How FreshClaim works
The essential elements of a claim
How FreshClaim manages your claim information
An ECLIPSE claim aggregates multiple pieces of claim data into a single payload submitted to the system. Here are the essential elements FreshClaim uses to build every basic claim type.
Patient identity and eligibility
Name, date of birth, and Medicare number have to match what Medicare holds, and eligibility has to be current for the service date. FreshClaim reads this straight off the patient sticker. If any of it’s missing from the sticker, it goes into the app’s extra-information fields, and once entered, it’s saved so you’re not retyping it next admission.
Referral validity
Every ECLIPSE claim needs a valid referral. That’s a GP referral (valid 12 months), a specialist-to-specialist referral (valid 3 months), or a hospital-based referral, which is what the large majority of FreshClaim’s inpatient claims run on: as long as it’s documented in the hospital notes, it’s valid for the duration of the admission.
Provider details
Treating provider numbers have to be correct for the site of service. A provider number that’s valid at one hospital isn’t automatically valid at another. FreshClaim holds your provider number against the hospital location you’ve given us, so the right one attaches to the right claim without you having to remember which applies where.
Item numbers and claim logic
MBS items have their own internal rules: which items can be co-claimed, which derive their fee from another item, which time-based items need a unit calculation. FreshClaim applies current MBS logic at the point of entry.
Claim item specifics
Some claims fall outside the standard rules: a multitude of specific settings and special conditions apply to individual situations and need extra handling beyond a straightforward item entry. In this situation, FreshClaim will contact you for extra information and liaise directly with funds and Medicare on your behalf to resolve these claims.
Assignment of benefit and consent
Since the 1 July 2026 changes, every claim needs a valid, current assignment of benefit tied to the right consent pathway. For privately insured patients, FreshClaim presumes implied assignment of benefit is obtained through the hospital admission process, which covers the entire treating team, not just the admitting doctor. It’s worth checking with your hospitals that this process is actually in place on their end. For bulk-billed claims, the requirement is more rigorous, and consent needs to be obtained either before or after the episode of care. FreshClaim can provide the relevant paperwork for this. There are a number of transitional provisions in place while the new system phases in, so if anything here is unclear, get in touch and we’ll walk you through it.
Summary
Typically, our claim submission app holds most of the valid information in the very first claim page, and adding these fields alone will qualify the vast majority of incoming claims. A shared database of referring doctors (filtered by state and hospital location) is in development, to remove as much manual data entry as possible when adding referral details. Beyond this, a general service text box is available for adding any useful information to help claims move along. Our goal is to always present a quick, easy-to-use process, and our team of developers is constantly working on ways to make even the complex simple.
Questions about how any of this applies to your claims?
FreshClaim · Australian ECLIPSE-native claiming