PHO Guidance on Covid Assessment Claims Scenarios for Approval or Rejection of Claims
(5 Nov 20)
PHO receives a significant number of duplicate claims for Covid Assessments via Halcyon. The high cost of claims means there is an increased focus on the accuracy of practice claiming and the PHO approval process. We appreciate practice support in responding to PHO queries verifying claims are for appropriate COVID-19 Assessments. • •
COVID claims should be raised only for COVID Assessments (with or without swabs). Subsequent appointments to manage ongoing respiratory symptoms are not funded.
Practice Managers and Clinical staff have asked for greater clarity of what constitutes ongoing respiratory management as opposed to a Covid Assessment claim. The following Scenarios help determine when the patient should be charged for the consult.
Patient A:
Presents to the Practice for the first time with symptoms meeting the case definition
Assessed to establish Risk Factors, HIS Status and Discuss Value of COVID Swab New episode of care
No charge to patient Covid Claim Raised on Halcyon If patient re-presents then see scenario for ‘Patient B’
Patient B:
Previously seen at the Practice COVID Assessed +/- Negative Swab Confirmed Re-presents to Practice with Continuing Symptoms (No change to Risk Factor)
Re-presents to Practice with New or Worsening Symptoms (or New Risk Factor)
Re-Assessed for the same illness
Re-Assessed for a new illness
Same episode of care
New episode of care
This is ongoing management of existing respiratory illness
This is new assessment of potential COVID case
Patient invoiced as per normal medical consult No Covid Claim Raised on Halcyon
No charge to patient Covid Claim Raised on Halcyon
In cases of multiple claims for patients who re-present, clinicians are encouraged to include comments in the Halcyon Claim form to support a Covid claim. This will reduce the need for PHO to query claims. Full PPE is required when taking a swab. In other circumstances appropriate PPE may be required. Please note; we have not included a scenario for Asymptomatic Surveillance testing as this can be claimed with appropriate frequency.