.:
Community Nursing Program
Claiming Voucher Spreadsheet
and Claim Header Completion
Guide
1 March 2010
Table of Contents
1
CLAIMING METHODS ................................................................................................................1
1.1
Completing the claiming voucher spreadsheet (voucher spreadsheet)..........................1
1.2
Purpose ..................................................................................................................................1
1.3
How to use this document ....................................................................................................1
1.4
Completing voucher spreadsheet........................................................................................1
2
2.1
3
ACCESSING THE VOUCHER SPREADSHEET ........................................................................2
Downloading the voucher spreadsheet ..............................................................................2
COMPLETING A CLAIMING VOUCHER SPREADSHEET .......................................................4
3.1
Completing the claiming voucher spreadsheet contd.......................................................5
3.1.1 Completing the Provider Details on the voucher spreadsheet............................................6
3.1.2 Completing the Claim Details ..............................................................................................6
3.1.3 Sample of the completed claiming voucher spreadsheet ...................................................9
4
COMPLETING THE CLAIM FOR TREATMENT SERVICES (CLAIM HEADER D1217) ........10
4.1
Example of the claim header - D1217 ................................................................................10
4.2
Submission of completed voucher spreadsheet for payment........................................11
4.3
Example of the completed claim header – D1217 ............................................................12
1 Claiming Methods
DVA-contracted community nursing providers can claim for payment by either using a paper based
claiming method or an electronic method. This guide only discusses the paper based claiming method
using the Claiming Voucher Spreadsheet.
The claiming method is made up of 2 parts:
1. Claiming Voucher Spreadsheet (voucher spreadsheet)
2. Claim for Treatment Services (claim header)
1.1 Completing the claiming voucher spreadsheet
(voucher spreadsheet)
This document outlines the procedure to be followed when completing the voucher spreadsheet by
Community Nursing Provider.
Read this document in conjunction with:
• The Guidelines for the provision of community nursing services, the Guidelines are available
through the DVA website and to access the Guidelines either use the following link:
http://www.dva.gov.au/service_providers/community_nursing/Pages/Guidelines.aspx OR
follow the menu path www.dva.gov.au > Service Providers > Community Nursing >
Information for DVA Community Nursing Providers > Community Nursing Guidelines
• Paper-Based Community Nursing Claiming documents, to access the documents use the
following link:
http://www.dva.gov.au/service_providers/community_nursing/Claiming_voucher_spreadsheet/Pages/Claiming_vouchers.aspx
OR follow the menu path www.dva.gov.au > Service Providers > Community Nursing >
Information for DVA Community Nursing Providers > Claiming Vouchers
1.2 Purpose
To guide the user through the claiming procedure and introduce them to the terms and formats used
to complete the voucher spreadsheet.
1.3 How to use this document
The prospective users of this user guide will be:
• DVA – contracted community nursing providers using the voucher spreadsheet provided by
DVA
• DVA – contracted community nursing providers using a voucher spreadsheet developed in
their practice management software
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DVA – contracted community nursing providers that develop a voucher
spreadsheet in their own practice management software must follow the format
instructions provided by DVA in the voucher spreadsheet.
1.4 Completing voucher spreadsheet
Process of completing the claiming voucher spreadsheet in this document has been broken into three
segments.
1.
Accessing and downloading a claiming voucher spreadsheet
2.
Completing a claiming voucher spreadsheet
3.
Completing a claim for treatment services (claim header D1217)
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
1
2 Accessing the voucher spreadsheet
Microsoft Excel format is the preferred option to complete and submit the voucher spreadsheet. The
voucher spreadsheet, including the format instructions, is available online and the user is required to
download the voucher spreadsheet through the DVA website.
2.1 Downloading the voucher spreadsheet
This part of the guide will take you through a step by step method to download the claiming voucher
spreadsheet and format instructions from the Internet
Step 1.
Open the Internet Web browser and key in http://www.dva.gov.au to display the DVA home page
¡
Department of Veterans’ Affairs home page will be displayed.
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
Step 2.
Click on the link > Service providers > Community Nursing to proceed to the
Information for Community Nursing Providers page
¡
Select Claiming Vouchers from the Information for Community Nursing Providers
page
Click on the Claiming voucher spreadsheet link to proceed
¡
A File Download dialogue box similar to this will be displayed
Excel
spreadsheet
Click on the Save
¡
button to proceed
A Save as dialogue box will be displayed
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
Save in:
File name:
Save as type:
Click on the Save
Select or create an appropriately named folder
Rename the file from ‘claiming_spreadsheet’ as appropriate
Microsoft Excel Worksheet
button to proceed
3 Completing a claiming voucher spreadsheet
Open the saved Microsoft Excel Worksheet – Claiming voucher spreadsheet
¡
The Claiming voucher spreadsheet will be displayed
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
The Claiming voucher spreadsheet consists of three worksheets.
1.
Instructions on how to use
This page describes how to complete the claiming voucher spreadsheet and handy tips.
2.
Format Instructions
This page outlines the formats to be used whilst completing the claiming voucher
spreadsheet.
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3.
The format instructions need to be used if creating a voucher spreadsheet in
practice management software
Do not enter more than 14 claims on one page
Do not enter any data in the grey fields
Claiming spreadsheet
The claiming information is entered in this spreadsheet.
3.1 Completing the claiming voucher spreadsheet
step-by-step
This part of the user guide will take you via a step-by-step method to complete the claiming voucher
spreadsheet.
In the claiming voucher spreadsheet each numbered line represents one community nursing 28-day
claim period for an entitled person.
If you are claiming for more than one 28-day claim period for an entitled person multiple lines will
need to be completed.
The voucher spreadsheet is divided into two sections
1.
Provider details
2.
Claim details
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
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Details are mandatory and all fields must be entered in a correct format
The field provider declaration is included on the service voucher but not
on the claiming voucher spreadsheet
All other information on the service voucher is included on the claiming
voucher spreadsheet
Step 1
3.1.1 Completing the Provider Details on the claiming voucher
spreadsheet
Provider Name:
Enter DVA-contracted community nursing provider’s Legal
Entity name
Provider Number: Enter provider number
Claim for Treatment Services No. (D1217):
Enter D1217 number (Step 3: Section 4)
Step 2
3.1.2 Completing the claim details
Column
No.
Details
Explanation and Examples
Line number for each claim Serial number is automatically populated by default.
period
• Do not make any change.
DVA FILE NO Enter DVA File Number of DVA File Numbers are alphanumeric.
the Entitled Person
Examples:
– Veteran in own right - NX001235, NSWP12334, or
QX123456 (8 digits)
– Spouse - NX001235A (9 digits)
SURNAME
Enter surname of the
Preferred format to enter the Entitled Person’s surname is
Entitled Person
upper case.
Example: BLOGGS
FIRST NAME Enter first name of the
Preferred format to enter the Entitled Person’s first name is
Entitled Person
upper case.
Example: JOE
DOB
Enter date of birth of the
Enter birth date in DD/MM/YYYY format only.
Entitled Person
Example: 16/11/1927
CLAIM
PERIOD
Enter the date on which
the claim period
commenced (Claim Start
Date)
Claim period must be at least 28 days since the Claim
Start Date of the last claim.
Claim date must be entered in DD/MM/YYYY format.
Example: 16/04/2010
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
ITEM NO
Enter the item number for
the delivered services
This field is mandatory and cannot be left blank (do not
enter text such as ‘No Visits’)
Item numbers identify the services delivered and consist of
4 alphanumeric characters. First two characters are alpha
and last two characters are numeric.
Examples: NA01, NY06, NZ13, NO59 etc.
Refer to the Community Nursing Schedule of Item Numbers
and Fees (Schedule of Fees). The Schedule of Fees is
available on the DVA Community Nursing website:
http://www.dva.gov.au/service_providers/community_nursing/Pages/index.aspx
REF
PROVIDER
Enter referring provider
number as shown on the
referral (only for the first
claim of the 12 month
referral period)
Referring provider number is the provider number of an
authorised referral source (ie. LMO, GP, Hospital
Discharge Planner).
The referring provider number is entered ONLY for the first
28-day claim period of an entitled person’s 12 month
referral period.
REF DATE
Enter the referral date
The referral date must be entered for the first 28-day claim
for payment.
The referral date must be before the commencement of
service or the admission date – the first face-to-face visit).
The referral date is the date when the referral was
provided for an entitled person’s episode of care. If a
verbal referral was provided before a written referral, the
date of the verbal referral should be used.
This field must be completed on the claiming voucher
spreadsheet ONLY for the first 28-day claim period of an
entitled person’s episode of care.
Referral date must be entered in DD/MM/YYYY format.
Example: 14/04/2010
ADMISS
DATE
(admission
date)
Enter entitled person’s
admission date
The admission date is the date when the entitled person is
first admitted to Community Nursing Services (ie. the first
face-to-face visit).
This field must be completed on the claiming voucher
spreadsheet ONLY for the first 28-day claim period of an
entitled person’s episode of care.
Admission date must be entered in DD/MM/YYYY format.
Example: 16/04/2010
DISC DATE
(discharge
date)
Enter entitled person’s
discharge date
Discharge date (or date of death) is when the entitled
person was discharged from Community Nursing Services
(ie. the last day of service provided to the veteran or the
date of death)
Discharge date must be entered in DD/MM/YYYY format.
Example: 10/07/2010
This field must be completed on the service voucher
for the last 28-day claim period. If a claim has already
been made, then no further action is required.
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
WHITE CARD Enter ‘Y’ if the entitled
person is a White Card
(eligibility
holder who is eligible to
checked)
receive CN services
Some White Card holders are entitled to Community
Nursing Services, however eligibility MUST be checked
with DVA location office prior to the commencement of the
services.
Recording a ‘Y’ in this field indicates that you have
completed this eligibility check for the White Card holder.
Note: All Gold Card holders are entitled to Community
Nursing Services.
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You must print the completed claiming voucher spreadsheet as the claiming
voucher spreadsheet cannot be submitted electronically
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
3.1.3 Example of a completed claiming voucher spreadsheet
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No. DVAFILENO SURNAME
1
QX123456
2
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3
NSS12345
4
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WHITE
CARD
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FIRST NAME
REF
ITEM NO PROVIDER REF DATE
008
PERIOD
JOE
0110211922 - r 1201o
VETERAN
JOE
0110211922 - r 1201o
NC13
CITIZEN
JOHN
3/04/1926 - r 1201o
NZ0 4
VX123456A
WIDOW
MARY
28107/1932 - r 1201o
NY10
QX123456
BLOGGS
JOE
04/10/1926 - r 1201o
NY02
6
QX123456
BLOGGS
JOE
04/10/1926 - r 1201o
NT5 8
7
QX123456
BLOGGS
JOE
04/10/1926 - r 1201o
N801
8
TKM12345A
WIDOWS
NELLIE
19/0B/1920 - r 1201o
N056
9
WSM12345
MEMBER
GEO
2810 4/1965 - r 1201o
NY01
VETERAN
I
Claim for Treatment Services No.:
(01217)
CLAIM
3
H
t
ouider Name:
2 Provider Humber:
NY02
0123456Y
01/03/2010
ADMISSDATE
DISC DATE
(-e ligiblit,
c•-ec•cd)
02/03/2010
8
9
y
10
11
12
13
16104/2010
14
15
16
17
18
19
20
21
0654321A 1110512010
1510512010
y
22
23
10
24
25
11
26
27
12
28
29
13
30
31
14
32
rE- uider Name:
rE35
Provider Humber:
t
0
0
t
I
36
No.
DVAFILENO SURNAME
FIRST NAME
008
CLAIM
PERIOD
Claim for Treatment Services No.:
(01217)
REF
ITEM NO PROVIDER REF DATE
0
WHITE
CARD
ADMISS DATE DISC DATE
(eligiblit'
c•-ec•cd)
37
38
15
39
40
16
41
, • • •'.I\
4?
1
Instructions on how to use
L
Format Instructions
Claimina Soreadsheet
DVA Community Nursing Progrcon- Guide to completing the claiming voucher spreadsheet1 March 2010
J.!..l
Step 3
4 Completing the Claim for Treatment Services
(claim header D1217)
The claim header must be completed and attached to the claiming voucher spreadsheet sent to
Medicare Australia.
The claim header is divided into three sections
1.
Provider details
2.
Claims details
3.
Provider declaration
Copies of the voucher spreadsheet and the claim header can be requested:
– online at http://www.dva.gov.au/service_providers/Pages/Forms.aspx
– by telephone on 1800 155 355
– by fax on 1800 671 670
– by mail to:
DVA Distribution
c/- Moore ADS Pty Ltd
Building 23
9 Ashley St
West Footscray VIC 3012
4.1 Example of the claim header - D1217
Claims
details
Details of Service
Provider
Provider declaration
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
Details of Service Provider
Name:
Address:
Provider Number:
Payee’s Provider Number:
Enter your Legal Entity name
Enter your address details
Enter your provider number
Enter only if the payment is to be made to another provider.
(The field Payee’s provider number should only be filled in if
the DVA-contracted community nursing provider’s payment
will be made to another provider number)
Claim for Treatment Services
Date of Claim:
Claim number:
Number of Vouchers:
Total Amount Claimed:
Enter the date of claim **/**/**
AREADY PRINTED ON FORM
Enter the number of service vouchers (number of claims)
contained in the voucher spreadsheet
Enter the total claim amount
(The total claim amount must be exclusive of GST. GST will
be added to each service voucher by Medicare Australia
when the service voucher is processed for payment)
Provider Declaration
Signature of the Provider: Sign and date the declaration
(Date of the signature must be same as the Date of Claim)
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Always use a ballpoint pen to complete the header
When completing the number of vouchers, the total number of vouchers attached
to a claim header using the voucher spreadsheet cannot exceed forty (40) entries
4.2 Submission of completed claiming voucher
spreadsheet for payment
Submit the completed claiming voucher spreadsheet to the following address:
Medicare Australia
GPO Box 964
ADELAIDE SA 5001
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010
4.3 Example of a completed claim header – D1217
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Examples used in this document do not contain real data and must be used as a
reference material only.
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Please use this document in conjunction with the ‘Guidelines for the provision of
community nursing services – effective 1 March 2010’
DVA Community Nursing Program - Guide to completing the claiming voucher spreadsheet 1 March 2010