Making accurate claims
Identifying the essential points of making accurate claims for the practice team
04 December 2019
While the ultimate responsibility for making general ophthalmic services (GOS) claims rests with the practitioner submitting the form, the wider team is key in helping to ensure that the practice makes appropriate claims for the GOS services it provides and that patients get the support to which they are entitled. Navigating through a system that can at times seem quite complicated is key.
The background check
The process starts when a patient contacts the practice for an appointment. It is useful to check, either in the practice records or by asking the patient, when their last test was to avoid patients presenting too early for a routine test. It is important to remember though that if they are ‘not due’ you should check the reason why they want an appointment – if a patient has symptoms, they can be seen under GOS with an appropriate code so they should be given an appointment. It is helpful to note this in the diary for clinical staff to see.
One of the most common reasons a patient who had glasses supplied under the voucher scheme will return to the practice is for repair of those glasses
When the patient attends for their appointment you should confirm that they are eligible for a GOS test (other than in cases where this is readily apparent, for example, due to their age or the test being carried out in Scotland) and mark the appropriate box on the claim form.
If a patient requires new glasses, it is important to check that they are still eligible for a GOS voucher at the date of dispense. This is usually the same day as their test, but may be at a later date, and just because they were eligible in the past or even on the day of their test does not mean they are entitled to the voucher at a later date if their circumstances have changed (for instance, if they no longer receive the appropriate benefit, have left full time education or are now beyond the appropriate age).
Conversely, if a patient becomes eligible and they require new glasses, they can be issued a voucher at that time. This does not require another sight test, but you should note this clearly in the records and a voucher can be issued by an optometrist in the practice.
If an adult presents to the practice with broken glasses which were supplied on a voucher then you should contact the local NHS to apply for a repair
One of the most common reasons a patient who had glasses supplied under the voucher scheme will return to the practice is for repair of those glasses. Those under 16 years of age can have their glasses repaired as often as necessary, but a good record of these repairs is vital for any payment verification checks. You should make sure that it is clearly recorded in the notes what was required to be repaired (for example, side broken/lens(es) scratched), what voucher was claimed and the relevant dates. This saves time for your optometrist or dispensing optician as they only have to quickly check that information and then sign the form.
Those over 16 years of age are only entitled to repairs under certain circumstances and these must all be approved before the form is submitted for payment. If an adult presents to the practice with broken glasses which were supplied on a voucher then you should contact the local NHS to apply for a repair. If they approve this request, a code will be issued which should be inserted on the form allowing a claim to be made. Once again, you should also record the reason for the repair, what was repaired and the relevant dates.
GOS3 or GOS4
When completing a GOS3 or GOS4, it is important to remember that the maximum amount claimable is the lower of the usual retail price or the voucher value. This is particularly important if your practice offers a complete price option which is less than the voucher value. Similarly, for repairs, you can claim either the cost of the repair or the appropriate voucher for that type of repair, whichever is lower.
Other articles in this series
- The ABC of GDPR: Demystifying the regulation and what it means for the practice
- Social media: the rules of engagement: The importance of ensuring a positive impression online for the practice
- A smooth journey: A clinical technician’s take on capturing images
- The DNA of effective complaint resolution: Taking a systematic approach when handling complaints
- Passing the baton: Discussing teamwork and the handover in practice
- Ethical dilemmas for the practice team: Scenario-based assessments.