1. Welcome to HICAPS CSS!

2. HICAPS Files and Reports
What files and reports are sent to the Funds

3. Provider Files and Fund Reports
Fund Reports and Files
HICAPS produces a number of Files and Reports that are send to the funds for several reasons :
Update the fund systems so that they have the current provider information for HICAPS providers.
Assist the Fund in identifying issues or limitations with there claiming system
Assist in identifying transactions that may fall outside the “Statistical Norm”
HICAPS uses National Online Corporate facility to securely send Files and Reports daily.
The naming convention is fyydddnn.HNI where;
f = File Type
yyddd = year and day of the year (Julian date)
nn = last 2 digits of the Funds Issuer Identifier ( )

4. Provider Files ‘A’ file – New Providers
Contains details of new providers added to HICAPS
Funds are requested to load or Decline these providers within 4 business days.
‘B’ file – Changes and Deletions
Contains details of any changes to or deletions of providers
Finds are requested to load these providers on the day it is received/
‘I’ file – Active Providers
Contains details of all providers registered with HICAPS
Sent monthly, does not have to be loaded, but if loaded, must be done in order
This file is available to funds on request

5. Fund Reports ‘J’ file – Multi-Swipe Report
Provides a listing of any providers who process 2 or more transactions with the same card on the same day.

6. Fund Reports ‘K’ file – HICAPS Management Report
Number of available providers by Modality
This is a list of the number of new providers, changes to provider details or providers removed from the HICAPS system for each modality that the Fund accepts
Providers currently not available by Modality
This is a list of the number of new providers, changes to provider details or providers removed from the HICAPS system for each modality that the Fund does not accept
New Providers previously suspended by fund
This is a list of providers that a Fund may have previously suspended that may now be operating in a different location.
Number of Providers on the Multi Swipe Report
Displays the number of providers that appear on the Multi Swipe Report (J file)
CSS Settlement Value
Displays the total settlement value for the day (excluding in doubt transactions)

7. Fund Reports ‘K’ file – HICAPS Management Report Cont…..
CSS Transactions Reversals completed by the Fund
Number of Transactions that have been reversed by the Fund
Top 20 Providers by Claim Benefit Amount
List of the top 20 providers where the greatest benefit has been paid
Top 20 Memberships by Claim Benefit Amount
List of the top 20 Memberships where the greatest benefit has been paid.
Claim Line Breakdown by Return Code + Average over the switch
List of the number of items processed for each item return code with a comparison against the whole HICAPS system.
Transactions Breakdown by Return Code + Average over the switch
List of the number of transactions processed for each transaction return code with a comparison against the whole HICAPS system.
Invalid Item Numbers
List of all the invalid item numbers that have been returned by the Fund
Providers Declined by Fund
List of all the providers that the fund has declined with
01 Provider not approved by fund
03 Invalid provider number
60 Provider not registered with fund

8. Fund Reports ‘K’ file – HICAPS Management Report Cont…..
Outstanding Pending Reversals
List of transaction has been reversed but has not yet been authorised
Zero Benefit on approved transactions
List of transactions where there is zero benefit but the transaction is approved
Benefit paid on a declined transactions
List of transactions where a benefit has been paid but the overall transaction has been declined
Fund System Inoperative / Timeout
List of transactions that have timed out and reported fund down.

9. Fund Reports ‘KM’ file – HICAPS Management Report
Number of available providers by Modality
This is a list of the number of new providers, changes to provider details or providers removed from the HICAPS system for each modality that the Fund accepts
Providers currently not available by Modality
This is a list of the number of new providers, changes to provider details or providers removed from the HICAPS system for each modality that the Fund does not accept
Number of Claims Processed for the Month
Display’s the number of claims processed for the month
Value of Claims Processed for the Month
Displays the total settlement value for the day (excluding in doubt transactions)
Number of Quotes Processed by Fund for the Month
Displays the number of quotes processed by the Fund for the Month.

10. Fund Reports ‘KM’ file – HICAPS Management Report …. Cont.
Top 20 Providers by Benefit Amount
Displays the Top 20 providers who appeared more than 5 times on the K report in the Month
Top 20 Memberships by Benefit Amount
Displays the Top 20 Memberships by benefit paid for the month
Top 20 Number Member Claims
Displays the Top 20 Members by the Number of claims processed against the card for the month
Claim Line Breakdown by Return Code
List of the number of items for each item return code with a comparison against the whole HICAPS system.
Transactions Breakdown by Return Code
List of the number of transactions for each transaction return code with a comparison against the whole HICAPS system.

11. Fund Reports ‘KM’ file – HICAPS Management Report …. Cont.
Providers Declined by Fund
Displays the Providers that are still declining with a Fund even after the fund has been notified.
‘L’ file – HAO User Audit Report
Contains which users have made changes to the HICAPS Accounts Online System
‘M’ file – Quote Report
Contains Transactions where a quote has been processed within 10 minutes of a claim.

12. Fund Reports ‘N’ Report – Average Item Value Report
The N report is the Daily Average Item Value by Provider Report
Displays the average item value for your fund for a provider compared with the average item value across the HICAPS switch for the same provider.
Aimed at those funds who pay percentage based benefits.
Will be run every day and sent via National Online.
Configurable for each fund
This reports are available to Funds upon request

13. Fund Reports ‘NM’ Report – Monthly Average Item Value Report
The NM report is the Monthly Average Item Value by Provider Report
Displays the average item value for your fund for a provider compared with the average item value across the HICAPS switch for the same provider.
Aimed at those funds who pay percentage based benefits.
Will be run on the 3rd day of the month and sent via National Online.
Configurable for each fund
The NM report is available to the Funds upon request

14. Fund Reports N and NM Report Configuration
This report is configurable for the following set of values for each fund
Fund accepts or declines to receive the report.
Percentage difference before an item appears on the report
Both Positive and Negative exceptions to the percentage difference.
Positive exceptions only to the percentage difference.
Report Format
Report
Data (Fixed Field Text File)

15. Fund Reports ‘O’ Report – Invalid Item Transactions Report
This report show where the Fund has returned a item number that is not represented in the industry agreed item schedules.
The Item Number returned does not match the Providers Modality
Exception : If the Fund returns one of the 4 Item Return Codes listed below the transaction will not appear on the report.
10 Invalid Item Number
11 Item Number Ceased
12 Item Not Valid for Provider
43 Transaction Declined – Refer Transaction Response Code
The Item Number returned is valid however the Return Code is a 10 or 11.
Exception : If the fund returns the Item Return Code 12 Item Not Valid for Provider the transaction will not appear on the report.
All Transaction where a Item Return code 10 Invalid Item Number is returned

16. Fund Reports ‘P’ Report – Estimated Maximum Daily Transactions Report
This displays where a provider has processed a greater number of transactions in a day than the number indicated by the funds for a provider group.

17. CSS & HICAPS Accounts Online
What, why and how?

18. What is HICAPS CSS HICAPS CSS is the settlement of health claim
transactions and issuance of statements / remittances
on behalf of the HICAPS health Funds to HICAPS
health service providers.
In conjunction with settlement and statementing
HICAPS has included a interactive WEB interface to
allow Funds (and Providers) interrogate the settlement system.

19. Why HICAPS CSS Why use HICAPS CSS ? Cost Savings
Reduced Payment Enquires to Funds
Increase eClaiming by easier Reconciliation for providers
View a transaction up to 18 months
Reverse transactions to 18 months
Currently the CSS system holds 7.5 years of data available for access by both Providers and Funds.
View Provider details held by HICAPS
View Provider Documentation
Transaction Reporting

20. HICAPS Accounts Online
HICAPS Accounts Online (HAO) was released at the same time as the Statement and Settlement piece of CSS.
The HAO allows the Funds and providers to view transactions that have been processed through the CSS System.
All Funds now have access to HICAPS Accounts Online.
All Providers have access to HICAPS Accounts Online.
All transactions processed via the HICAPS System are now available in HICAPS Account Online.

22. When using the Search Engine the user is able to build the search criteria that they would like to use

23. The search engine allowed the user to select the criteria they would like to use for the search

24. For Example
With an entry in the Member # field and in the Provider # file the search will look for and records that have the Member Number of AND a Provider # AF

25. Each field with the same name added to the search criteria will be added as an “OR”
For Example :
If we have 3 fields with Provider Number in each the system would search for any records that contained a Provider Number of AF OR Provider Number AF OR Provider Number AF.

26. The system will automatically insert a wildcard at the end of the data entered into any field.
Ie In the provider number field if you enter the provider stem the system will display all the provider attached to that stem.
Enter in the provider field the system will search on *
In this case transactions would be displayed for the following providers.
123456AF or AJ

27. The search engine allowed the user to select the result fields they would like returned search

28. Once the Criteria and results has been set
Select the search button to display a list of the transactions that match the search criteria chosen.
Click on the line in the display results to drill down on the transactions for more information.

30. The system also allows the user to export transactions to a CSV file
(CSV = Comma Separated Values)
These files are able to be read by other applications for example Microsoft Excel and Microsoft Access which allows the user to do further analysis of the data.

33. Transaction Reversal
The HICAPS Accounts Online facility gives the fund the ability to be able to reverse a HICAPS transaction that has been processed by the HICAPS CSS system.

34. To reverse a transaction the fund would need select the transaction be reversed.

35. “Click to Reverse Transaction”
The authorised fund user would then need to select the above link
“Click to Reverse Transaction”

36. Transaction Reversal Guidelines
Transaction Reversals
The Provider MUST be contacted prior to processing a claim reversal.
In the event that a transactions needs to be reversed not only must it be reversed in the Health Fund claiming system , but the value must be reversed in CSS, through HICAPS Accounts Online
The transaction can be reversed (with the right authority) from the transaction details screen

38. The authorised fund user is able to approve or decline the request to reverse the transaction.
The user that approves the reversal request is not able to be the same as the user one that initiated the reversal.

44. Funds are able to approve and decline HICAPS providers from the Provider details screen.
Declining a provider will advise HICAPS to stop sending updates for this provider.
It will not stop transactions from this provider being received by the fund.

45. Questions

46. That’s all folks
Thanks for coming along and listening, I hope you all got something out of it!