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Page | 1 PPN Training Manual – Optimum Version 2011

OPTIMUM TRAINING MANUAL


INDEX

1. Registration 2. Log In

3. Home Page

4. Validate Membership

5. Benefit Confirmations

6. Capturing a claim

7. Action a Rejection

8. View Claim listing

9. Resubmissions

10. Credit Notes

11. View Remittance Advice

12. News, Help & Training

13. Optimum Online Support

14. Log Out


1. REGISTRATION

Please make sure that your practice is registered to use the Optimum website. This website allows you to:

Validate Membership Confirm Benefits Capture Claims Rejections View Claim Listing and Resubmissions Credit Notes View Remittances Receive PPN News/Updates Optimum Support

To register for the Optimum system, please contact our membership department for a registration form: Contact Person Denise Johnson Contact Number 041-506 5938 or PPN call centre on 086 0103 529 Either Denise Johnson or the PPN call centre will forward your practice a Registration form that should be completed and returned to the PPN Membership Department Once you are registered as a user, you can LOGIN to the website: http://optimum.ppn.co.za


2. LOG IN: Enter the Practice Number, Username and Password and then CLICK on “Proceed” Please read through the information on the Login Page for important communications that will be loaded from time to time.


3. HOME PAGE The following Home Page will display: The Top Menu Bar highlighted in dark grey are for any Updates and Support as well as your logout option. The Bottom Menu Bar includes all the tools your practice will require for Benefit, Claim and Payment information.

4. MEMBER VALIDATION IMPORTANT INFORMATION WHEN DOING A MEMBER VALIDATION: When entering:

a. BANKMED & POLMED the membership number MUST have 9 digits; add “00” in front of the membership number until it is 9 digits.

b. Please ensure you capture the Carecross Bankmed Basic under Carecross Bankmed Basic and NOT under Bankmed

c. BP SOUTH AFRICA the “0” in front of the membership number falls away.

All the other Medical aid numbers should be entered as displayed on the MEMBER Medical aid card Click on MEMBERSHIP VALIDATION to Validate the Member and continue to the Benefit confirmation screen.


After completing all the required fields, click on ‘SEARCH’ to VALIDATE the MEMBERSHIP NUMBER.

The next screen should automatically be displayed. Incorrect information loaded: The screen is not responding with member details but will confirm that no membership information was found for your search criteria, phone the PPN call centre on 086 0103 529 for assistance


Correct Information loaded: Should the correct information be supplied, the following screen will be displayed confirming the dependant’s membership details.


5. BENEFIT CONFIRMATIONS: Once the Membership has been validated, you can click on the AVAILABLE BENEFIT ICON, allocated under options on the right hand side of the page to confirm the benefits available. No benefit available: When the line item displays “(No Benefit available)”, then the member has used his benefit entitlement within his current benefit cycle and he has no benefits available at that point in time. The dates on which the member will be in benefit again will be displayed at the bottom of the page as per the below screenshot reflects:


Benefit available: Should the member have available benefits it will be displayed as in the screen shot below:


6. CAPTURING A CLAIM:

To go to the capturing screen by selecting one of 2 options:

a. Option 1 - Click on the CAPTURE CLAIM ICON on the right hand side b. Option 2 - Click on the CLAIM CAPTURE TAB at the top of the page

The following screen will be displayed – complete the Practice & Invoice information and click on VALIDATE MEMBERSHIP to continue: Complete the Practice & Invoice Information required Complete the Medical Aid & Membership Information required Group practices only: The “Optom #” field has been added to the capturing site for those practices operating under a group practice number. Group practices MUST specify the optometrist number of the optometrist that consults the patient. Normal optometric providers will ignore this field. Discounts on your invoice: If you have to capture a discount amount on your invoice, then please check the Discount Apply block to activate the discount column on the capturing screen. Click on Validate Membership.

This screen will extend and display the Principal Member Information. Under Claim Information, please select:

a. The Dependant b. Payment information - who should be paid: Practice or Patient.


Click on Validate Patient.


Once you have clicked on Validate patient your will enter the Line Item Information – Capture the claim as it reflects on your system and as per the services and materials dispensed to the member/dependant:

Tick Boxes: Please ensure that you have ticked both tick boxes before clicking on the Submit icon. The claim will not be submitted should these tick boxes be left unchecked. Remember to invoice the following:

1. Correct tariff structure PPN1/2 2. ICD 10 information 3. Correct pricing as per the tariff structure 4. Script, VA, Visual Fields, IOP, NVS tag and Lab information


Important script validations

• Sphere – can be either Plus (+) or Minus (-) • Cyl – ALWAYS Minus (-) , can never be Plus (+) • Axis – between 1 and 180, can be a decimal (e.g.: 7.5) • Add – ALWAYS Plus (+), can never be Minus (-) • Prism – can be a decimal (e.g.: 1.5) • Base – should be alpha characters • V/A – must be either a fraction (6/6) or a decimal (1.00)

cannot be a single digit only (e.g.: 1 or 6) • IOP – cannot be a fraction (6/6), but it can be a decimal (e.g.: 8.5) • Visual Fields – can never be 0 or a slash only (/), a dash (-), a hash (#)

or a comma (,) Example: Full / Normal / Compromised / NAD / WNL

150/80, 155/85 Script examples: When capturing the script, only complete the fields that are supplied

1. If the lens prescription is plano - capture 0.00 only under the Sphere and leave the remaining fields BLANK

2. If the lens prescription is +1.00 - capture +1.00 under the Sphere and leave the

remaining fields BLANK (never capture the cyl or axis as 0.00 or 0)

3. If there is no reading add – capture only the prescribed information and leave the remaining fields BLANK

4. If there is a cyl script, then the AXIS must be captured and vice versa

Lab Information: Lab Name – select the lab from the drop down box - if selecting lab 131 (Other), please specify the lab details in the notes

facility on the capturing screen Order Number – supply the order number used to order the lenses from the lab. The lab name and order number option will only become available when a patient is dispensed with either bifocal or multifocal lenses. Please ensure that when entering the lab that you select the correct lab and that you have confirmed with your lab that they are ACCREDITED with PPN.

PPN Frames: When invoicing for the PPN Frame, please invoice it under code 70406 at a value of R150.00 to ensure that you qualify for the replacement frame and rebate offering.


7. ACTION A REJECTION

Once you have submitted the claim, it will automatically give you the rejection codes should the information be insufficient or incorrectly entered next to each line that has been rejected as shown below:

The rejection reasons per rejection code will be displayed at the top of the same page:


You can then correct the invoice/capturing lines and click SUBMIT for the account to be processed again. If the account gets accepted, you will be given a reference number:


8. CLAIM LISTING To view your accounts by “Status”, go to “Transaction Type”, click on the drop-down list, and select the option that you would like your accounts to be listed by e.g. “Accepted” or “Rejected”. Go to “Captured Date” and complete the date range you want to view.

Click on “Search” and a listing of all claims matching the criteria entered will be supplied. Should you wish to view the detailed claim, click on the question mark icon.


9. RESUBMISSIONS OF “BATCHED – REJECTED” ACCOUNTS

When an account has been rejected on “CLAIM LISTING” with the following Status “Batched – Rejected”, you can resubmit the amended account directly on Optimum.

The amended claim must be recaptured on the Optimum system.


10. CREDIT NOTE

Should a practice need to process a credit note after incorrectly capturing a claim OR due to a member canceling their spectacles OR the member changed their minds about the products they selected, then Click on the Claim Listing icon and proceeds to search for the applicable claim. Only claims that have a positive value and are in the “Batched – Accepted” status may be credited on Optimum. Please note:

a) Credit notes can only be processed on Optimum for Capitated Medical Schemes (PPN 1 tariffs).

b) Credit notes for Fee for Service Schemes (PPN 2 tariffs), as well as Bankmed CAN NOT be processed on Optimum. These requests should be submitted directly to PPN via either contacting the PPN call centre on 086 0103 529 or via email to [email protected]

In Claim Listing search for the claim that requires reversal, then click ‘C’ icon on the right hand side of the page.

Firstly the claim details will appear and once the practice has confirmed that this is the correct claim to be reversed, they can continue and click on “Credit Claim”.


Once they have clicked on “Credit Claim”, the practice will then have to enter a descriptive note as to why the claim needs to be credited. Click “Submit Credit Note”

The system will supply them with a reference number for their Credit request.


11. REMITTANCE ADVICE

Click on the Remittances icon at the top of the page to view remittances Click on the icon listed on the right of the remittance that you are requesting to display the remittance information for the specific run:

12. NEWS, HELP & TRAINING:

Click on the NEWS, HELP & TRAINING icon to view the latest information: Click on the ADOBE icon on the right-hand side to open the document:


13. OPTIMUM ONLINE SUPPORT

This is a support tool designed to assist practices when they come across any problems on the website. Click on “Support”, and type a brief description of your query, and click “Submit”. An automatic e-mail is generated to the Support Group, which will reply via e-mail to the practice OR by contacting your practice directly for more information.

Please ensure that your e-mail address is updated at all times – if it changes, please inform Denise Topkin in our membership department via email on [email protected]

14. LOG OUT

Keep your USERNAME and PASSWORD safe and make sure that you logout when you are not at your PC by simply clicking on the logout icon at the top of the page. PPN can track which user captured a claim on the system. Should any discrepancies occur or a fraudulent claim needs to be tracked back to a specific user, that user will be held responsible for such an account. SHOULD YOU HAVE ANY DIFFICULTY USING THIS SYSTEM, DO NOT HESITATE TO CONTACT THE PPN CALL CENTRE ON 086 0103 529 OR 086 1101 477

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