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Circular No 08/18

General PHIAC Circulars

AGREEMENT OF PHIAC 3 AND PHIAC 4 WITH PHIAC 1 FORM

Insurers are reminded that the amounts reported on the quarterly PHIAC 3 Prostheses Report and PHIAC 4 Medical Gap Report should be consistent with data reported in the quarterly PHIAC 1 Form. The totals reported on the PHIAC 3 Form for prosthetic items and benefits and PHIAC 4 Form for medical services, amount charged and benefits, should agree with the totals on the PHIAC 1 Form.

The following rules apply when comparing the Forms:

PHIAC 3 to agree with PHIAC 1

• the total number of prostheses should equal field s0451 on the PHIAC 1

• the total benefits paid for prostheses should equal field s0454 on the PHIAC 1

PHIAC 4 to agree with PHIAC 1

• Section 4.1.1 Total number of services. The total for No gap agreement should be equal to the sum of fields s2380, s2381, s2382, s2383and s2384 on the PHIAC 1. The total for Known gap agreement services should be equal to the sum of fields s2385, s2386, s2387 and s2388 on the PHIAC 1.The No agreement services should be equal to field s2395 on the PHIAC 1

• Section 4.1.2 Total amount charged for in-hospital medical services. The sum of the totals under the three categories should be equal to field s2316 on the PHIAC 1

• Section 4.1.3 Total Medicare benefits paid for in-hospital medical services. The sum of the totals under the three categories should be equal to field s2336 on the PHIAC 1

• Section 4.1.4 Total fund benefits paid for in-hospital medical services. The sum of the totals under the three categories should be equal to field s2356 on the PHIAC 1

• Section 4.1.5 No of gap services. The total for No gap agreement should be equal to zero. The total for Known gap agreement services should be equal to the sum of fields s2385, s2386, s2387 and s2388 on the PHIAC 1. No agreement services should be less than or equal to the sum of fields s2391, s2392, s2393 and s2394 on the PHIAC 1.

PHIAC has detected both small and large discrepancies between the returns for some insurers. It is expected that, as the returns report data for the same period in every state, the totals should agree. PHIAC will query returns that are not consistent. It will be appreciated if insurers do their own consistency checks before submitting data to PHIAC.