Don’t pay
System Is Down/Unavailable

Process the payment in the POS system

Enter the prescription number into the point-of-sale system. Any contribution by Southern Cross toward the cost will be noted on-screen. Any balance not paid by Southern Cross will need to be paid for by the patient at the time of purchase.
Once payment has been obtained, the medication and receipt can be given to the patient and their Member card returned.

Preventing a medicine from being claimed

For various reasons a Southern Cross member may ask for a particular medication not to be processed as an Easy-claim. It is possible to set up the prescription so that it won’t be sent to Southern Cross.

Within the prescription window, click the Status tab
Un-tick the Southern Cross field to exclude the prescription item from claiming.
Continue with the prescription as normal.

Examples of Easy-claim receipts

This section explains the four Easy-claim receipt scenarios and relevant messaging to members when handing back their Member card and prescription.

Scenario 1: Southern Cross pays in full. ‘Patient pays’ $0.00.

Message to member from the pharmacy: “Here are your medications. There is no charge as your Southern Cross policy covers the cost of this prescription. Thank you and have a nice day.” “For more details about this claim you can call Southern Cross on 0800 800 181.”

Scenario 2: Southern Cross part pay

‘Patient pays’ is a partial payment of the total cost. This could happen for a number of reasons (the type of plan the member has, the amount of benefit they have left on their policy at the time of the transaction, etc).

Message to member from the pharmacy: “Here are your medications. The prescription in total costs $xxx, so there will only be a part charge of $yyy as Southern Cross has paid part of the prescription charge for you today. Thank you and have a nice day.” “For more details on this claim you can call Southern Cross directly on 0800 800 181.”

Scenario 3: Southern Cross don’t pay

Patient to pay the full amount.

Message to member from the pharmacy: “Here are your medications. Your prescription has been processed as an Easy-claim with Southern Cross, but there is unfortunately no immediate contribution provided towards your costs. You will need to pay the full amount for these medications today. Confirmation of whether or not Southern Cross will make a contribution will be sent to you.”

Scenario 4: System is unavailable/item not claimed

No Southern Cross messaging will be shown on the receipt. The item has not been claimed electronically therefore the member will need to send the receipt with a completed claim form to Southern Cross for reimbursement.

Message to member from the pharmacy : “Here are your medications. Unfortunately we can’t process your Easy-claim today due to a technical issue so you will need to pay the full amount for these medications. You will also need to send in a claim form with this receipt to Southern Cross.” “If you have any questions about claiming please contact Southern Cross on 0800 800 181.”

I didn't receive the result I expected. Can I try again? Please accept the result of what has come through and advise the member accordingly. Processing the claim again will create duplicate records and confusion for the member.

Why hasn't this been paid by Southern Cross?

Common reasons why a claim may not be paid (or be paid immediately) include:

there’s no benefit on the policy for the item or service being claimed
the annual benefit has been used up
policy premiums are not up to date
the value of the claim has exceeded a threshold and requires manual assessment by Southern Cross Claims Assessors.

Please do not try to explain to the member why Southern Cross may or may not have contributed to the amount due. We suggest the following wording be used where the member is concerned with the level of reimbursement:

“For more details about this claim, you'll need to call Southern Cross as we don't know the specifics of your policy. Their number is 0800 800 181”.

What if the system is unavailable?

If the system is unavailable, the member will need to pay the practice in store and manually submit a claim to Southern Cross.

Do all Southern Cross policies have prescription benefits?

It’s important to note that not all Southern Cross members will have pharmacy benefits, and even if they do, they may not meet the criteria for their claim for their prescription to be covered by Southern Cross. In short, the Member card does not guarantee cover.

Changing/correcting an Easy-claim script

Find the script in question in the current day’s Dispensary log or click View > Display Other Scripts to search for the script by date range or script number.
Click the script in the list to highlight it, then click Edit > Edit Script > Edit Script or simply right-click the script in the list then click Edit Script.
Update the prescription as required, then click Finish.
On completing the edit, the dispensary application will connect to Southern Cross to adjust the Easy-claim and updated labels and receipts will print.
- The first receipt advises that the prescription is being claimed from Southern Cross and can be entered into the point-of-sale system in the absence of the second receipt.
- The second receipt will print shortly after, and confirms one of four claim outcomes:
  - Southern Cross Pay in full
  - Southern Cross Part pay
  - Southern Cross Don’t pay
  - System Is Down/Unavailable
- Examples of these receipts are provided in the next section. You can use these examples to help interpret the different outcomes.

Payment outcomes for the Easy-claim adjustment depends on when the change was made:
BEFORE the Southern Cross payment was made (ie adjustment was made same day), the adjustments will be paid overnight with the new amount as appropriate. No payment adjustments are required and no documentation will be sent if there is no payment to be made by Southern Cross as a result of the adjustment.
AFTER the Southern Cross payment was made, adjusted payments will be processed and reversals will be taken from subsequent payments to the pharmacy. Documentation confirming the adjustment will be sent.

Can I use this process to try get a different outcome?

Please accept the result of what came through with the original claim and advise the member accordingly. Performing cosmetic ‘edits’ of the prescription in an attempt to force the claim through are not likely to be successful because there are numerous reasons a claim may not pay, and those reasons are not known to you.

Deleting/reversing an Easy-claim script

Find the script in question in the current day’s log or click View > Display Other Scripts to search for the script by date range or script number.
Click the script in the list to highlight it, then click Edit > Edit Script > Edit Script or simply right-click the script in the list then click Edit Script.
Click Delete. A prompt will appear as below – click Yes.
The dispensary application will update the script to reflect that it has been deleted, and in doing so will connect to Southern Cross to reverse the Easy-claim. No receipts or labels will be printed.
A prompt will appear to indicate the script has been deleted.
Southern Cross will deduct any amounts paid from subsequent payments due to be made to the pharmacy.

When might I use this process?

You may want to return medication to stock because it wasn't collected. You can do this as normal and the related Easy-claim will be adjusted automatically as appropriate. As this process is likely to happen after the initial claim/payment has been processed, the payment will be deducted by Southern Cross from the next payment due to the pharmacy.

Can I process a script to ‘test’ the system, the cancel it?

We do not recommend testing the processing of Easy-claims in a ‘live’ system. If you have processed a test prescription, it must be reversed using this process on the SAME DAY. Otherwise, payments will be processed and documents will be produced and sent to the member and pharmacy.

Receiving a remittance advice

Once an Easy-claim has been submitted to Southern Cross and processed, key steps are triggered - payment, and notification of that payment.
Any payments due are paid to (or reversals deducted from) the pharmacy overnight. Payments are made every day except Sunday.
This payment will trigger documents to be sent the following day. The member and the pharmacy will receive documents confirming what has been paid.
Members receive a Claim assessment advice either by post or via our online member portal, My Southern Cross.
Pharmacies receive a Remittance advice via post, email, or both. The Remittance advice will contain payments for all transactions that have been adjudicated successfully since the last payment was processed (and the last Remittance advice was sent).
Full reversals will show on both the Claims assessment advice and Remittance advice if the payment was already processed (ie reversals completed on the same day of the original transaction will not show on these documents).

Remittance advice examples

A Remittance advices is sent to the pharmacy once Easy-claims for the day have been paid.There are currently several methods for receiving a Remittance advice – via post, or email, or both. Emailed remittance advices will be sent in PDF format by default, but can be sent as a CSV file if your prefer. Below are examples of how these documents are set out.Posted / Emailed as a PDF (default option) Emailed as a CSV format fileThe file has headers that show what each field contains (see example below). If you’d prefer to receive your remittance advice in CSV format, contact the Easy-claim Helpdesk on 0800 700 053. They’ll update your requirements in the Southern Cross system.

How can I reconcile the Remittance advices with my bank statement?

Each remittance advice contains a unique EFT Number which will appear on your statement. You can use this number to assist you with reconciling the payments.

Easy-claim support Frequently asked questions (FAQs)

Here are some frequently asked questions that may help you assist Southern Cross members throughout the Easy-claim process.

What is my Member card number?

Your Member card number is on the front of your Member card. It is the 16-digit number which starts with 6101 11xx xxxx xxxx. If you do not have your card with you, or have misplaced it, you’ll need to talk to Southern Cross on 0800 800 181 to get a replacement.

Why do you need my Member card?

Can’t I call Southern Cross to get my Member Card number and provide that to you?

For your first Easy-claim with our pharmacy, Southern Cross have requested that we see your Member card.

I have my old blue ‘plus’ Member card – is that okay?

We can try to use it as your card number may be the same. However, it may not work (your Member card number may have changed if you’ve been issued with a new card from Southern Cross). You will need to call Southern Cross on 0800 800 181 to ask for a replacement card to be sent. Request a replacement for your old card if you have not received one already.

What type of policy am I on?

We can’t tell you what kind of policy you have. You will need to contact Southern Cross on 0800 800 181 for details about your policy.

Is my policy one that can make pharmacy claims?

For details on your policy you will need to contact Southern Cross. However the following policies/plans have pharmacy benefits:

RegularCare/RegularCare Budget
SuperCare
SureCare Concessionary
Wellbeing plans with Day-to-day care or Healthy Workplace modules
VIP 2+ / 3 / 4• First Cover 1+ / 2+
UltraCare

What happens if I only want to claim particular prescriptions/medications with Southern Cross?

This is possible. Our system can exclude particular prescriptions from the Easy-claim process. Just let us know when you give us the prescription for processing.

How was my refund worked out?

For details about the claiming process please contact Southern Cross on 0800 800 181. Our system works with the Southern Cross system and advises us how much Southern Cross will contribute based on your policy type and benefit available. For details about the claiming process and benefits under your policy, you’ll need to talk to Southern Cross .

Why was my claim declined? Why didn't Southern Cross pay?

We can’t provide you with details about the outcome of your claim. To discuss this information please contact Southern Cross on 0800 800 181.

Can you please call Southern Cross for me?

Southern Cross will require authorisation from you that I can speak on your behalf and they may ask me queries about your policy that I won’t be able to answer. It is likely to be much easier for you to contact Southern Cross directly on 0800 800 181.

If the system is unavailable, how can I claim?

Unfortunately, as the system is unavailable you won’t be able to claim via Easy-claim. You will need to pay your bill in full but keep a hold of your receipts so that you can claim manually with Southern Cross. You can do this by filling out a claim form and sending it to Southern Cross. If you have any questions about claiming please contact Southern Cross on 0800 800 181.

How soon will Southern Cross pay my claim?

When your Easy-claim is processed, your receipt will confirm how much Southern Cross will pay. This amount will be paid to us direct overnight.

I’ve changed my mind and don’t want to pick up these medications now – what happens to my claim with Southern Cross?

We can remove details of this prescription from our system – this will also reverse the claim with Southern Cross.

Will the Easy-claim process expand to other services?

Southern Cross has plans to use Easy-claim with other health related service providers.For any other general queries about Easy-claim from Southern Cross membersIf you have any questions or would like further information on the Southern Cross Easy-claim process, please call Southern Cross on 0800 800 181.

Easy-claim support/queries

To raise any queries you may have about Easy-claim: For any system related issues you have

Contact the HealthSoft team in the first instance on 09 300 7007. They will liaise with Southern Cross or other relevant parties to resolve the issue. It is possible that the Easy-claim system may be unavailable for use at times. If there is an outage initiated by Southern Cross, the pharmacy will be contacted by the Easy-claim Help Desk before the outage.

For any issues from customers/Southern Cross members – particularly relating to their Southern Cross policy, outcomes of the Easy-claim (e.g. Why didn't Southern Cross pay?) etc.

Ensure you use the ‘frequently asked questions’ in this guide to help you troubleshoot issues as much as possible. Please do not try to advise the member on issues about their Southern Cross policy, benefits or claims.
If you are unable to answer the query, and it‘s related to the Southern Cross member’s policy, ask the member to contact Southern Cross on 0800 800 181. This team will help the member with their query.
On the back of the Member card, there are details about how the Southern Cross member can contact Southern Cross .
If you need to contact someone from Southern Cross to ask a query related to a member interaction, contact the Easy-claim Help Desk on 0800 700 053 or easy-claim@southerncross.co.nz.

For any changes to agreement details (eg updated address details, change in bank account, etc.)

Contact the Easy-claim Help Desk on 0800 700 053 or easy-claim@southerncross.co.nz
Some changes may require forms to be filled in. The Easy-claim team will let you know if this is necessary.
You may need to alter information in your system to ensure Easy-claim processing can continue.

For any other queries or issues related to Easy-claim

For feedback, improvement ideas, operating guide updates, etc, please feel free to contact the Easy-claim Help Desk on 0800 700 053 or easy-claim@southerncross.co.nz

Southern Cross Easy Claim User Guide