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eClaims are electronic claims - invoices that are sent via the internet to funders (medical aids and Injury on Duty funders).  eClaims have a number of obvious advantages over sending statements by post, namely:

  • Speed - claims arrive at the destination the same day.  Realtime claims can arrive within seconds!
  • Reliability - eClaims are guaranteed to arrive at their destination.
  • Cost - eClaims are actually substantially cheaper than "snail mail" (postal system).
  • Security - eClaims cannot be intercepted and viewed by unauthorized third parties.
  • Convenience - clicking a button is much easier than printing a statement, placing it in an envelope and licking a stamp.

You get the picture!

If you would like to know what an eClaims switch is and why you need it click here .

eClaims Destinations

In order to route eClaims a number of predefined eClaims Destinations exist.  These must be configured on each of your funders.  Click here  for more information.

How does it work?

In general the following steps are followed when sending eClaims:

  1. An invoice is captured by you for services rendered (and perhaps medicines and materials).
  2. At some point the eClaim is prepared and sent.
  3. The switch processes the eClaim and may accept or reject the eClaim (or individual lines in the eClaim).
  4. The eClaim is delivered to the eClaims Destination (e.g. medical aid).
  5. The eClaims Destination assesses the eClaim to determine if it should be paid, and how much should be paid.
  6. Some eClaims Destinations will send Assessment Responses indicating the results of the assessment.

After capturing each invoice Panacea will determine if the invoice should be sent electronically.  For details on how this decision is made click here .

If the eClaim is to be sent in realtime Panacea will take you to the Prepare eClaim tab .  See Batch vs Realtime below for more details.

If the eClaim is to be sent in a batch then you will need to go to eClaims - Send all unsent eClaims or Send unsent eClaims captured by you at a later stage - perhaps the end of each day - to send the eClaims that have accumulated into the current batch.

Switch Responses
Once eClaims have been sent to the switch they will be checked by the switch for validity.  Each eClaim line will either be accepted or rejected by the switch.  Accepted eClaims require no further action by you, but rejected eClaims must be fixed and resent.  For details on how the switch notifies you of rejections and how to rectify them click here .

Assessment Responses
Once eClaims have been accepted by the switch they will be delivered to the eClaims Destination.  This may be done immediately (if they are realtime-enabled) or it may be done at the end of the day.  Some eClaims Destinations are able to send Assessment Responses.  This means that once the eClaims Destination has assessed your eClaim they will send you the results of that assessment.  This includes messages indicating whether the eClaim has been accepted or rejected as well as the amounts that will be paid out.  For details on how Panacea notifies you of short-paid Assessment Responses and how to act on them click here .

Batch vs Realtime

Datamax supports two approaches to eClaims:

  • Batch - claims accumulate into a batch and are all sent together at the end of the day.
  • Realtime - each invoice is sent immediately (on it's own).  After capturing each invoice Panacea takes you to the Prepare eClaim tab  where you can check it and send it.  Note that if you do not send the eClaim on the Prepare eClaim tab  then it will automatically accumalate into your current batch.  i.e. you can actually decide whether each eClaim is sent in realtime while you work.

Panacea can be configured in various ways to suite your preference.  By default Panacea is configured to send each invoice immediately after you have saved it, i.e. in realtime.  This behaviour can be changed on the eClaims settings tab .

Once eClaims reach the switch they may or may not be delivered in realtime.  This depends on whether the eClaims destination to which it was sent is realtime-enabled.  It also depends on how many eClaims are in the batch.  If a batch contains more than one eClaim then it will not be delivered in realtime.

Notice, therefore, that realtime is always available between you and the switch.  i.e. the switch can always process your eClaim and respond immediately.  However, not all eClaims Destinations can assess and respond in realtime.  This is not particularly important for you to know.  Just be aware that you may not get Assessment Responses immediately from all eClaims Destinations.

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