Ask DSC: What do I need to know about Claim Types?

A Plan Manager has given us feedback that we’re using the incorrect Claim Type for some lines on our invoices. When I'm submitting claims for services, what exactly is a Claim Type, and what do I need to do with it? And what are the implications of doing it incorrectly?

You are not the only provider who is confused and frustrated by Claim Types. But they are really important to ensure our billing is correct, particularly with the NDIA ramping up scrutiny with Payment Integrity Audits. Let’s run through what a Claim Type is and why they matter in getting paid.

What is a Claim Type?

A Claim Type is just like what it sounds - it’s a tag that lets the NDIA and the participant (and in this case, the Plan Manager) know some more details about the service. Claim Types apply to all Item Numbers and all claims. If you’re still doing claims in the Portal directly (as a Single Payment Request) you’ll have a drop-down menu to select the Claim Type. There are seven different Claim Types:

Direct Service - this is the default, so unless the Claim Type is changed, then the Portal assumes it was a Direct Service. This is for when the service is delivered directly, face-to-face with the person.
Cancellation Charges - this is for when a Short Notice Cancellation occurs.
Irregular SIL Supports - SIL services that are delivered beyond the regular SIL supports funded in the Plan.
Non-Face-to-Face Services - services that are eligible to be funded from the NDIS, but the person wasn’t with the worker. Things like writing reports or meeting with other providers in a person’s life might be justified as Non-Face-to-Face supports. More details about NF2F are available on page 17 of the Pricing Arrangements and Price Limits document (PAPL).
NDIA Required Report - this is only really used by Allied Health Professionals and Support Coordinators, for situations where the NDIA formally requests a report.
Telehealth - direct services delivered remotely over video calling.
Provider Travel - the labour component of a worker travelling to deliver a support. More details about Provider Travel are available on page 18 of the PAPL, or in our self-paced elearning here.

Why does the NDIA insist on these?

Mostly it’s about transparency, for both the NDIA and the participant. For example, an Allied Health Professional might spend 25 minutes travelling to a person’s home, 50 minutes doing therapy, 20 minutes travelling back to the office, then 35 minutes while at the office developing additional therapeutic tools and updating the person’s in-home support provider about some new therapy routines.

If that entire 2hrs 10mins is billed as a single line on the invoice, the person has no idea how much the provider is charging them for Travel, or how much is being spent on Non-Face-to-Face services. This means the person can’t make an informed judgment or decision on whether they are getting good value from their service.

Equally, the NDIA can’t do a Scheme-level comparison on how much different providers are spending on different types of supports, unless providers are using the correct Claim Types.

The system allows only one Claim Type to be selected per line on the invoice. So that service from the Allied Health Professional needs to be four lines on the invoice:

25 mins of Provider Travel
50 mins of Direct Service
20 mins of Provider Travel
35 mins of Non-Face-to-Face

What happens if we don’t use the right Claim Type?

The increase in Payment Integrity Audits means there is more scrutiny on providers to use the correct Claim Type. Implications for using incorrect Claim Types include:

Delayed or rejected payments, as the NDIA aren’t able to match what services were delivered to what was agreed with the person and what is on the invoice/claim.
Increased admin and paperwork of having to retrospectively prove how the service was delivered, and altering the Claim Type accordingly.
More complaints and queries from participants, their supporters and Plan Managers. A person is likely to be unhappy if their therapist was only with them for 50 mins, but the invoice has 2hrs 10mins listed on it. Using correct Claim Types lays out what exactly is being delivered and claimed.
If invoices are being sent to Plan Managers, ultimately it’s them who will be submitting the claims. So if they aren’t satisfied that the invoices meet the billing compliance standards required from the Pricing Arrangements and Price Limits (which includes using Claim Types), then they will knock the invoice back for correction.

In short: to be paid promptly, smoothly and accurately, use the right Claim Types.

That’s great for everyone except the provider that has to shoulder the extra admin burden of breaking our services down into Claim Types. How can we do this without multiplying our admin time?

I’m afraid nobody can solve that problem with a click of the fingers. This isn’t a new requirement, it is just under more scrutiny now. That being said, there are a few things I know other providers find useful:

Good CRMs and billing systems will have options for Claim Types in the Bulk Request Template to claim from the Portal. Other CRMs will struggle with different Claim Types delivered on the same day. So lean on your software vendor/supplier. Many CRMs have this functionality built in, you might just need to find the right training package or ask for it to be turned on.
You might need to ask workers to collect extra information or add details to timesheets, to accurately track what services are delivered.
Reference Claim Types and how you’ll claim in your Service Agreements and Schedules of Support to avoid disputes at the invoicing stage.