The various claims a surgery has to process to derive its income is given below:
- PPA – Prescription prescribing authority.
- Medicines – prescription issued
Others – services provided for the patients include:
CH — Child Health Surveillance
CS — Contraceptive Services
IN — Immediately Necessary Treatment
MA — Maternity Services
MS — Minor Surgery
NV — Night Visits
RF — Registration Fee
TR — Temporary Residents
VI — Vaccinations and Immunisations.
The following claims types will be received at the surgeries HA from fringe HAs:
MX — Fringe Maternity Services
RX — Fringe Registration Fee.
Child Health Cancellations – notification to the GP Practice that their CH claim has been cancelled. These transactions are generated automatically for the relevant GP Practice when the relevant claim is either manually cancelled or superseded by a newer claim.
* Contraceptive Services Cancellations – notification to the GP Practice that their CS claim has been cancelled. These transactions are generated automatically for the relevant GP Practice when the relevant claim is either manually cancelled or superseded by a newer claim.
* Fringe Maternity Services (MX) – submitted for authorisation to the HA with whom the claiming GP is responsible. These transactions are automatically generated for claims, which have been entered manually, received from IOS, linked GP Practices, or for adjustments made on the GM screen to paid maternity claims for non-responsible GPs.
* Fringe Registration Fee (RX) – submitted for authorisation to the HA with whom the claiming GP is responsible. These transactions are automatically generated for claims that have either been entered manually or received from IOS linked GP Practices.
* Quarterly Cut-Off Dates – these transactions are generated automatically for IOS linked GP Practices (only for GP Practices who are responsible to your HA) either initially using the Link Code Cross Reference (PT) screen when upgrading the GP Practice to IOS, or by closing the finance quarter on the GMS General Data (GG) screen. The cut-off dates are generated from the information set up on the Links Cut-Off Dates (QD) screen.
* Payment Notifications – notification to the GP Practice that the relevant claim has been authorised for payment
Reject Notifications – notification to the GP Practice that the relevant claim has not been authorised for payment (along with any reasons for justifying the rejection).
Maternity Adjustments – notification to the GP Practice (only for GP Practices who are responsible to your HA) when an adjustment has been made to the eligible fee for a Maternity Service claim.
GP Payment Statements – GMSQP payment statements can be sent in electronic form to linked GP Practices. The GP Practice can receive electronic payments statements (generated by closing the finance quarter on the GG screen) even if they are only linked for Registration.
5.1.1 Background to HA-PCT/GP Links
The HA/GP Links Project is a national initiative to provide Electronic Data Interchange (EDI) between HAs and GP Practices operating throughout England and Wales.
The objective of the project was to move towards a paperless transaction base between GP Practices and HAs/PCTs by replacing Registration and Items of Service (IOS) forms with electronic transactions transmitted via a communications network (NHSNET).
This was achieved by:
- Receiving Registration details from GP Practices and providing the means for automatic update of the HA patient database.
- Transmitting to GP Practices the details of Registration changes made on the HA patient database to allow the same patient details to be updated onto the Practice’s patient database.
- Receiving IOS claims from GP Practices and providing the facility to both automatically validate and update the HA General Medical Services Quarterly Payment (GMSQP) system with those claims which are eligible for payment.
- Transmitting electronic GP statements to GP Practices.
The major benefits of the project would be:
- Speedier exchange of information between GP Practices and HAs/PCTs.
- Improved accuracy of information between GP Practices and HAs/PCTs.
- Data will be captured once at the GP Practice, thereby eliminating duplication of effort.
- Reduced administration costs for GP Practices and HAs/PCTs.
- Reduced costs for GP Practices and HAs/PCTs in support of existing communication methods (e.g. telephone, postage).
- Standard national approach to data collection and thus complete compatibility between GP Practices and HAs/PCTs.
- Audit trail of data exchanged between GP Practices and HAs/PCTs, thus reducing the possibility of discrepancies.
5.1.3 Items of Service (IOS) Link – already dealt with in Section 5
The success and reliability of the computerised link depended upon both the accuracy of the data being exchanged and on the number of GP Practices using the link.
The reconciliation process is fundamental to the smooth running of the Items Of Service (IOS) Link because much of the data used for patient identification with regard to claims relies on both the GP Practice and HA/PCT systems holding the same patient information. If time does not allow a full reconciliation to be performed then the minimum patient information should be reconciled, i.e. Surname, Forename(s), Date of Birth, NHS Number, GP Code, and Sex.
A GP Practice can only become linked for IOS once its link for Registration is running successfully.
Achieved via the following transactions:
- Acceptances – new patient registrations onto a GP’s list.
- Amendments – changes to patient registration details.
- Removals (Out of Area)
- Reconciliation Downloads.
- Amendments – changes to patient registration details.
- Deductions – removes patient from GP’s list.
- Rejections – rejection of a GP Acceptance transaction.
- Approvals – notification of a patient being accepted onto GP’s list.
- Medical Record Flag Removals
- Medical Records Sent Reconciliation Uploads
Phase 2 Registration Links
The Phase 2 functionality includes the following additional transactions:
- Deduction Requests – allows a GP Practice to request the deduction of a patient for reasons of Death, Embarkation or Other Reason.
- Close Quarter Notifications – notification to the GP Practice to close the registration quarter on their system.
- FP69 Prior Notifications.
- FP69 Flag Removals – notification to the GP Practice that a patient’s FP69 status has been cancelled.
- Deduction Request Rejections – notification to the GP Practice that the request to deduct a patient from the list had been refused.
Pay/Reject acknowledgements will advise whether Maternity Services claims and adjustments and Registration Fee claims sent have been authorised for payment or rejected.
Cut-off dates currently enable to identify which claims will be included in a particular financial period.
A cut-off date must be set for each type of claim and these must be transmitted to each GP Practice using the Health link Network. Until this has been done no transmission of claims information could occur.
Once the Links cut-off dates have been received by a GP Practice, they can start submitting their first claim transactions over the Health link Network.
This tightening of controls had the benefit that the Practice could more easily reconcile their payment and thus significantly reduces the number of queries a Practice will have regarding the claims they have transmitted.