Introduction

Billing Principles: Introduction


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The AXA Health Billing Principles are a binding part of the terms of your recognition. They're set out to provide clarity in your work with us and support for your patients' care. We're very proud to have a prompt, effective relationship with over 40,000 clinicians, working in collaboration with our members - your patients.

In these Principles, we explain which services and treatment we will and won't pay for. The information will guide you on when you need to contact us, what you need to do to ensure invoices are paid quickly and ensures our work together runs smoothly.

Following these Principles also means giving us the information we need, at the right time. This helps ensure we can best support your patient's care and that commercial discussions don't get in the way of treatment.


Important Points


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  • We'll pay eligible fees in full at the rates we have agreed with you at the time of your recognition, provided that you always charge up to the level shown within the Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/ for treatment you've provided (unless otherwise agreed with AXA Health).

  • We only pay for care that involves a definite consultation as set out in the terms below, or for procedures where a CCSD code exists and is charged under the terms of our policies and our billing and recognition terms, unless explicitly agreed by AXA Health in writing in advance.

  • We won't pay you to provide assistance to another clinician where they are billing for a procedure or service which we would typically expect to be undertaken by one clinician.

  • We'll only pay you for the services you directly undertake. We won't pay for you to supervise, oversee, or otherwise support, but not deliver, services provided by others.

  • Publication of a code in the Schedule doesn't guarantee eligibility for any member. We expect you to ensure that all treatment has been pre-authorised before it takes place.

  • If you're not sure about the billing or use of a potential code or combination of codes, please contact us in advance and we'll always be happy to help with your queries. Billing for any service or treatment that isn't listed in the Schedule of Procedures and Fees, outlined in these Billing Principles or outlined in your contract without first seeking approval from AXA Health, or intentionally billing in a misleading way, may be considered fraudulent and may result in AXA Health taking action against you.

  • In line with your professional obligations, any medical records or information you send us must be complete, accurate, clear and signed by the treating provider. They must include details of procedures, treatments or consultations as appropriate and include the patient's name, relevant dates and treatment start and end times.

  • Our memberships are designed to cover the costs of the short-term treatment of acute medical conditions. As with other private medical insurers in the UK, we have exclusions for certain types of care, such as treatments and procedures:

    • for ongoing or chronic conditions

    • which are primarily cosmetic in nature

    • for weight loss treatment

    • which are related to professional sports

    • which could reasonably be treated within primary care.

There are some exceptions to the above - for example, following treatment for cancer.

We don't fund treatment that's not eligible for funding under the terms of our and our members' policies. We expect specialists to use reasonable endeavours to understand what's covered in the policies that we offer our members and to work with our members in doing so.

  • We expect you to undertake care in a reasonable setting and with reference to relevant guidelines and standards for the type of care, whether outpatient, day case, or inpatient.

  • If a member is admitted as an inpatient and we subsequently find out their admission is not covered under the terms of their policy, we expect your cooperation in supporting the member with their choice of continuing care on a self-pay basis, transfer, or any other appropriate resolution.

  • You're responsible for ensuring that the information provided in relation to your funding from AXA Health, such as coding or medical notes, is clear, accurate, and complete. This is important as we use this information to assess eligibility and to settle claims. Providing false, misleading, or selective information may be considered fraudulent and may result in AXA Health concluding our commercial relationship with you and/or taking action against you.

  • We need time to consider pre-operative requests which may affect your fees or the way you carry out a procedure. Please send us the relevant information at least five working days before the scheduled treatment, unless there are genuinely extenuating reasons that this is not possible, in which case we would require the information at least two days before the scheduled treatment. Please note that if this information isn't reasonably provided in advance, or clinicians threaten to not proceed with care if exceptional financial requests are not met, this may affect your recognition status with us, and you may temporarily or permanently be suspended from authorisations with new members.

We reserve the right to conclude our recognition of individual specialists for commercial reasons.


1: Pre-treatment and Pre-authorisation Provisions


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1.1 - Consultations

We define a consultation, whether face-to-face or remote (online or by phone), as a meeting between patient and provider which:

  • evaluates the nature and progress of an active condition

  • establishes a diagnosis, prognosis and treatment plan; and

  • includes at least ten minutes of direct interaction between you and the patient.

Emails or other correspondence with patients are not chargeable or payable.

AXA Health set the consultation fee rates:

  • to include all charges relating to that consultation, whether face-to-face or remote (online or by phone), for example, room fees, IT costs and administration, and

  • to accommodate all consultations, including those which may be both shorter and longer, or less or more complex.

We won't pay additional or multiple fees when consultations are longer than expected.

For recognised consultants, we typically expect to be billed for only one consultation for each patient on any given day, and no more than one consultation per week, and no more than two per month, except in exceptional circumstances on a named basis where you've contacted us in advance, and this has been agreed with us.

For recognised therapists, our expectation is that members will typically attend no more than one therapy session per week, for as long as clinically necessary. If there are legitimate clinical factors that necessitate additional sessions, these may be scheduled accordingly but must be agreed in writing in advance and at our discretion.
Our fees for your services are based on the clinical necessity of the treatment, not on the length of the session.

We don't pay for cancelled, missed, or declined appointments. Intentionally billing for consultations or sessions that didn't take place may constitute fraud and will result in recognition removal.

We'll pay for inpatient consultations if:

  • you're a general medical physician in charge of the patient's care, and

  • you've visited them in hospital and spent at least ten minutes face to face with them per consultation, and

  • the patient has been in hospital for over ten days, and

  • you or another clinician in your specialty have not performed a procedure on or provided anaesthesia to the patient in question within the past 10 days, and are not performing a procedure or anaesthesia on that day, and

  • you're not providing routine post-operative care.

These will be paid at the daily attendance fee rate.

We don't pay for consultations by anaesthetists (unless separately recognised as a pain management specialist and providing outpatient consultations for this purpose), pathologists, radiologists, or neurophysiologists.

If there's a legitimate clinical need for a pre-operative consultation by an anaesthetist, you must seek advance approval from AXA Health, supplying satisfactory evidence of clinical necessity. If we don't receive this in advance, then the consultation won't be eligible for funding by AXA Health.


1.2 - Tests and pathology

We'll fund diagnostic tests or pathology tests when you have reasonable suspicion of a medical condition and where the tests are likely to make a demonstrable difference to the treatment our members will receive.

Diagnostic tests and pathology must be carried out in line with national guidelines and evidence-based practice, where such tests are required to direct and manage a patient's treatment plan.
Screening tests are generally not eligible for funding.

Diagnostic tests must take place at one of our recognised facilities and scans must take place at a facility within our scanning network.

A single fee is paid for diagnostic tests, typically to a facility. Fees for interpretation of diagnostic tests are paid as part of this single fee. AXA Health and our members don't pay for the undertaking, interpretation, or other stages of tests, including where a hospital, clinic, or other facility has invoiced for the test, or where a test charge includes or is reasonably expected to include a component relating to a specialist. We pay the hospital, clinic or facility directly for these services. If required, you should negotiate appropriate payment for your services directly with the facility.

Where a CCSD coded test or diagnostic procedure takes place during or on the same day as a consultation, there are certain services for which we wouldn't expect to see any additional charge, including fees for diagnostic tests or procedures that routinely form part of a follow up consultation.

Please see the FAQ for further details about diagnostic testing.

The above doesn't apply to clinicians billing for specific eligible therapeutic interventional radiology procedures in line with our Schedule of Procedures and Fees.

All monitoring, including remote monitoring, is not chargeable.

Phlebotomy is not chargeable.


1.3 - Information you should provide to members before and after a consultation

Before confirming an outpatient consultation appointment, we expect our members to receive all of the following information from you:

  • the estimated cost of the consultation

  • details of any financial interests you may have in the facility or its equipment

  • a statement advising insured patients to check their level of cover with their insurer

  • a clear explanation of any planned tests or treatments, alongside, or as part of the consultation, including what they are, their rationale, and a summary of key benefits and risks.

Following their first consultation with you, we expect our members to receive the following information from you:

  • a clear explanation of any further tests or treatment that you've proposed, including what they are, their rationale, and a summary of key benefits and risks

  • an estimate of the cumulative cost of the treatment pathway which has been recommended, which should include:

    • all fees you charge (separately from hospital fees)

    • contact details for any other consultants whose fees are not included in the quote

    • a statement of services which haven't been included in the estimate, such as those which could result from unforeseeable complications. Where alternative treatments are available, but the appropriate treatment can only be decided during surgery, the estimate should set out the relevant options and associated fees.

After the consultation, you should provide your patient with all relevant CCSD coding for any proposed treatment. If a patient doesn't have correct codes, this may delay pre-authorisation.


1.3.a - Professional obligations and conflicts of interest

We expect you to follow the professional guidance provided by your regulatory body.

We expect you to adhere at all times to the GMC's Good Medical Practice guidance and the Medical Capacity Act 2005, and we expect you to comply with the Private Healthcare Market Investigation Order 2014 (as published by the Competition and Markets Authority).

Conflicts of interest are taken extremely seriously by AXA Health. You must explicitly disclose perceived, potential, or actual conflicts of interest in full and in advance to both AXA Health and each member you see. This includes, but is not limited to:

  • Direct or indirect compensation or recognition for referrals to clinical or non-clinical services (including consulting and advisory services) undertaken at hospitals, clinics, or other facilities, or any company involved in developing or selling drugs, medical devices, or prostheses.

  • Direct or indirect compensation or recognition for referrals to clinical or non-clinical services (including consulting and advisory services) undertaken by other clinicians.

  • Shareholding in any organisations where you're undertaking or referring care, or prescribing or using the medical devices, drugs, or other products, produced, marketed or sold by those organisations.

We may suspend your recognition if you make referrals which we consider (in our absolute discretion) are motivated by direct or indirect financial gain for you or a third party. We don't expect you to accept referrals where you're aware that you're not able to fully support the members' needs with the express intention of referring the member on to another specialist (for either of your direct or indirect financial gain).


1.4 - Urgent care centres and admissions from urgent or emergency appointments

Medical admissions resulting from Urgent Care Centre visits or other urgent or emergency appointments are not eligible for funding.


2: Treatment Provisions


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2.1 - Coding

Pre-authorisation for any proposed treatment is needed in advance of the treatment taking place. Your patients need to confirm that they're eligible for any proposed treatment plan by contacting our Personal Advisory Team. We give our members contact information within their policy documents.

We work with the CCSD group to help create industry standard procedure codes. We publish any codes we introduce in the "Important information" section of our Schedule of Procedures and Fees. Please use these codes when billing us for treatment. They should be reasonable and within their intended purpose, as defined by the CCSD: https://www.ccsd.org.uk/

Please provide our members with all relevant CCSD codes in advance of their treatment so this information can be added to their claim. Without this information being provided upfront there may be delays in pre-authorisation being given.

We may, at our discretion, cover procedures which aren't listed by code in our Schedule of Procedures and Fees. We'll need additional information from you to help us consider your proposed treatment.

If you can't find the code you need, please:


We'll use this information to help find the correct code and we'll tell you the corresponding fee. When there is no appropriate procedure code, we'll allocate the nearest code and may also review the fee independently, considering any additional complexities. Once you have the right code, please share this with your patient so they can pre-authorise their treatment. This will also help avoid any doubt when you invoice us. If you believe there is no appropriate code for the treatment you wish to carry out, or that the narrative does not reflect what you're doing, please contact CCSD directly and request a new code. We review requests and possible changes with them regularly.

For eligible robotic procedures, you should use the relevant robotic procedure code rather than a conventional code. Not all robotic codes are eligible for funding, so you'll need to check prior to going ahead with robotically assisted surgery. Where the robotic procedure is not eligible, but we allow the conventional equivalent, we'll provide the appropriate procedure code for you and pay the conventional fee only.

You shouldn't use codes covering existing procedures for new and as yet uncoded procedures.

For the avoidance of doubt, CCSD codes are paid per procedure and not per specialist.

If incorrect codes are intentionally used to facilitate authorisation of an ineligible claim, this may constitute fraud.


2.2 - The fees that AXA Health pay

We list the majority of procedures we pay for in our Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/. We'll pay eligible fees in full at the rates we've agreed with you at the time of your recognition provided that you always charge up to the level shown within the Schedule of Procedures and Fees (unless otherwise agreed with AXA Health). We won't pay for you to supervise services provided by others. You won't be reimbursed for any shortfall which arises from billing below these agreed rates. Our fees include all component parts, for example:

  • pre-operative assessment

  • the procedure itself, including local anaesthetic and/or intravenous (IV) sedation by the main operator

  • all routine post operative aftercare, including any consultations within 10 days of the procedure.

Please see Section 2.3 of these Principles for guidance on submitting an exception to this principle.

We pay the hospital, facility or clinic directly for the in-patient services listed below. We don't pay you separately for these services:

  • consumables, including drug costs

  • equipment charges

  • inpatient therapies

  • near patient testing.

If required, you should negotiate appropriate payment for your services with the facility.

Any inpatient procedure fee includes the cost of a daily review of the patient. You'll undertake daily reviews of any patients who you undertake a procedure for and who has an inpatient stay. If you're unable to undertake daily reviews for any unforeseen reason, you'll arrange daily reviews by a recognised specialist with similar expertise to you which will not be chargeable to AXA Health.

If a member's policy is subject to an excess, the member will be responsible for making any shortfall payment directly to you. You may obtain such payment from the member, but you must not in any event charge the member more than the applicable excess amount or make a direct charge to the member in any other circumstances.


2.3 - Our fees: Exceptions

Please don't bill for any service or treatment not listed in the Schedule of Procedures and Fees, outlined in these Billing Principles or outlined in your contract.

If you believe an additional fee is appropriate, please:



2.4 - Unbundling

We take a common-sense approach to unbundling.

We list the most frequently occurring procedures together on our website, on our Schedule of Procedures and Fees. We also publish some unbundled codes on our "Important changes" document on our website.


2.5 - Sole procedures

A code has "sole procedure" in the narrative when it is performed by itself. You may only bill sole procedures in isolation.


2.6 - Bilateral procedures

Where a bilateral procedure CCSD code exists, we expect providers to use this to undertake a procedure. Where there is no code for a bilateral procedure and the procedure is only in exceptional circumstances undertaken bilaterally, we'll pay for a second procedure in accordance with the multiple procedure rules if pre-authorisation is requested and explicit consent to bill in this manner is provided in writing.


2.7 - Provider code

Your Provider Code is your unique identifying code. Your Provider Code should be used solely to bill for treatment that you've carried out yourself for a member. You mustn't use your Provider Code to invoice for any treatment or services provided by anyone else.


3: Bespoke Requests


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3.1 - Fee uplifts and multiple specialist requests

On occasion, you may need to submit more than one code for surgery. When this happens, we'll pay the full amount for the procedure with the highest complexity and 50% of the fee for the second procedure.

We appreciate that we can't address every medical situation or surgical complication in setting fees. If you're planning a genuinely exceptional and complex series of procedures which aren't covered in the principle outlined in the paragraph above and aren't likely to recur, we may consider a bespoke request. For all other code changes we encourage you to contact CCSD as noted above.

We expect our providers to make uplift requests pre-operatively unless there are strong extenuating reasons not to do so. Our guidelines on pre-operative uplift requests are set out below, along with circumstances in which you may submit post-operative uplift requests or multiple specialist requests. Please note that we don't expect you to redirect a patient's care or cancel treatment if you're unable to agree your preferred fee with us. We'll take situations like this seriously and we may withdraw your recognition in these circumstances.


Pre-operative uplift request

Where you anticipate a procedure will be more complex than expected, for a specific clinical reason, we'll estimate the fee. We'll need:

  • an explanation of why an enhanced fee is appropriate, and why the standard codes are not appropriate

  • the estimated time in theatre (including specific operative time and total time)

  • an indication of what you wish to charge

  • a full description of the procedure being performed and

  • associated procedure codes.

Please note we'll periodically audit the pre-operative requests we receive and may request operation notes and anaesthetic charts post-operatively.


Post-operative uplift request

We understand that unexpected situations can occur which substantially elongate and complicate surgery. We'll consider paying an enhanced fee if this occurs. Please send us any information you think will help us decide whether an increased fee is appropriate. As a minimum we will need:

  • a copy of the original operation notes (please also submit typed notes if handwritten notes are unclear)

  • anaesthetic charts

  • theatre in/out charts

  • an indication of the fee requested.


Multiple specialist requests

Multiple specialist requests are generally only considered where there's a clear evidence base for funding multiple providers in specific and rare circumstances.

We'll only consider requests for additional specialists who are recognised by AXA Health for benefit purposes in connection with the provision of treatment to members, where the lead surgeon retains ultimate responsibility for the patient.

We won't pay for the fees, costs or expenses of any additional specialist where you've not submitted a request to us for approval of the additional specialist.

When agreeing treatment, we'll provide an estimate of fees paid for all specialists in connection with the treatment. If, after treatment, you would like us to adjust our estimate, please send us your operation notes and anaesthetic charts, so we can understand:

  • your role and each additional specialist's role in the procedure

  • the time spent in theatre (knife to skin)

  • specific evidence, including clear and unambiguous national guidelines, for multiple specialist involvement being the standard of care for the procedure you're undertaking, and for the procedure being rare, and

  • any other evidence you wish us to consider.

We'll then confirm the fee we will pay for the treatment.

We won't pay you for the fees, costs or expenses of any additional specialists. Additional specialists who are recognised by AXA Health will need to bill us separately under their own Provider Code.

If you involve an additional clinician who isn't recognised by AXA Health, in line with our terms and conditions, we won't be liable for their fees. Please submit your bespoke request using the specialist fees enquiry form on our Provider website https://provider.axahealth.co.uk/individual/individual-provider-support/.

We review all requests individually using the evidence you provide.

We want to make sure your patients can confidently book treatment without worrying about what we'll pay. To support with this, please allow at least five working days' notice for any pre-operative requests, including coding queries and requests for multiple specialists. We need this time to review the information you send us. Otherwise, we'll review your request post-operatively.


Treatment at a facility outside our network

The majority of our members choose a policy requiring them to receive treatment at one of our network facilities.

We pay all charges for eligible treatment at any hospital listed as a network facility in line with our agreements. In normal circumstances, we pay only a limited daily benefit for treatment at a facility that is outside of our network and is not listed in our directory.

If a member is likely to require treatment, and the treatment is available at a facility from which you operate, the member should be supported to access care at that facility (provided it is in our network/the member's chosen network).

If the required treatment is not available at a facility from which you operate, we'll expect you to, where possible, offer to refer the member to another specialist who is able to provide the treatment at a facility within our network.

In exceptional circumstances, if a patient needs access to facilities or treatments which aren't available at one of our network facilities, we may in our discretion pay the charges.

This specific exemption must be requested before treatment commences. Where we've agreed, we'll pay all charges for eligible treatment at the relevant facility which is best placed to provide the necessary care.

To request an exemption, please complete the Hospital Exemption Request form on our Provider website https://www.axahealth.co.uk/network-exemption.


3.2 - Unproven treatment

We expect specialists to understand in detail the evidence base of, and guidelines for, the treatment they provide. We expect specialists to be able to clearly explain the evidence base and guidelines to members and AXA Health.

We generally don't fully cover treatment or surgery that isn't conventional treatment for the member's medical condition ("unproven treatment").

We'll only pay for treatment that we agree is a suitable equivalent to conventional treatment for the member's medical condition. This also means we'll never pay for an unproven treatment if there's no established conventional treatment available for the member's medical condition.

For information on how AXA funds treatment please see the following link:

https://provider.axahealth.co.uk/funding-safe-effective-care/.


Conventional treatment

We define conventional treatment as treatment that is established as effective and delivered as best medical practice for a member's medical condition. It must be practiced widely in the UK for the member's medical condition. It must be known to be clinically safe, effective and appropriate in terms of necessity, type, frequency, extent and duration. It must include the involvement of a multidisciplinary team, and where required, must be delivered at an appropriate facility or location.

In addition, to meet our definition, it must be approved by NICE (The National Institute for Health and Care Excellence) as a treatment which may be used in routine practice for the relevant medical condition and underpinned by high quality evidence.

Otherwise, it must have evidence that meets the guidance criteria we set out which is available at axahealth.co.uk/healthcare-funding or on request.

Drug treatment which we fund must be:

  • licenced for use by the European Medicines Agency or the Medicines and Healthcare products Regulatory Agency

  • and used according to that licence.

We expect specialists to have regard of the cost-effectiveness of the care they undertake and where we believe there is unexplained variation or individual cases of concern, may ask them to explain their choices of treatment, including choices of drug or prosthesis.


4: Specific Provisions


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4.1 - Anaesthesia and sedation provisions

Anaesthesia is only funded for eligible surgical treatment.

The anaesthetic reimbursement charge for a procedure includes all pre-operative and post-operative care, including:

  • pre-operative assessment, on the ward or at a clinic, whether this is performed directly by an anaesthetist or otherwise

  • the anaesthetic itself, including all intra-operative and post-operative care and any care in an ITU or high dependency unit (HDU) expected during the procedure

  • inserting and removing all lines and catheters, including central venous pressure (CVP), arterial (ART), continuous cardiac output (CCO), hemofiltration vascaths, nasogastric and urinary tubes

  • monitoring

  • topical or infiltration anaesthesia

  • analgesia, including nerve blockage, neuroaxial blockade or patient- controlled analgesia

  • any other procedures that take place while the member is being anesthetised until they are awaken, save chargeable anaesthesia for a return to theatre after a minimum period of three hours out of theatre and recovery and

  • follow up with the patient for the duration they remain in hospital.

You shouldn't list any of these items as additional charges.

We don't pay specialists for local or topical anaesthesia as a standalone charge.

We don't pay fees for any sedation administered by a main operator or where this could generally be expected to be administered by a main operator or nursing staff.

Following the Guidelines for the Provision of Intensive Care Services jointly published by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) (Edition 1.1 2016), we'll pay a daily fee as listed in our Schedule of Procedures and Fees to the intensivist caring for a patient receiving Level 3 care in an ITU. This pays for all ITU care including, but not limited to:

  • any procedures undertaken by an intensivist, including insertion and care of CVP/ART/vascath/pulmonary artery catheters

  • dialysis/haemofiltration

  • chest drains and

  • tracheostomy insertion or endotracheal tube changes

  • provided the consultant always spends at least ten minutes of direct contact or care with the member and there is credible documentary evidence of this.

We won't pay this fee to the anaesthetist present during the surgery.


4.2 - Injections and infusions

As they're not separate surgical procedures, we don't accept separate charges for the following, whether a relevant CCSD code exists or not:

  • subcutaneous, intramuscular or intravenous injections, including vaccinations where eligible

  • drug/electrolyte infusions, including blood/fresh frozen plasma/platelets.

We include injections and infusions within our standard consultation or hospital fee, whether given during a planned consultation or by appropriate nursing staff during a hospital stay.


4.3 - Chemotherapy and radiotherapy

Charges for the prescribing and supervision of chemotherapy should be made in accordance with the schedule set out in Chapter 18 of our Schedule of Procedures and Fees https://provider.axahealth.co.uk/schedule-of-procedures-and-fees/.


Chemotherapy

The coding covers all care relating to the clinical supervision and planning of the delivery of chemotherapy (only ONE of the following: X0001 OR X0002 OR X0003 OR X0004) regimens and the engagement and management of patients, including but not limited to:

  • regime prescription

  • supervision of planning and treatment delivery

  • side effects management and the prescription of an alternative regimen

  • supervision of all outpatient, day patient, and inpatient care.

Only one supervision fee will be paid for any course of treatment regardless of whether a single or multiple drug combination is used. We expect that invoices for chemotherapy and biological supervision should be made at the end of the cycle of treatment.

We'll pay a chemotherapy supervision fee when a member is receiving chemotherapy as an inpatient. We won't pay consultation fees in addition to chemotherapy supervision fees during this time.

We won't pay for a consultation while a member is receiving chemotherapy treatment as an out patient or day case.

Oncologists can charge the daily inpatient consultation fee for each day the member is in hospital due to side effects of chemotherapy when the treatment has stopped, provided that the consultation fee is otherwise eligible.

Consultations can only be billed when there is a break in treatment and the period to which the chemotherapy supervision charges apply has concluded.

When a member is on long term maintenance treatment, we won't pay for follow up consultations unless there's a break in treatment and no supervision fee has been paid which covers the date of the consultation.


Radiotherapy

Charges for the prescribing and supervision of radiotherapy should be made in accordance with the schedule set out in Chapter 20 of the CCSD Schedule.

As per CCSD guidance, it is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery. Please see the CCSD Schedule for more information: https://www.ccsd.org.uk/.

These codes cover all care relating to the clinical supervision and planning of the delivery of radiotherapy regimens and the engagement and management of patients, including but not limited to:

  • regime prescription

  • supervision of planning and treatment delivery

  • expected side effects management and the prescription of an alternative regimen

  • supervision of all outpatient, day patient, and inpatient care, including any transfusion of blood/blood products

  • consultations relating to the delivery, monitoring, or other aspects of or related to radiotherapy.

We expect invoices for radiotherapy supervision and treatment delivery to be issued at the end of the cycle of treatment.


4.4 - Consent

Any procedure fee includes the cost of ensuring high quality, clear, effective informed consent, and a discussion and estimate of the benefits and risks of a procedure.

You must ensure that members are informed of the likelihood of benefits and risks using a personalised estimation, and this must include a quantitative estimate of the likelihood of death, major complications, and the resolution of the symptoms or condition which the procedure is intended to resolve.

Consent isn't generally expected to be taken immediately prior to an inpatient procedure except in a genuine emergency.


5: Administration and Governance


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5.1 - Submitting invoices

You must submit all invoices for eligible claims with clear and full information, including an accurate diagnosis code at the date of service, no later than six months after the date of treatment.

You must settle your invoices with us directly. We may suspend your recognition if you send patients invoices or seek payment from them directly (unless you're recouping an agreed excess amount in accordance with these Principles).

We'll immediately withdraw your recognition if you conceal (or ask a member to conceal) a request for direct payment.

To help us to pay you promptly, we recommend you submit invoices electronically via our e-billing provider Healthcode.

Any items billed twice in a day must note the times at which the services took place to be eligible for payment.

Invoices must include or be accompanied by any information which you reasonably believe is important for AXA Health to make a decision on the eligibility of a charge or claim especially if this information could affect the eligibility for insurance funding.

If you're invoicing us for treatment which has taken place over more than one day, you must send us individual itemised invoices for each day on which treatment took place.


5.2 - Payment

We send you remittance advice telling you the total amount we're paying you for treatment, which patient the payment relates to and any reasons the invoice wasn't paid in full (for example, if there was a membership limitation).

Your patients receive similar statements advising them of any costs their membership doesn't cover, which they must settle with you.

To ensure patients can pay you quickly, please let us share your bank details with your patients by updating your details on PPR: https://www.healthcode.co.uk/the-ppr/.

We'll also send your patients the invoice address you gave us when you became recognised. Please ensure it is an address you are happy for your patients to know (a business, rather than a home address, for example). If you'd like us to use a different address, please update your details on the PPR. We're unable to assist when the dispute in payment is the member's liability (excess, cost share etc.).

It's your responsibility, as the provider, to bill us at your contracted rate.

We reserve the right to recoup any ineligible payments which we have made to you, including but not limited to:

  • any payment made by us in error

  • any payment for treatment carried out which wasn't eligible as a benefit under the member's policy

  • any payment for treatment which wasn't pre-authorised by us

  • any other ineligible payments identified during an audit by us of your invoicing history.



5.3 - Requests for medical documentation

During your patient's treatment we may request medical information or documentation to make a decision about a claim.

As the treating provider, we expect you to ensure that the information you provide, such as coding or medical notes, is accurate. This is important as we use this information to agree treatment for patients and settle their claims quickly.

We expect you to comply with the good practice guidance of your regulatory authority when submitting this information.

For example, the general medical record keeping standards of the Royal College of Physicians expect that "every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed". https://www.rcplondon.ac.uk/projects/outputs/generic-medical-record-keeping-standards.

We expect your documents to be complete, accurate, clear and signed by you. They should include details of procedures, treatments or consultations as appropriate and should include the patient's name, relevant dates and treatment start and end times.

If you submit documents or information that don't adhere to these standards, we won't be able to review them or consider your request. If in doubt, please supply typed notes with the original copies.

Please note:

  • We'll let you know where to send this information when we request it.

  • We'll ask for this information to be submitted as soon as possible, but no later than 10 days after we have asked for it - accepting that there will also be occasions (for example, cancer cases) where we may require this information to be provided sooner.

  • It's your responsibility to gain your patient's consent to share this information.

  • Without this consent, we may not be able to review the information you've sent us.

  • We try to request the minimum appropriate information needed to make a decision.

  • Under the General Data Protection Regulation (GDPR), you're the controller of this information, and you're responsible for ensuring you send the correct information to us.

We don't pay you for providing this information or for completing reports.

We may audit medical notes as part of our quality control procedures. Once the member signs a consent form authorising this disclosure, we'll ask you to provide this information.


5.4 - Providing inaccurate information, fraud and misrepresentation

Our business is conducted on the basis of good faith. We monitor claims using data mining software and routinely audit claims by reference to medical records.

We won't tolerate fraud and misrepresentation and will cease doing business with any provider who provides false, misleading or selective information. We may also refer cases of fraud to the GMC (or relevant regulator), any relevant fraud databases and the police, as appropriate.

We consider the following examples constitute inappropriate and potentially fraudulent billing. We may suspend your recognition without notice and/or take action against you if we believe that any of these are taking place or have taken place:

  • billing for care that did not occur

  • billing for care that you did not directly and wholly or near-wholly undertake and provide, including on behalf of another clinician

  • billing with an inaccurate diagnostic or procedural code, or with a less accurate code when a more accurate one exists

  • billing with more codes than needed to accurately summarise the care undertaken, including unbundling

  • billing for consultations, investigations, or procedures on multiple days when the procedures can reasonably be expected to be undertaken on the same day

  • billing for any care that would have been ineligible but for you withholding or not otherwise disclosing relevant information to us, where it is reasonable to assume this information would have been shared in a medical report (e.g., the accurate date of onset of the first related condition or symptoms to a member's presenting complaint)

  • billing for any care where misrepresentation, including but not limited to careless misrepresentation and omission of key facts, has led to (or could have potentially led to) a decision of eligibility for funding

  • billing for items which are explicitly set out as neither chargeable nor payable in these Principles

  • using technical information which is presented in a way likely to mislead: a claim for laser in situ keratomileusis (LASIK), for example, coded as keratoplasty.

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