Interpret ECLIPSE Claims

Interpret ECLIPSE Claims

TIme to decode Medicare error code 500 and 159: This example uses screen shots from the Genie Practice Management Software, but the interpretation can be applied to any ECLIPSE transaction.

It can be difficult to know which particular item is causing a multi-item ECLIPSE Claim to fail. But here is one common thing you can look for – the Medicare Codes:

Medicare codes can be confusing, so let’s look at two very common ones – Error 500 and Error 159.

Here is a great example: This claim has three rejected items. How can we work out which one is the problem?

Genie ECLIPSE Processing Report

Look at the rejection message against each item. There we see:

1. ITEM 30490: This item was “rejected in association with another item”. This typically means that this item was rejected because another item in the claim has a problem, and therefore all items were rejected. Medicare will reject all items rather than guess at which might be correct. This error code usually suggests that this is not the problem item but merely rejected as a consequence of the real issue.

Genie ECLIPSE service-level messages

2.  ITEM 32093: This next item error is the Medicare code 159 – “Item associated with other service on which benefit payable”. This typically means that this item is in conflict with another item on the claim. When we see this error, it it time to go looking for another item which may not be billed with this one.

3. ITEM 32084: The third item has the same error code as the previous one – Error 159. This would indicate that this item and the one above are likely to be the culprits causing the rejection.

Genie ECLIPSE service-level messages

So we have narrowed the cause down to two possible items. We can check MBSOnline to investigate further. By searching MBSOnline for item 32093 we can immediately see that it is related to item 32084. Being related generally means they cannot be billed together, unless they were two entirely separate procedures, performed at different times on the same day:

MBS item 32093

As it is important not to guess with your billing, the next step is to go back to the provider, the quote or, even better, the official Operation Report, for confirmation of the correct service performed. Resubmit the correct items and credit any remaining items that were billed in error.

If in doubt – ask for help. Sometimes a little training can go a long way!

Cracking the Medicare Error code 432

Cracking the Medicare Error code 432

Eureka! Thanks to the lovely ladies at Medicare and Medibank Private I have finally worked out the meaning of that elusive Error “432 – Not multi-op – more information required to pay benefit”.

If you are like me and many of my sites, occasionally you get a Medicare claim error either in the bulk billing or via ECLIPSE that you just can’t work out how to resolve. I have had some people say you need to send a report, and others just write it off. But it has all been guesswork…until today. Several people in Medicare claims had never even heard of the error and that never inspires confidence.

So what is the problem? When you see the 432 “not multi-op” error it means that for some reason the services for the procedure have been split and potentially paid separately. This might occur because a diagnostic item has been billed separately to its procedural items, or it might occur because one procedure item was claimed and then a second claim has been sent containing an item that should have been the first (100%) item on the account under the Multiple Item Rule. It might also arise because the health fund has, for some reason, split the items when they sent them to Medicare for approval. To put it another way, it means that Medicare have already paid an item that would have been paid at a lower rate (per the multiple item rule) had they received all the items together, so they can’t just pay on the extra item/s without adjusting the already paid item.

And the solution? The new item/s either need to be

Differentiated as having occurred separately. i.e. If the service/s were performed as two unique procedures, then they need to be differentiated by TIME in the item service text and by using the “not multiple procedure” Medicare override.  In this case, the items will be paid as a separate procedure.


Reconciled as having occurred together. i.e. Medicare need to know that the items were performed together and Medicare will need to perform an adjustment of the already paid item. This is done using a single form – the Medicare HW023 form for Simplified Billing or ECLIPSE
adjustment or the Medicare DB018 form for a correction to a bulk billed claim. Complete the form with as much detail as possible, attach the correct invoice with ALL the items performed, and send it to Medicare for processing. They will either make a top up payment or request reimbursement. Make sure you specify clearly and exactly what you want them to do, otherwise they will send the form back for correction. And if in doubt, call Medicare for advice.

How can you avoid this error arising?

Ensure you have ALL the services to bill before you start, and put everything on the one invoice/claim. Simples! 🙂

I love learning new things. Have a great day – I am off to reconcile some more billing…