TELUS eClaims

Table of Contents

1. Overview
2. Initial Setup
   • 2.1 General Settings
   • 2.2 Setting Up Providers
   • 2.3 Setting Up Patients
   • 2.4 Configuring Products
3. Workflow 1: Sale Order → Check Insurance → Invoice → Submit eClaim
4. Workflow 2: Direct Claim Submission
5. Workflow 3: Direct Invoice Claim Submission
6. Workflow 4: Manual Nullify Claim
7. Understanding Claim Statuses
8. Understanding Responses
9. UAT Simulator Scenarios
10. Claim Form Tabs Reference
11. Troubleshooting

1. Overview

The TELUS eClaims module allows vision care providers to electronically submit insurance claims to TELUS Health directly from Got2. It integrates with the existing Sale Order and Invoicing workflows so that insurance predetermination, claim submission, and payment reconciliation all happen within your normal business flow.

Key capabilities:

• Submit insurance claims (invoices) to TELUS Health and receive Explanation of Benefits (EOB) responses
• Run predetermination checks ("Check Insurance") before confirming a sale to estimate insurance coverage
• Nullify/cancel previously submitted claims
• Automatically post insurance payments against invoices
• Track claim statuses (Paid, Pended, Rejected, Error, Nullified) with full audit trail
• Attach EOB PDFs and request/response XML to records for reference

2. Initial Setup

2.1 General Settings

Navigate to Configuration → Settings → TELUS eClaims.

Here you configure the global production mode toggle:

• Production Mode OFF — All claims are sent to the TELUS UAT (testing) environment at ehealthswitch.uat.telushealth.com    . Use this for all testing and certification.
• Production Mode ON — Claims are sent to the live TELUS production environment at ehealthswitch.telushealth.com    . Only enable this after certification is complete and you are ready to submit real claims.

⚠️ Warning: Never enable Production Mode during testing. Real claims submitted to real insurers involve real money and cannot be easily reversed.

2.2 Setting Up Providers

Providers are configured on the Employee record. Any employee can be designated as a TELUS provider.

Steps:

1. Go to Employees from the main menu.
2. Open the employee who will be submitting claims.
3. Click the "TELUS eClaims" tab at the bottom of the employee form.
4. Check "Is TELUS Provider" to reveal all configuration fields.

Provider fields to fill in:

Provider Types:

2.3 Setting Up Patients

Patients are configured on the Patient record under the TELUS Insurance tab.

Steps:

1. Go to Patients from the main menu.
2. Open the patient record.
3. Click the "TELUS Insurance" tab.
4. Check "Is TELUS Patient" to reveal all insurance fields.

Patient fields to fill in:

Secondary Coverage (Optional):

If the patient has a second insurance plan, check "Has Secondary Coverage" and fill in the secondary insurer fields. If the secondary insurer participates in eClaims, keep "Sec is eClaims" checked. If they do not participate (e.g., Accerta), uncheck it — the system will use the carrier-specific OID format (2.16.840.1.113883.3.368.10.1.6.<Carrier ID>    ).

2.4 Configuring Products

For the Sale Order workflow, your products need to be mapped to TELUS service codes so the system knows which items are claimable.

Steps:

1. Go to a Product form.
2. In the product settings, enable "eClaims Claimable" (eclaims_is_claimable    ).
3. Set the "eClaims Service Code" (eclaims_service_code    ) to the appropriate TELUS service code.

Common service codes by provider role:

Only products with "eClaims Claimable" enabled will be included when submitting claims from invoices. Non-claimable products on the same invoice are ignored.

3. Workflow 1: Sale Order → Check Insurance → Invoice → Submit eClaim

This is the recommended workflow for day-to-day use. It integrates insurance checking and claim submission into your normal sales flow.

Step 1: Create a Sale Order

Create a Sale Order as you normally would. Add products that have "eClaims Claimable" enabled and a service code configured. Set the patient and select the provider.

Step 2: Check Insurance (Predetermination)

Click the "Check Insurance" button on the Sale Order. This sends a predetermination request to TELUS for each claimable line, asking "how much will the insurer cover?"

The system sends the claim details to TELUS without actually submitting a final claim. TELUS responds with an estimated coverage amount for each service line.

After the predetermination completes, each SO line shows the estimated insurance coverage so you and the patient can see the expected out-of-pocket cost before proceeding.

Step 3: Confirm the Sale Order

Once the patient agrees to proceed, click Confirm to convert the quotation into a confirmed Sale Order, just like the standard Got2 flow.

Step 4: Create the Invoice

Click Create Invoice to generate the customer invoice from the confirmed Sale Order. The invoice is created in Draft state.

Step 5: Submit eClaim from the Invoice

On the invoice (account.move    ), click the "Submit eClaim" button. This sends the actual insurance claim to TELUS.

If the claim is approved, TELUS responds with an Explanation of Benefits (EOB). The system automatically:

• Posts an insurance payment (account.payment    ) against the invoice for the amount TELUS approved
• Reconciles the payment with the invoice
• Attaches the EOB PDF to the invoice record
• Updates the claim status to Paid/EOB

The remaining balance on the invoice is what the patient owes out of pocket.

Step 6: Collect Patient Balance

The invoice now shows the remaining balance after the insurance payment. Send the invoice to the patient or collect payment through your normal process.

4. Workflow 2: Direct Claim Submission

For cases where you want to submit a claim without going through the Sale Order flow (e.g., quick one-off claims or testing).

Steps:

1. Go to eClaims → Claims.
2. Click New to create a new claim.
3. Fill in the claim form:
   • Select Provider (the employee configured as a TELUS provider)
   • Select Patient (must have TELUS insurance configured)
   • Set Claim Type to "Invoice"
   • Set Service Date (must be today or earlier, within 31 days)
   • Set Service Code (e.g., V2020)
   • Set Cost (e.g., $100.00)
   • Optionally set Eye Indicator (Left, Right, or leave blank for Both)
   • If using UAT, select the Simulator Scenario (e.g., DYNAMIC_ACCEPT for a successful test)
4. Go to the Terms & Conditions tab and accept the T&C.
5. Click "Submit to TELUS".

The claim processes and the status updates automatically based on the response.

5. Workflow 3: Direct Invoice Claim Submission

For cases where you already have an invoice created (from a different source or manual entry) and want to submit it as an eClaim.

Steps:

1. Open the invoice in Invoicing → Customer Invoices.
2. Ensure the invoice contains products with "eClaims Claimable" enabled and valid service codes.
3. Click the "Submit eClaim" button in the invoice header.
4. The system builds the FHIR payload from the claimable invoice lines and submits to TELUS.
5. On success, the insurance payment is posted and reconciled automatically.

This workflow skips the predetermination step. Use it when you already know the coverage or don't need an estimate beforehand.

6. Workflow 4: Manual Nullify Claim

For nullifying a claim from the eClaims menu directly.

Steps:

1. Go to eClaims → Claims.
2. Click New to create a new claim.
3. Set Claim Type to "Nullify / Cancel".
4. Enter the Original Claim Reference — this is the TELUS claim ID of the claim you want to cancel (found on the original claim record).
5. Select the Nullify Reason (EIE or ALTD).
6. Click "Submit to TELUS".

8. Understanding Claim Statuses

9. Understanding Responses

When a claim is submitted, TELUS responds with one of these:

Explanation of Benefits (EOB) — The claim was approved. The EOB contains the payment breakdown: what the insurer pays, deductibles, co-pays, and the patient's responsibility. The EOB PDF is automatically extracted and attached to the claim/invoice record.

Acknowledgement (ACK) — The claim was received but is being held for review. This typically means the insurer needs more time or information. The claim status is set to "Pended." Do not resubmit — wait for the insurer to process it.

Rejection — The claim was denied. The error message from TELUS explains the reason (e.g., patient not covered, service not eligible, duplicate claim). Review the error, correct the issue, reset to draft, and resubmit if appropriate.

Detected Issue (OperationOutcome) — A structural validation error. The FHIR payload had a problem that prevented processing (e.g., missing required field, invalid OID, profile mismatch). Returns HTTP 400. Fix the underlying data issue and resubmit.

10. UAT Simulator Scenarios

When testing in the UAT environment (Production Mode OFF), you can control the response type using the Simulator Scenario field on the claim form. This tells the TELUS Simulated Adjudicator what kind of response to return.

Note: The Simulator Scenario field is only relevant in UAT mode. In production, real insurers process claims based on actual policy data — there is no simulator control.

11. Claim Form Tabs Reference

The claim form has several tabs for different aspects of the submission:

Main Tab — Provider, patient, claim type, service details, cost, and simulator scenario.

Service Lines Tab — For claims with multiple services (e.g., V2020 Frames + V2750 Other Lens). Each line has its own service code, quantity, unit price, and optional eye indicator.

Terms & Conditions Tab — Displays the TELUS eClaims Terms & Conditions (English and French). The provider must accept the T&C before submitting any claim. Submission is blocked if T&C is not accepted.

Advanced Tab — Additional configuration including payee type override, secondary coverage settings, and the Provincial Insurance Exhausted (PIE) override for test 2.2.2.48.

Request XML Tab — After submission, displays the complete FHIR XML request that was sent to TELUS with syntax highlighting. Useful for debugging and for sharing with TELUS support if needed.

Response XML Tab — After submission, displays the complete FHIR XML response received from TELUS with syntax highlighting.

12. Troubleshooting

"You must accept the Terms & Conditions before submitting"

Go to the Terms & Conditions tab on the claim form and toggle the acceptance to Yes. This is required for every submission.

"Network is unreachable" or connection timeout

Your server cannot reach the TELUS endpoint. Check your internet connection, firewall rules, and VPN if applicable. The UAT endpoint is ehealthswitch.uat.telushealth.com     on port 443.

HTTP 400 — OperationOutcome / Detected Issue

The FHIR payload has a structural problem. Check the Response XML tab for the specific error message from TELUS. Common causes include missing required fields, wrong OID values, or invalid service codes for the provider role.

"Service code 'XXXXX' is NOT in the standard vocabulary for your provider role"

The service code you entered is not valid for the selected provider's role. Opticians (OPTICSPY/RO) use V-codes (V2020, V2100, etc.) and Optometrists (OPT) use evaluation codes (92002, 92004, etc.). Change the service code or change the provider.

Claim shows "Paid/EOB" but should be "Pended"

This was a known issue in earlier versions where ACK responses were misclassified. Ensure you are on module version 4.0.0 or later which correctly detects ACK and PREDACK form codes.

Duplicate claim / cached response from TELUS

TELUS UAT returns cached responses when the same Message ID is reused. If you reset a claim to draft and resubmit, the module automatically generates a fresh UUID. If you still see unexpected results, create a new claim instead.

ISS.0088.9112 — intermittent server exception

This is a known intermittent TELUS UAT server error, not related to your payload. The module has built-in retry logic with progressive backoff (up to 5 attempts). If it persists, wait a few minutes and try again.

Service date must be within 31 days

TELUS requires the service date to be today or earlier, and within 31 days of the submission date. If testing from a different timezone, use yesterday's date to avoid timezone-related future-date rejections.

"Reset to Draft" and resubmit

If a claim fails, click "Reset to Draft" to return it to draft state. Fix the issue (wrong service code, missing field, etc.) and click "Submit to TELUS" again. A new message ID is generated automatically.

Insurance payment not reconciling with invoice

Ensure the invoice is in a posted/validated state before submitting the eClaim. The insurance payment (account.payment    ) is created and reconciled against the existing invoice automatically.

Nullify rejected — "THE CLAIM CANNOT BE REVERSED"

The original claim has already been nullified or is outside the permitted reversal window. Check the original claim status — if it's already Nullified, no further action is needed.