Business Rules
National Enrolment Service and
Capitation Based Funding
________________________________
Version 2.0
Revision history
This document is the working draft approved by PSAAP for use in the roll out of the National Enrolment
Service to Contracted Providers.
Feedback on this document can be provided to the Primary Care team at the Ministry of Health.
Date
Version
Description
Author
May 2015
1.0
New document to reflect the implementation of the National Jess White
Enrolment Service scheduled 1 July 2015
March 2016
1.1
Updated draft in light of revised implementation date and Alastair McLean
trialling of production software
March 2016
1.2
Updated following internal consultation within the Ministry
June 2016
2.0
Draft approved by the sector working group convened by Alastair McLean
PSAAP to review the business rules and enrolment
requirements in light of the implementation of the National
Enrolment Service.
Alastair McLean
Page 2 of 31
Table of Contents
REVISION HISTORY................................................................................................................................................. 2
INTRODUCTION ..................................................................................................................................................... 4
PURPOSE ............................................................................................................................................................... 6
BUSINESS RULE #1: CONTRACTUAL REQUIREMENTS .............................................................................................. 7
BR# 1.1 - PHO SERVICES AGREEMENT ..............................................................................................................................7
BR# 1.2 - SUBCONTRACTED (BACK TO BACK) AGREEMENTS...................................................................................................8
A PHO MUST HOLD A CURRENT BACK-TO-BACK AGREEMENT WITH EACH OF THEIR CONTRACTED PROVIDERS IN ORDER TO RECEIVE CBF
PAYMENTS. ................................................................................................................................................................... 8
BUSINESS RULE #2: ENROLMENT ........................................................................................................................... 9
BR# 2.1 – ENROLMENT ..................................................................................................................................................9
BR# 2.2 – ENROLMENT EXPIRY ......................................................................................................................................10
BR# 2.3 - PRELIMINARY ENROLMENT PROCESS FOR NEWBORNS...........................................................................................11
BUSINESS RULE #3: NATIONAL ENROLMENT SERVICE .......................................................................................... 12
BR# 3.1 - PATIENT IDENTITY AND NHI VALIDATION ...........................................................................................................12
BR# 3.2 – GEOCODING VALIDATION ...............................................................................................................................13
BR# 3.3 – DATE OF BIRTH, ETHNICITY AND GENDER VALIDATION .........................................................................................14
BR# 3.4 - HIGH USER HEALTH CARD (HUHC) VALIDATION .................................................................................................15
BR# 3.5 - NES ENROLMENT UPDATES.............................................................................................................................16
BR# 3.6 - NES SNAPSHOT ............................................................................................................................................18
BUSINESS RULE #4: CAPITATION BASED FUNDING ............................................................................................... 19
BR# 4.1 - FUNDING CALCULATION ..................................................................................................................................19
BR# 4.2 – PAYMENT PROCESS .......................................................................................................................................21
BR# 4.3 GENERAL MEDICAL SERVICE (GMS) DEDUCTIONS FROM CAPITATION BASED FUNDING .................................................22
BR# 4.4 - PHO NOTIFICATION OF CHANGE TO CAPITATION BASED FUNDING...........................................................................24
BR# 4.5 – INCORRECT PAYMENTS...................................................................................................................................26
BUSINESS RULE #5: REPORTING ........................................................................................................................... 27
BR# 5.1 – NES AND CAPITATION BASED FUNDING PAYMENT REPORTING ..............................................................................27
DEFINITIONS, ACRONYMS, AND ABBREVIATIONS ................................................................................................ 29
REFERENCES......................................................................................................................................................... 31
Page 3 of 31
Introduction
Capitation Based Funding (CBF) is the subsidy funding that Primary Health Organisations (PHOs) receive
based on the number and demographic characteristics of the PHO’s Enrolled Population. This
population-based approach to primary health care provision focuses on maintaining, restoring and
improving people’s health using funding according to the needs of the population served.
CBF is the Ministry of Health’s system for linking funding to population health needs and thereby
pursuing the vision of the primary health care strategy.
Enrolment has four steps:
1) a person chooses a Contracted Provider of First Level and Urgent Care Services (eg. general
practice or Health Care Home) to be their regular and on-going provider of these services; and
2) the Contracted Provider assesses whether the person is entitled to be enrolled; and is eligible for
the full range of publicly funded health and disability services.
3) the eligible person formally enrols with a Contracted Provider and becomes part of the PHO’s
Enrolled Population; and
4) the enrolled person is recorded in the National Enrolment Service.
Contracted Providers and PHOs are to take all reasonable steps to ensure that correct data is collected
and updated correctly in the National Enrolment Service (NES). NES is the enrolment service hosted by
the Ministry of Health and is the master source of truth for individual’s enrolment status with links to
other core services, which is used to assess individual patient demographics, entitlement to enrol and
eligibility for funded healthcare. Patient demographics are sourced from the National Health Index,
which is the master source of truth for such data. The NHI number holds the following information:
-
Name (including alternative names such as maiden names),
-
NHI number
-
Address
-
date of birth
-
Sex
-
New Zealand resident status
-
Ethnicity
-
and if appropriate, date of death, or flags indicating any medical warnings or donor
information.
Page 4 of 31
The main mechanism to update the National Enrolment Service is via the enrolment services integrated
into a Contracted Provider’s Practice Management System. The National Enrolment Service will capture
changes to a person’s enrolment information and status in a national database in real time.
Once the thresholds1 agreed by PSAAP (PHO Services Agreement Amendment Protocol) have been met,
a monthly snapshot from NES is used to calculate the Capitation Based Funding paid to PHOs and
Contracted Providers for delivering primary care services.
NES enrolments refer only to Enrolment with a Contracted Provider of First Level Services and its
Contracting PHO (in accordance with the PHO Services Agreement) for the purpose of calculation and
payment of primary care CBF payments.
1
PSAAP has agreed to accepting NES as business as usual for CBF payments once a minimum of 98% of practices in all PHOs are
live with NES and the national CBF payments calculated from NES data are within 0.02% of the payments calculated by the
existing CBF process. In addition no individual practice can have a greater than 0.2% discrepancy in its CBF funding between
payments calculated from NES data and payments calculated by the existing CBF process.
Page 5 of 31
Purpose
The purpose of this document is to provide the business rules for the calculation and payment of PHO
Capitation Based Funding using NES as the source of a PHOs enrolled population.
This document is divided into the following broad categories:
1) Contractual Requirements
2) Enrolment
3) National Enrolment Service Requirements
4) Capitation Based Funding Payment
5) Reporting
The intended audience for this document is DHBs, PHOs, Management Services Organisations (MSOs)
and Contracted Providers.
Unique Identifier
Rule number
Title / Name
Rule title
Rule
Rule statement
Event
Circumstances under which rule applies
Description
Detailed clauses
Source
Source of data under rule
Related Rules
BR# 1.2
References
PHO Services Agreement
Page 6 of 31
Business Rule #1: Contractual Requirements
BR# 1.1 – PHO Services Agreement
Item
Details
Unique Identifier
BR# 1.1
Title / Name
PHO Services Agreement
Rule
A PHO must hold a current PHO Services Agreement with a DHB to receive
CBF payments. The DHB must notify the Ministry of Health of this
Agreement.
Event
Formation of a new PHO
Source
Ministry of Health Contract Management System
Related Rules
BR# 1.2
References
PHO Services Agreement
The PHO Services Agreement must specify how the parties to the Agreement
are identified, for example by NZBN, HPI Org-ID, Perorg number, payee
Notes
number, or others as required.
Page 7 of 31
BR# 1.2 – Subcontracted (Back to Back) Agreements
Item
Details
Unique Identifier
BR# 1.2
Title / Name
Subcontracted (Back to Back) Agreements
Rule
A PHO must hold a current Back-to-Back Agreement with each of their
Contracted Providers in order to receive CBF payments.
Event
A new Contracted Provider contracts with a PHO or an existing Contracted
Provider changes PHO
i.
Description
When a Back to Back Agreement is signed with a new
Contracted Provider, PHOs will apply to the Ministry of Health
via its contact centre for an HPI-Organisation identifier for that
Contracted Provider so that Enrolment information can be
recorded accurately in NES.
Related Rules
BR# 1.1
References
PHO Services Agreement
Page 8 of 31
Business Rule #2: Enrolment
BR# 2.1 – Enrolment
Item
Details
Unique Identifier
BR# 2.1
Title / Name
Enrolment Rules
Rule
NES will hold one active Enrolment per person per day.
Event
A person and the Contracted Provider complete the enrolment process in
accordance with the Enrolment Requirements for Contracted Providers and
Primary Health Organisations, and on confirmation of that person’s
enrolment the Contracted Provider will enter the enrolment details into the
Practice Management System (PMS), with an automatic synchronisation to
NES.
i.
Description
A person’s enrolment start date in NES is the date in which the
Contracted Provider enters that person’s enrolment information into the
PMS with an automatic synchronisation to NES.
ii. NES will not allow a person to be enrolled with two Contracted Providers
on the same day.
Source
NES
References
Enrolment Requirements for Contracted Providers and Primary Health
Organisations
Notes
The enrolment start date may or may not be the date the enrolment form
was signed and dated by an authorised person. The enrolment start date will
be the date in which the Contracted Provider enters enrolment information
into the PMS with an automatic synchronisation to NES.
Hard copy enrolment forms will remain in place during and NES
implementation and will continue until such time as patient completed
electronic enrolment is possible.
Page 9 of 31
BR# 2.2 – Enrolment Expiry
Item
Details
Unique Identifier
BR# 2.2
Title / Name
Enrolment Expiry
Rule
A person’s Enrolment will expire and be ended in NES if that Enrolment
exceeds the three year maximum period without a First Level Service
Consultation; or Confirmation of Enrolment by that person; with the
Contracted Provider.
Event
A person has not presented for First Level Services at their Contracted
Provider for three years
NES management of expired enrolments includes:
i.
Description
Automatically ending expired Enrolments by a batch process run once a
day between 2300 and 0600.
ii. Expired Enrolments automatically ended in NES will be notified to the
Contracted Provider
iii. The Contracted Provider’s PMS will process the NES notifications to
ensure that the local PMS is synchronised with NES. Expired Enrolments
within NES are not extracted for Capitation Based Funding purposes.
iv. The enrolment end date is the date the enrolment expired within NES.
Source
NES
References
Enrolment Requirements for Contracted Providers and PHOs
Notes
Enrolments due to be expired are included in the PHO Enrolment Report
generated from NES.
Page 10 of 31
BR# 2.3 – Preliminary Enrolment Process for Newborns
Item
Details
Unique Identifier
BR #2.3
Title / Name
Preliminary Enrolment Process for Newborns
Rule
A Contracted Provider may enrol a newborn baby with a ‘pre-enrolled’
status (B code) for funding purposes before the Enrolment Process is
completed.
Event
A Contracted Provider receives a notification of birth from the National
Immunisation Register (NIR) and may enrol the newborn with a ‘preenrolled’ status.
i.
Description
A newborn enrolment with a pre-enrolled status will be accepted for
Capitation Based Funding for a period of 90 days.
ii. A newborn pre-enrolment status will expire in NES after 90 days unless
the status is updated to “Enrolled” by completion of the Enrolment
Process.
iii. Funding for a newborn pre-enrolment will cease at the third monthly
CBF payment following acceptance of the pre-enrolment in NES. The
newborn pre-enrolment or Enrolment date may not precede the
newborn date of birth.
Source
NES
References
Enrolment Requirements for Contracted Providers and Primary Health
Organisations.
The NES system can produce reports to provide details of newborn preenrolments due to expire before the next payment cycle.
Notes
A ‘B’ code is the pre-enrolment code used by some PMS to denote a
newborn that has been accepted for funding before the Enrolment Process
has been completed. NES records preliminary newborn enrolments as ‘preenrolment’ and does not record the ‘B’ code.
Page 11 of 31
Business Rule #3: National Enrolment Service
BR# 3.1 - Patient Identity and NHI Validation
Item
Details
Unique Identifier
BR# 3.1
Title / Name
Patient Identity and NHI Validation
All Enrolled Persons with a validated NHI will have a record in NES. NHI
Rule
validation will occur through the NHI Patient Identity Service.
Event
A person wishes to enroll with a Contracted Provider.
i.
Description
When an individual presents, Contracted Providers can search and view
the NHI records for an individual from within the PMS, and update the
PMS with the most recent demographic data for the patient if the NHI
data is more current.
ii. Authorised NES users will also be able to update the NHI record if new
information is available, synchronise both the PMS and NHI with the
most recent demographic data for the individual patient, and add a new
NHI record if the individual is new to the NZ health system.
iii. Enrolled Persons’ demographic details drawn from the NHI patient
identity service and held in NES will be extracted on the snapshot date
to calculate the CBF payment.
Source
National Health Index patient demographic information.
Related Rules
BR# 3.2, 3.3, 3.4, 3.5,
Page 12 of 31
BR# 3.2 – Geocoding Validation
Item
Details
Unique Identifier
BR #3.2
Title / Name
Geocoding Validation
Rule
A person’s primary residential address recorded in the NHI patient identity
service will determine the geocoding and deprivation quintile used for the
CBF calculation and payment.
Event
Geocoding an enrolled person’s address in NES
i.
Description
An Enrolled Person’s primary residential address should be validated by
the approved geocoding service before being added to that individual’s
NHI record.
ii. The NES snapshot will extract the individual’s primary residential
address details drawn from the NHI patient identity service and held in
NES to calculate the CBF payment.
iii. An Enrolled Person with a non-validated address at the snapshot date
will receive Capitation Based Funding in the unknown quintile
deprivation payment category.
Source
NHI Patient Identity Service for all demographic information.
Related Rules
BR# 3.1, 3.3, 3.4, 3.5
Notes
Authorised users may update the NHI with a person’s validated primary
residential address by recording the validated address in their PMS and
synchronising it with the NHI.
Page 13 of 31
BR# 3.3 – Date of Birth, Ethnicity and Gender Validation
Item
Details
Unique Identifier
BR# 3.3
Title / Name
Date of Birth, ethnicity and gender validation
Rule
An Enrolled Person’s date of birth, ethnicity and gender demographic
information are recorded on the NHI Patient Identity Service and will be
used for Capitation Based Funding calculation and payment.
Event
Calculation of Capitation Based Funding payments.
i.
Description
A person’s date of birth, ethnicity and gender demographic
information is validated and recorded in the NHI Patient Identity
Service.
Source
NHI Patient Identity Service for all demographic information.
Related Rules
BR# 3.1, 3.2, 4.1
Notes
An Enrolled Person’s age, gender, ethnicity and deprivation quintile as at the
snapshot date, is used for Capitation Based Funding calculation purposes.
Page 14 of 31
BR# 3.4 – High User Health Card (HUHC) Validation
Item
Details
Unique Identifier
BR# 3.4
Title / Name
High User Health Card (HUHC) Validation
The NHI number, HUHC number and HUHC expiry date held in an Enrolled
Rule
Person’s NES record will be validated against the HUHC reference data held
at the Ministry of Health for Capitation Based Funding purposes.
Event
Calculation of Capitation Based Funding payments.
An Enrolled Person will be marked as a valid HUHC holder when:
Description
i.
The NHI number, date of birth and gender of the HUHC holder
match HUHC reference data held at the Ministry of Health; and
ii.
The HUHC expiry date is not more than one month prior to the
date of the NES snapshot; and
iii.
The HUHC card is not declined or cancelled.
Source
Ministry of Health HUHC reference data
Related Rules
BR# 4.1
Notes
NES will store HUHC entitlement card information referenced against its
source database.
Page 15 of 31
BR# 3.5 – NES Enrolment Updates
Item
Details
Unique Identifier
BR# 3.5
Title / Name
NES Enrolment Updates
Rule
A person’s enrolment status in NES will be automatically ended following a
number of events. Contracted Providers will be able to view changes to an
Enrolled Person’s enrolment status within NES.
Event
A person can have only one active enrolment in the NES. A person’s
Enrolment will automatically end in the NES following a number of events.
A person’s Enrolment in NES will be automatically ended; and the
Contracted Provider will receive notification of any update to a person’s
Enrolment in the following events:
Date of Death:
i.
Description
When a registered date of death for a person is recorded in the NHI
Patient Identity Service, that person’s Enrolment in NES will be
automatically ended; or
ii. When a Contracted Provider receives provisional notification of date of
death, or a death overseas, and the Contracted Provider can confirm this
notification; the Contracted Provider should manually end that person’s
Enrolment in NES.
iii. CBF will cease at the next payment cycle after the date in which the
deceased person’s Enrolment in NES is ended.
Patient Transfers
iv. When a Contracted Provider enrols a person, any previous Enrolments
for that person will be ended. The Enrolment end date will be the day
before the new Enrolment start date.
Duplicate Patients
v. When a duplicate Enrolment occurs for a person as a result of merging
Page 16 of 31
two NHIs the Contracted Provider with the most recent enrolment date
or Confirmation of Enrolment date at the time of merging two NHIs will
retain the person’s Enrolment. The enrolment with an older date will be
ended and the Contracted Provider notified.
vi. The enrolment end date will be the date it was updated in NES.
Prisoners
vii. When a person is sent to prison they will not be entitled to Capitation
Based Funding for the term of their imprisonment.
Other Exclusions
viii. Appendix One of the Enrolment Requirements for Providers and PHOs
lists categories of Visa that qualify for Capitation based Funding. Visas
categories outside this list do not qualify for funding
Source
NES
References
Enrolment Requirements for Providers and PHOs
Notes
The NES Enrolment Report provides details of change of enrolment status.
Page 17 of 31
BR# 3.6 – NES Snapshot
Item
Details
Unique Identifier
BR# 3.6
Title / Name
NES Snapshot
Payment will be calculated on a snapshot of active enrolments on the first
day of each calendar month. An enrolment (enrolled or pre-enrolled) is
considered ‘active) in a specific date if the patient is living, eligible, and the
enrolment:
Rule
-
Was recorded on or prior to the specified date; AND
-
Has not ended prior to, or on the specified date AND
-
Is for an available health service AND
-
Relates to an active service provider or allocating authority
organisation.
Event
Monthly NES Snapshot
i.
Description
.The NES snapshot will be an extract of Enrolment, NHI and HPI data
used in the calculation of Capitation Based Funding. This snapshot of
NES data will be used for Capitation Based Funding calculation and
payment processing.
ii. CBF payments made from the snapshot of NES data will cover persons
enrolled in the month prior to the snapshot being taken.
Source
NES
Related Rules
BR# 3.5, 4.1, 4.2
Page 18 of 31
Business Rule #4: Capitation Based Funding
BR# 4.1 – Funding Calculation
Item
Details
Unique Identifier
BR# 4.1
Title / Name
Funding Payment Calculation
An Enrolled Person’s Funding is calculated according to the age, HUHC
status, ethnicity, deprivation quintile and gender. This information is sourced
Rule
using the NES snapshot taken at 0001 hours on the first day of each month,
and calculated using the Ministry of Health Payments Calculator.
Event
Calculation of Funding for Enrolled Persons
Capitation Based Funding
Each Enrolled Person’s record will be assigned an individual category based
on a combination of the following subcategories.
i.
Age: is calculated by the difference between first day of the month and
date of birth.
ii. Gender: is either male, female or unknown. A person with an unknown
gender will be assigned the male value.
iii. HUHC status: is derived as either cardholder or non-cardholder.
Description
iv. Deprivation quintile: Deprivation quintile (1–5) is derived from the
individual’s validated primary residential address. Addresses that are not
validated using a geo-coding service will be counted in the ‘quintile 1–4’
deprivation payment category.
v. Ethnicity: is derived as either ‘Māori/Pacific Island’ or ‘non-Māori/Pacific
Island’.
Additional Funding available to Enrolled Persons
i.
Funding formula type: Access Practice or non-Access Practice
ii. Additional payment formulas: Very Low Cost Access (VLCA), Zero Fees
Page 19 of 31
Under 6s, Zero Fees Under 13s.
Source
i.
NHI Patient Identity Service for all demographic information.
ii. Ministry of Health HUHC reference data.
Related Rules
BR# 3.1, 3.2, 4.2
References
Ethnicity Data Protocols for the Health and Disability Sector 2004
Page 20 of 31
BR# 4.2 – Payment Process
Item
Details
Unique Identifier
BR# 4.2
Title / Name
Monthly funding payment
Funding payments will be made to PHOs on a monthly basis and calculated
Rule
using the Ministry of Health Payments Calculator.
Event
Funding payments made to PHOs
i.
Description
On the 15th day (or next business day) of each month each PHO will be
paid Funding derived from the NES snapshot taken on the first day of
every month (regardless of whether it is a business day or not) and
calculated through the Ministry of Health Payments Calculator.
ii. Adjustments are made to the next payment after DHB approval is given.
Any fee for service deductions amounts will be applied to the next
available payment date following approval.
iii. A negative balance will result in no payment being made and that
balance carrying over until the next payment.
iv. The lead DHB account will be debited for all services associated with
each PHO’s Enrolled Population.
Source
NES Enrolment, Eligibility and Entitlement database
Related Rules
BR# 3.6, 4.1
Notes
The DHB of domicile will be retained for other purposes
Page 21 of 31
BR# 4.3 – General Medical Service (GMS) deductions from Capitation
Based Funding
Item
Details
Unique Identifier
BR #4.3
Title / Name
GMS deductions
When a payment on a GMS claim is made for First Level Services provided by
a General Practitioner or Practice Nurse employed by a Contracted Provider
Rule
other than the Contracted Provider that the person receiving those services
is Enrolled with; the GMS payment will be deducted from the next CBF
payment from the PHO in which the Enrolled Person is funded.
Event
GMS deductions from Capitation Based Funding payments
i.
Description
Where a GMS claim is paid and the Enrolled Person’s NHI, Enrolling
Organisation HPI-O, PHO HPI-O, and date of service match the PHOs
records for payments for Enrolled Persons; the fee for service subsidy
amount paid will be deducted from the next available Capitation Based
Funding payment for the corresponding PHO.
ii. The number of GMS deductions against an Enrolled Person’s CBF
Payment will be ‘capped’ at three consultations within a given month
(based on date of service).
iii. GMS deductions will not be made for a newborn with a pre-enrolment
status (B code) during the pre-enrolment period of 90 days.
Source
NES and GMS Claims
References
PHO Services Agreement
GMS deductions will be reported to the PHO.
Notes
GMS claims that have not been deducted as a result of the deduction ‘cap’
will also be reported to the PHO.
The timeframe for submitting a GMS claim is 60 days after the date of
Page 22 of 31
service.
A newborn pre-enrolment status is consistent with the commonly used term
‘B- code’ for newborn pre-enrolment.
Page 23 of 31
BR# 4.4 – PHO notification of change to Capitation Based Funding
Item
Details
Unique Identifier
BR# 4.4
Title / Name
PHO Notifications
A PHO must notify the lead DHB of changes to a Contracted Provider or a
Contracted Provider’s funding formula entitlement status. PHOs and their
Rule
funding
DHBs
must
notify
the
CBF
admin
team
(CBF-
[email protected] or Shreya Patel 048163924) of all changes
that affect payment.
A Contracted Provider of a PHO has an agreed change to a Contracted
Event
Provider’s entity status, or a Contracted Provider’s funding formula
entitlement status.
PHOs and their funding DHBs must notify the CBF admin team ([email protected] or Shreya Patel 048163924) of all
changes that affect payment. The situations whereby this notification
is required are:
i.
The opening or closure of a Contracted Provider’ service entity.
ii. A split or merger of a Contracted Provider’s service entity.
Description
iii. Any changes to the funding formula entitlement status of a Contracted
Provider. For example if they enter, exit or change between Very Low
Cost Access, Zero Fees for Under 6 or Zero Fees for Under 13s funding
formulas.
This will ensure that correct Capitation Based Funding calculation and
payment can be made on a monthly basis.
If no notification by the PHO is received by the Ministry of Health Sector
Operations Group at least ten business days prior to the NES snapshot the
changes will not be reflected in the snapshot taken on the first day of the
month.
Page 24 of 31
Related Rules
BR #4.2, 4.5
References
PHO Services Agreement
PHO notification of General Practice changes must be in accordance with
the PHO Services Agreement. A new practice or a practice changing PHOs
Notes
must hold a Contracted Provider Agreement with the existing or new PHO.
Page 25 of 31
BR# 4.5 – Incorrect Payments
Item
Details
Unique Identifier
BR# 4.5
Title / Name
Incorrect Payments
Rule
Capitation Based Funding re-calculations and wash-ups for PHOs will be
completed in the next monthly NES snapshot and Capitation Based Funding
payment following the notification of an incorrect payment as per the PHO
Services Agreement Clause F.15 Incorrect Payments.
Event
The Capitation Based Funding payment made to a PHO is incorrect.
Description
i.
If there is an error in the payment as a result of Ministry of Health or
DHB payment agent processes, a manual adjustment will be made to
correct the error after agreement with the Ministry of Health, DHB and
PHO where applicable, in a timely manner.
ii.
If there is an error in payment as a result of DHB or PHO/Contracted
Provider error the Ministry of Health will correct the payment in the next
payment cycle following notification of an incorrect payment as per the
PHO Services Agreement Part F.
iii. Adjustments will be made as simple debit and credit adjustments.
Whenever one type of adjustment is made to a PHO, a balancing
adjustment must be made to a lead DHB or the Ministry of Health.
Source
References
Notes
Notification and evidence of an incorrect payment provided to the DHB
Payment Agent
PHO Services Agreement
Where payments are disputed, the disputed payment process outlined in the
PHO Services Agreement will be followed.
Page 26 of 31
Business Rule #5: Reporting
BR# 5.1 – NES and Capitation Based Funding Payment Reporting
Item
Details
Unique Identifier
BR# 5.1
Title / Name
NES and CBF reporting
The Ministry will make the monthly reports derived from NES available
securely to PHOs, and PHOs will be able to extract and analyse these reports
Rule
at practice level, practitioner level (if applicable), and NHI level within their
PHO data.
Event
NES and CBF reporting
Reporting to PHOs will provide information at practice level, practitioner
level (if applicable), and NHI level within their PHO. This will support service
development and delivery, funding, monitoring, and planning functions.
The following mandatory reports will be available to PHOs:
Capitation Based Funding Payment Reports:
i.
Capitation Payment Summary Report
ii. Capitation Payment Detailed Report
Description
iii. Buyer Created Tax Invoice
iv. General Medical Service Claim Report
v. Fee for Service Deduction Report
NES Report:
i.
PHO Enrolment Report
The following mandatory reports will be available to DHBs and MoH:
i.
Capitation Payment Summary Report
ii. Capitation Payment Detailed Report (anonymized for DHBs)
Page 27 of 31
iii. Fee for Service Deduction Report
iv. Fee for Service Claim Report (including time and location)
Source
NES and the Ministry of Health Payments Calculator.
Related Rules
BR# 4.1, 4.3, 4.4 and 4.5
References
PHO Services Agreement
PHOs will still be required to submit monitoring data reports to their DHBs
and the MoH as per the contractual obligations of the PHO Service
Agreement between PHOs and DHBs on a quarterly basis.
Notes
This includes:
i.
service utilisation data,
ii. clinical performance indicators and
iii. Provider information.
Page 28 of 31
Definitions, Acronyms, and Abbreviations
Term
Meaning
BR
Business Rules
Contracted Provider
A Contracted Provider means a health service provider, whether an
organisation, individual, or a Practitioner that the PHO subcontracts to deliver
the Services, and includes the Contracted Provider's employees, agents and
subcontractors.
DHB
District Health Board
Enrolling Organisation
The Provider of First Level Services a person is Enrolled with, identified by an
HPI-Organisation ID that is assigned to the Provider in NES
General Practice Entity A General Practice organisation that may be a ‘Contracted Provider’ to provide
Contracted Provider
GP HPI-O identifier
First Level Services.
The Health Practitioner Index - Organisation identifier assigned to a General
Practice
The Health Practitioner Index (HPI) is a national database holding information
to identify health providers and practitioners. The HPI comprises three separate
Health
Practitioner
Index (HPI)
indexes for:
i.
Organisation – HPI-Organisation Id
ii. Facility – HPI-Facility Id
iii. Practitioner – HPI-CPN
A Health Practitioner Index - Common Person Number in this document refers
to the identifier assigned to a practitioner providing First Level Services.
The HPI-CPN is the common index for health practitioners that are registered
HPI-CPN or CPN
with a registration agency (termed Responsible Authority in the Health
Practitioner Competence Assurance Act). An HPI-CPN is allocated to for
example (but not limited to) doctors, nurses, pharmacists, midwives,
physiotherapists.
Page 29 of 31
HPI-Facility,
MoH
National Immunisation
Register (NIR)
NES
The Health Practitioner Index – Facility identifier assigned to service facility
providing First Level Services
Ministry of Health
The National Immunisation Register (NIR) is a computerised information system
that holds national immunisation details for those immunisations on the
national schedule.
National Enrolment Service
The National Health Index (NHI) is an index of all individual’s with their identity
NHI and NHI number
and demographic details. Anyone receiving health care in NZ is assigned a
National Health Index Number (NHI number), and are recorded in the National
Health Index (NHI).
PHO
PHO HPI-O identifier
Primary Health Organisation
The Health Practitioner Index - Organisation identifier assigned to a Primary
Health Care Organisation
Registered death
Valid Identity
A valid identity is a set of identity attributes (NHI number name date of birth and
gender) that when matched to the NHI attributes scores above the threshold for
a valid match.
Page 30 of 31
References
This document should be read in conjunction with the following documents to provide greater clarity on
the business rules outlined.
#
Document Title
Description
Version
Sets out the roles and responsibilities of DHBs and
1
PHO Services
Agreement
District
PHOs to ensure that primary health care services are
funded in a way that is best for individuals, best for the
4.0
system and continually meets the Government's policy
2
Outlines the precise rules for determining an enrolled
Requirements for
individual.
Contracted Providers
and Primary Health
Organisations
Reference document as part of the PHO Services
Health
Boards and
PHOs
objectives.
Enrolment
Publisher
4.0
Ministry of
Health
Agreement V3.0.
Provides a summary of the business rules for the CBF
system that the Ministry of Health uses to calculate
the funding a PHO should receive.
Transition Period for NES:
The Business Rules: Capitation Based Funding v3.9
document will continue to be in use while the CBF
register submission method of submitting PHO
3
Business Rules:
registers for payment is still being used as a source for
Capitation Based
updating the NES.
Funding
NES Implementation
3.9
Ministry of
Health
On completion of the transition period; the Business
Rules: Capitation Based Funding v3.9 document will
become redundant, and The Business Rules: National
Enrolment Service Capitation Based Funding v2.0
document will come into effect.
This document will continue to be a reference
document of the PHO Services Agreement V3.0.
Page 31 of 31