SOP 2.3 NHS Making Accurate Claims (Scotland)
SOP 2.3 (Scotland)
Making accurate claims
Why do we need to make accurate claims
As per GOS contracts, all claims must be accurate as far as the information provided allows, to prevent fraudulent claims or overpayment. Local NHS teams audit claims in relation to GOS sight test and optical vouchers. They are legally entitled to inspect records relating to GOS patients which can be a combination of GOS and private records within the period requested. Failure to make accurate claims may result in further investigation of claims, extension of time period of records requested and possibly a fine/reclaim of overpayment.
How often can NHS patients be seen
It is the clinical judgement of the optometrist to determine how frequently a patient needs an eye examination. All examinations should be carried out for a clinical reason. The maximum primary examination frequencies are not recommended recall frequencies, and you should not apply blanket recall intervals to all patients within a category. If you do recall a patient earlier than these intervals, you should recall your justification on the record. All other necessary examinations within this maximum primary examination period may only be claimed as supplementary examinations.
Primary examination can be claimed where a patient presents at a new practice with a clinical reason, but the clinician does not have access to the patient’s previous records (code 7 should be used). The final exception is where a patient presents at the age of 16 but had been last seen when they were 15 and given a 1-year recall for a specific clinical reason (code 8 should be used). Therefore, changing the recall from annually to biennially. Code 9 should be used if an annual sight test is required for a sight impaired or severely sight impaired patient.
What if a patient presents earlier for an NHS examination
Patients may be entitled to an earlier sight test if they present with symptoms that require an eye examination. In these cases, a supplementary examination fee can be claimed, and the appropriate code should be used. Making clear notes as to the clinical reason that would support this is essential.
IMPORTANT TO REMEMBER
It is the presenting symptoms that validate a primary or supplementary examination, not the outcome of the test. The outcome of the test is never the determining factor of a claim.
For a guide to supplementary reason codes Click Here
What voucher value can I process
Voucher values are determined by patient’s prescription power. See voucher values at a glance for guidance Click Here
Eligibility for a voucher is determined by what the patient requires, not the appliance they choose. You can only claim the lower of the voucher value or the retail cost of the appliance. If dispensing later than the sight test date, the patient should be asked to confirm that they are still eligible for the voucher.
If a private patient becomes eligible for a voucher, you should only issue a voucher if there had been a significant change in the refraction, and it has been longer than 2 years since their last spectacles and they no longer have serviceable spectacles.
If a patient has no significant distance prescription but would like bifocals or varifocals, then a voucher A can be used towards the cost of these. Vouchers E-H can only be used towards the cost if there is a clinically significant distance prescription.
Anti-fatigue lenses are not suitable for a voucher E-H claim.
If a patient wishes to have longer working distance lenses for VDU use this is a reasonable claim however the patient would not be entitled to have a further voucher towards glasses for reading or multifocals.
Further information on making accurate claims Click Here