GENERAL OPHTHALMIC SERVICES GUIDELINES FOR MAKING CLAIMS

Transcription

1 GENERAL OPHTHALMIC SERVICES GUIDELINES FOR MAKING CLAIMS

2 GENERAL OPHTHALMIC SERVICES EXAMPLES OF SYSTEMS DOCUMENTATION AND STANDARD OPERATING PROCEDURES CONTENTS: A INTRODUCTION Page 3 B PRACTICE ADMINISTRATION Page 4 C SIGHT TESTS Page 5-7 D VOUCHERS Page 8-10 E REPAIRS/REPLACEMENTS Page F VERFICATION OF PRESCRIPTIONS Page 13 G CONTACT DETAILS & REFERENCES Page

3 A: INTRODUCTION It is strongly recommended that all Optometric practices introduce procedures within their practices to support claims made in respect of provision of General Ophthalmic Services. The following guidance has been issued to assist in the implementation of this specific recommendation. The systems documentation illustrated is for reference and it is recommended that all practices should adapt this guidance to ensure that it reflects the procedures which apply within the practice. The guidance is general and is not intended to be prescriptive or cover every situation for every practice. The type of documentation illustrated is a common feature in systems and is particularly important where systems are operated by one or two individuals, as often happens in smaller organisations. The regular updating of systems documentation and procedures avoids the risk of systems not being operated correctly, particularly in the event of key staff not being available or due to staff turnover. Reference should be made as necessary to the General Ophthalmic Services (Amendment) Regulations 2007, Memorandums for General Ophthalmic Services (MOS) and the Guidance for Optical Point of Service Checks. The Association of Optometrists have issued a booklet called Making Accurate Claims in Northern Ireland which is a useful tool for all Optometric Practices. In the event of uncertainty when submitting claims for General Ophthalmic Services please contact the Ophthalmic Services Directorate in the Business Services Organisation (BSO) or an Optometric Adviser in the Health and Social Care Board (HSCB). 3

4 B: PRACTICE ADMINISTRATION General: 1. In accordance with the General Ophthalmic Service (Amendment) Regulations 2007 records kept in respect of all patients to whom General Ophthalmic Services have been provided must be retained for a minimum period of seven years from the last date of service. This also applies to those patients who are deceased. Recent guidance issued by the HSCB MOS/272 (June 2012) advises longer periods of record retention in respect of various categories of patients. 2. All claim forms processed should be securely kept to avoid the risk of claim forms being lost or misplaced. 3. Prior to submission all claim forms should be checked for accuracy and completeness. Where possible this should be carried out by someone independent of the person who completed the claim. A check should be made to ensure that the appropriate person(s) have signed the claim forms. 4. Practice staff should NOT sign claim forms on behalf of patients, if in doubt contact the BSO or HSCB for advice. 5. A record should be kept of all claims made to the BSO for payment to ensure that full payment is received. It is recommended that a database is kept to include the specific details of individual claims patient name, date of service, service type and the payment due in respect of that service. 6. Claims should be submitted to the BSO by 12 noon on the 10 th day of each month for payment at the end of that particular month. The claim forms should be sent by recorded delivery or be hand delivered. The BSO will not take responsibility for claim forms sent in any other way other than those listed above. 7. The claims submitted to the BSO should be reconciled with the payments received at the end of each month. All discrepancies should be followed up in writing to the BSO as soon as possible. 4

5 C: SIGHT TESTS Exemption Criteria: 1. The categories of patients who may be entitled to an eye examination under General Ophthalmic Services should be known by ALL members of staff and this information should be updated if and when the categories of exemption change. It is the responsibility of the practice to ensure that these updates are implemented to comply with future changes. 2. In normal circumstances the BSO will accept payment for sight tests in accordance with MOS/275 Optometrists should however use their own clinical judgement to determine if a sight test is appropriate when presented with a situation where the sight test does not fall within the time intervals / categories stated in MOS/ Where a sight test is required for clinical reasons within 3 months of the original sight test, in line with MOS/275 approval / authorisation must be sought from an Optometric Adviser via the BSO and the GOS(NI)ST must be clearly annotated with the clinical reason for the early re-test and the approval / authorisation number given by the BSO. 4. The guidance above sets out the circumstances under which the BSO will accept payment for a claim without further justification. General: 1. It is recommended that when a booking is made for an eye examination the name and address of the patient should be detailed via the relevant appointment system. 2. Where an appointment is made for a domiciliary eye examination the patient must be asked to confirm why they are unable to attend the practice for the eye examination. The patient s clinical record should be annotated with reference to the domiciliary visit. 5

6 3. Patients should be advised to bring their Health and Social Care number / National Insurance number and all relevant details to support their claim for eligibility for General Ophthalmic Services. 4. Patient details and clinical records should be made available to the Optometrist at the time of the appointment and the date the patient is seen should be recorded on the clinical record. 5. The Optometrist should record full and complete clinical findings on the patient s record card for all services provided at the practice. The Optometrist should always ensure that the outcome of the eye examination is annotated clearly on the clinical record card. Full details of the reason for prescribing spectacles and the reason for tint prescribing (if applicable) must be noted on the clinical record. 6. It is recommended as good practice that the Optometrist signs or initialises the clinical record as an indicator of who has conducted the eye examination. This is particularly important in practice where there are several Optometrists working on the premises. 7. As noted in the section on exemption criteria if an early retest is necessary for clinical reasons then the GOS(NI)ST must be annotated to this effect and comments should be noted in the remarks box on the claim form. Detailed justification should always be recorded on the patient s clinical record. Completion of GOS (NI) ST claims forms: 1. After the eye examination the GOS(NI)ST should be completed including the patient details and outcomes based on the information recorded on the patient clinical record. The address /practice stamp should be annotated in the appropriate section. 6

7 2. If the patient is entitled to a GOS sight test on medical grounds e.g. diabetes or glaucoma then the name and address of the patient s GP / Hospital Consultant should be recorded in the appropriate box. 3. Patients should be asked to sign the declaration of eligibility on the GOS(NI)ST to confirm they are eligible. Where a patient under 16yrs has been examined the parent/guardian/ person in charge should sign the claim form. 4. Patients must be asked to show evidence to support their claim in line with the guidance for Optical Point of Service Checks and the appropriate exemption category should be ticked on the GOS(NI)ST form. If the patient is unable to produce evidence to support eligibility, then under the Exemption Check section, the box Evidence not seen should be marked by the practice with an X. 5. As mentioned previously in situations where an early re-test has been undertaken then the remarks section must be completed accordingly. 6. Details on the GOS(NI)ST should be checked and signed by the Optometrist after the eye examination. 7. GOS (NI) ST claims must be submitted within 6 months o f the date of service. Details of the claim form should be recorded in the claims database referred to earlier (Practice Administration Point 6). 8. The remarks section on the GOS (NI)ST can be used where appropriate to note other relevant information relating to the GOS(NI)ST claim. This is relevant where a domiciliary eye examination has been undertaken. 9. Where a domiciliary eye examination has been done the address at which the eye examination was carried out should be recorded in the appropriate section on the GOS(NI)ST claim form. If the patient was the 1 st or 2 nd tested at the time, at that address, the character 1 should be recorded in the domiciliary sight test box on the GOS (NI) ST claim form. For 3 rd or subsequent patients seen at the address the character 2 should be entered. 7

8 D: VOUCHERS Exemption Criteria: 1. The categories of patients who may be entitled to a voucher under General Ophthalmic Services should be known by ALL members of staff and this information should be updated if and when the categories of exemption change. It is the responsibility of the practice to ensure that these updates are implemented to comply with future changes. General: 1. Following an eye examination, if a patient is issued with a GOS(NI)V there are 2 options available to the patient: a) The patient may choose their new spectacles/contact lenses in the practice that issued the voucher, within a maximum 2yr period from the date of issue. If this is the case then the GOS(NI)V form should be completed in the normal manner and submitted to payment AFTER the appliance has been dispensed. b) The patient may take the GOS(NI)V to another supplier. In this instance only Parts 1 and 2 should be completed by the issuing practice. No voucher claim should be submitted for payment in these circumstances by the practice that issued the GOS(NI)V. 2. Where patients take their GOS(NI)V to another supplier to have their spectacles/ contact lenses dispensed only Part 3 of the GOS(NI)V should be competed by the supplying practice with the claim form being submitted in the usual manner. 3. It is important that the practice ensures that any GOS(NI)V submitted is valid i.e. within a period of 2yrs from the date of issue. It is also important that the practice ensures that the claim form is correctly completed. 8

9 4. If spectacles / contact lenses are ordered, the workshop order form or relevant documentation should be retained as a means of or to assist with post payment verification of service provision. 5. Where a claim for Small Glasses is being made the Optometrist or Dispensing Optician must ensure that the frame is eligible according to the criteria for the small frame supplement (SFS). 6. In exceptional circumstances where the Optometrist or Dispensing Optician believes that a SFS is required to fit a child accurately with spectacles BUT the criteria for SFS do not apply then approval must be sought from the BSO/Ophthalmic Adviser in advance of issuing or claiming a SFS. 7. When spectacles / contact lenses are ready for collection and the patient has been notified, the patient record card should be annotated. 8. When dispensing has taken place the patient record card should be referenced to this effect e.g. the date of collection and amount paid (this should include the GOS voucher value either in annotated form or monetary form). Completion of GOS(NI)V claims forms: 1. After spectacles / contact lenses have been ordered the GOS(NI)V should be completed to include full patient details and outcomes based on the information recorded on the patient s clinical record. The address /practice stamp should be annotated in the appropriate section. 2. No amendments should ever be made to a GOS(NI)V form without the agreement of the prescriber. 3. Patients should be asked to sign the declaration of eligibility on the GOS(NI)V form to confirm that they are eligible. Where a patient under 16yrs has been examined the parent/guardian/ person in charge should sign the claim form. 9

10 4. Patients must be asked to show evidence to support their claim in line with the guidance for Optical Point of Service Checks and the appropriate exemption category should be ticked on the GOS(NI)V form. This is of particular importance where there is a delay between the date of the eye examination and the date of dispensing as the patient s eligibility may have changed during this period. If the patient is unable to produce evidence to support eligibility, then under the Exemption Check section, the box Evidence not seen should be marked by the practice with an X. 5. If spectacles have not been collected after 3 months or where a patient has subsequently deceased the relevant GOS(NI)V can be submitted for payment in respect of the uncollected optical appliance. This claim form should be annotated as spectacles not collected / patient deceased and any reasons for the non-collection noted in the remarks box. GOS(NI)V claim forms must be submitted within 3 months of the date of supply. 6. If spectacles have not been collected within 6 months the relevant GOS(NI)V can be submitted for payment. This claim form should be annotated as spectacles not collected and any reasons for the non-collection noted in the remarks box. 7. Details on the GOS(NI)V claim form should be checked for accuracy and completeness. 8. Details of the claim form should be recorded in the claims database referred to earlier (see Practice Administration section: Point 6). 10

11 E: REPAIRS AND REPLACEMENTS Exemption Criteria: 1. Only children under 16yrs of age are eligible for GOS repairs or replacements in consequence of loss or damage without the prior consent of the () Health and Social Care Board or () BSO. 2. Patients who are 16yrs or over are only eligible for GOS repairs/replacements in exceptional circumstances. The () BSO must be satisfied that the loss/breakage was due to illness, or a disability. If a patient falls within these categories then authorisation / approval must be obtained from the () BSO and the relevant GOS(NI)R form must be annotated appropriately. The same criterion applies to contact lenses. 3. The categories of patients who are entitled to a GOS(NI)R under General Ophthalmic Services should be known by ALL members of staff and this information should be updated if and when the categories of exemption change. It is the responsibility of the practice to ensure that these updates are implemented to comply with future changes. General: 1. Where a claim for repair / replacement is to be submitted the full details of the claim should be recorded on the patient s clinical record. Details of minor repairs where no GOS claim is being made should also be recorded if at all possible. 2. If spectacles / contact lenses are ordered, the workshop order form or relevant documentation should be retained as a means of post payment verification of service provision. 3. Where a GOS(NI)R claim for Small Glasses is being made the Optometrist or Dispensing Optician must ensure that the frame is eligible according to the criteria for the small frame supplement (SFS). 4. In exceptional circumstances where the Optometrist or Dispensing Optician believes that a SFS is required to fit a child accurately with spectacles BUT the criteria for SFS do 11

12 not apply then approval must be sought from BSO/Optometric Adviser in advance of issuing or claiming a SFS. 5. When spectacles / contact lenses are ready for collection and the patient has been notified, the patient record card should be annotated. 6. When dispensing has taken place the patient record card should be referenced to this effect e.g. the date of collection and amount paid (this should include the GOS voucher value either in annotated form or monetary form). 7. It is good clinical practice that the practice records the reason why a GOS(NI)R claim is being made e.g. spectacles lost, spectacle lenses scratched, side broken etc. Completion of GOS(NI)R forms: 1. The GOS(NI)R claim form should be completed including the patient details and results based on the information recorded in the patient s clinical record. 2. The patient declaration should be signed in accordance with the General Ophthalmic Services (Amendment) Regulations 2007 and the General Ophthalmic Services Optical Charges and Payments Regulations. If the patient is under 16yrs or is incapable of signing the parent / guardian/ person in charge should sign the claim form. 3. The relevant box on the GOS(NI)R should always be ticked to distinguish between a repair and a complete replacement. 4. Details on the GOS(NI)R claim form should be checked for accuracy and completeness. 5. GOS(NI) R claims must be submitted within 3 months of the date of service. Details of the claim form should be recorded in the claims database referred to earlier (Practice Administration Point 6). 12

13 F: VERIFICATION OF PRESCRIPTIONS General: 1. It is recommended that the practice records details of external prescriptions in a clear and concise manner on the clinical record. This applies equally to prescriptions issued from Hospital Eye Departments, Children s Refraction Clinics and other Optometrists. 2. The full details of the prescription, the date of eye examination and the prescribing Optometrist / Optometric practice should be recorded accurately. The details of the prescription should not be altered in any way and any queries in respect of the prescription should be directed to the original prescriber. 3. It is good practice that updates in regard to patients who present with external prescriptions are made when appropriate and that these updates are clearly noted in a chronological manner on the patient s clinical record. 4. When spectacles are ordered as a result of a patient presenting with a prescription originating from another prescriber, the practice should take care to ensure that the spectacle laboratory order is accurate and correlates with the original prescription. 5. It is good practice that all spectacle laboratory orders are cross checked with the patient s clinical record prior to submission of the order to ensure accuracy of dispensing. 6. It is good practice that all spectacles are verified upon return from the laboratory. Full details including: prescription, lens type, lens material, lens centration, tints (if appropriate), and frame selected must be checked for accuracy. 7. It is good practice that all spectacles are fitted on the patient at the time of collection. In the case of children under 16yrs old and the blind/partially sighted patients, the Optometrist has a responsibility to ensure that fitting has been undertaken. 13

14 G: REFERENCES AND CONTACT DETAILS References: 1. General Ophthalmic Service (Amendment) Regulations Memorandums of Ophthalmic Services as distributed by BSO. 3. General Ophthalmic Services Optical Charges and Payments Regulations. 4. Guidance for Optical Point of Service Checks. 5. Making Accurate Claims in Northern Ireland, issued by the Association of Optometrists. ALL STAFF SHOULD HAVE FULL KNOWLEDGE OF THE ABOVE REGULATIONS / GUIDANCE TOGETHER WITH ANY RELEVANT UPDATES AS AND WHEN THEY ARE ISSUED. Contact Details: 1. Health and Social Care Board. Mr Raymond Curran MCOptom Assistant Director of Integrated Care, Head of Optometry Gransha Park House 15 Gransha Park Clooney Road Londonderry BT47 6FN Tel: Raymond.Curran@hscni.net 14

15 Mrs Margaret McMullan MCOptom Optometric Adviser Linenhall Street Belfast BT2 8BS Tel: Ms Fiona North MCOptom Optometric Adviser Tower Hill Armagh BT61 9DR Tel: Miss Janice McCrudden MCOptom Optometric Adviser County Hall 182 Galgorm Road Ballymena BT42 1QB Tel: Business Services Organisation Ophthalmic Directorate 3 rd Floor 2 Franklin Street Belfast BT2 8DQ Tel: / 5528 / Association of Optometrists Association of Optometrists 61 Southwark Street London SE1 0HL Tel: Fax: