ECLIPSE errors

Eligibility check response codes

These errors can occur for ECLIPSE claims, and the actions required provide solutions that may allow you to resubmit a claim. The source documentation word file (with Appendix A & B error codes) is available on the Services Australia website.

Response code

Message

Reason

Action required

1005

Facility ID not known to fund

The facility ID supplied is not registered at the fund/not current

Check the facility ID; if correct contact the fund, if incorrect re-submits with corrected data

1100

Not eligible for selected service

The patient is not eligible for treatment for the presenting illness or item according to the information supplied in the eligibility check

Tell the patient that they are not eligible for the service


1101

Eligible for service selected

Patient is eligible for the presenting illness or item according to information supplied in the eligibility check


1102

Eligible subject to conditions

Patient may be eligible for the presenting illness or item according to the information supplied in the eligibility check. However, there may be conditions you will need to note before you proceed such as: 

  • financial status 
  • reduced benefit is payable 
  • possible pre-existing condition

Refer to OEC guide for assistance on areas to check


1103

Resubmit for new assessment if presenting illness is shown

A general presenting illness or item was requested and a general answer displaying all benefit limitation or restriction that apply to the patients cover was returned in the response

Check the eligibility response carefully and re-submit if the actual presenting illness or item is displayed to obtain an accurate assessment 

1104

Eligible for selected service at previous cover

The patient is eligible for the presenting illness or item on the incoming eligibility request but not at their current cover. This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover

The patient is eligible for the service on their previous level of cover


1105

Not eligible for selected service – wait period applied     

The patient is not eligible for the presenting illness or item as they have not completed serving their required waiting periods


1106

Eligible for selected service at previous cover – wait period applied

The patient is eligible for the presenting illness or item as input on the incoming eligibility request but not at their current cover. This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover


1107

Not eligible for selected service – pre-existing ailment

The patient is not eligible for the presenting illness or item if it is deemed to be a pre-existing condition


1108

Eligible at previous cover subject to conditions

The patient is eligible for the presenting illness or item as input on the incoming eligibility request but not at their current cover. This message generally results where the patient is still serving the required waiting period applicable on the upgrade in cover


1109

Eligible subject to approval of accident certificate

Fund won’t guarantee payment of the service until an accident certificate is supplied and approved

Ask member to contact the fund


1110

Eligible subject to conditions and approval of accident certificate

Fund won’t guarantee payment of the service until an accident certificate is supplied and approved and there is another condition that will affect assessment. This could be: 

  • financial status 
  • pre-existing ailment or waiting period 
  • reduced benefit is payable

Ask member to contact the fund regarding the accident certificate and to check the other conditions of the eligibility response


1111

Unknown presenting item

The presenting illness or MBS item could be: 

  • incorrectly input 
  • ceased 
  • not on item database at the fund

Check the item number. If correct contact the fund, if incorrect amend and re-submit


1999

Processing error 


Contact fund

2001

Waiting period applies for pre-existing ailments

No benefit payable 


2002

Service is within the required waiting period

No benefit payable


2006

Benefit not payable for services claimed or requested

No benefit payable 


2007

Incorrect charge – charge exceeds the allowable amount for the claim type

Charge input is greater than the agreed rate for an agreement or scheme claim

Check the charge amount and claim type, correct the error and re-submit

2008

Public hospital table – Nil benefit

No benefit payable


2009

A benefit is not payable for this service under this level of cover

No benefit payable


2010

Membership was not paid to the date when the service was provided



2017

Default benefit only paid for this procedure

Lesser benefit paid for this service 


2026

Member issue as at date of service


Ask the member to contact the fund

2888

Refer to OEC response & assessment text

There is an issue with the overall eligibility response that will affect the service line assessment result

Check and correct the eligibility issue, then re-submit

2999

Processing error contact fund

The fund has a processing error that may be unique to the membership or claim supplied

Contact the fund to find out the reason for the error

Patient verification error messages

These errors can occur for ECLIPSE claims, and the actions required provide solutions that may allow you to resubmit a claim. The source documentation word file (with Appendix A & B error codes) is available on the Services Australia website.

Response code

Message

Reason

Action required

7026

DVA file number does not have a Gold or White card and may not be eligible for services 

DVA specific

Verify file number and resubmit claim

7028

Name does not match registered name for File Number

DVA specific


7035

Patient gender must be male or DVA specific IHC claims

DVA specific


9650

The patient data supplied failed validation checks against Medicare data

DVA specific


9662

Provider not recognised by fund 

Provider not recorded on health fund system

Location or provider to contact fund 

9663

Member number not recognised by fund 


Member number not known by the fund the claim was submitted to. No other patient data checked at this time

Check member number and fund, correct whichever is wrong and try again

9665

Patient not recognised on the membership 


Member number is valid

Cover for membership number is permitted – no patient is identified or multiple patients are identified


Check patient details and re-submit. Make change to the alias name if Medicare has sent back a successful response

Provide sufficient patient details to ensure unique match within membership

9666

Member to contact fund 


Possible fraud,  accident claim or membership issues

Member to contact fund 

9667

Cover is suspended or cancelled 


Member Number is valid

Can’t lodge a hospital claim as member is not covered for that service. Check with member

9668

Inappropriate cover 


Cover is either ancillary or ambulance only


Can’t lodge a hospital claim as member isn’t covered for that service. Check with member

9669

Patient is ceased or pending cessation 


Member number is valid

Appropriate cover for membership number

Patient details matched

Member to contact fund

Patient may not have current student registration


9686

Baby not known at fund 


No patient match is found and the DOB of the patient is less than 29 days from the earliest date of service in the Online Patient Verification Request

Member needs to register the baby at the fund