POAC business rules - Waikato

The Primary Options Acute Care (POAC) programme supports primary care through specific clinical services, to provide safe, acute care within the community where, in the absence of POAC funding the patient would be referred acutely to an emergency department. 

The Primary Options team is responsible for the management of POAC claims and processes. This service is provided to all Pinnacle general practices across the Waikato region.  

POAC funding eligibility

In order to receive a POAC funded service patients must:  

• be eligible to access funded New Zealand health care services - to ascertain eligibility for primary healthcare funding please refer to the Ministry of Health website
• meet the individual eligibility criteria for the specific service 
• have given their consent to the recommended treatment 
• have been advised and agree that they may be liable for costs should the claim be declined 
• agree that their information may be shared with another health provider as part of their treatment plan.  

Service delivery guidelines

We ask that you ensure that the service is delivered in line with the following: 

• it is clinically safe and appropriate to manage the patient’s care in the community 
• in the absence of POAC funding, the patient would be referred to hospital 
• the treating clinician is able to take responsibility for the patient’s care, or has the option to hand over the patient to another clinician 
• the services are delivered within the business rules set out here. 

Please refer to the individual programmes for specific criteria. 

General exclusions

The following are excluded from POAC. We are unable to fund these for any service. 

• Services where alternative funding streams are available (even if the funding is considered inadequate or partial), including but not confined to: 
  • ACC  
  • maternity and pregnancy related services 
  • PRIME funding 
  • innovation or other funded services through your PHO 
  • point of care ultrasound 
  • palliative home visits 
  • contracted services to rest homes 
  • GP beds.  
• Any patient care that would not require presentation to hospital as indicated in individual POAC services. 
• Any patient where the initial plan involves admission to hospital (i.e. high acuity) – refer to hospital. 
• In no circumstances should a patient be managed in primary care if the level of acuity is beyond the service provider’s capability and compromises patient safety. 
• POAC is not to be used as a top up to alternative funding available to a patient/practice. 

Please note that individual programmes may have specific exclusions. 

Exclusion criteria to access POAC funding should not preclude emergency treatment of any medical conditions. 

Additional referral guidelines  

Referral to an urgent care clinic when the GP practice is unable to complete the episode of care

Where a GP/NP cannot provide services, they may refer the patient to a local urgent care clinic or out of hours facility. The referring GP/NP must complete a clinical handover with the accepting treatment provider. A letter of referral must also be provided to the patient including the POAC case number, to be handed to the accepting treatment provider on presentation. The treatment provided to the patient will remain free as long as the patient meets POAC criteria.  

Patient transport – (referral to ambulance and/or taxi or free community transport)  

Transport to and from care/treatment locations if the patient cannot drive themselves and has no other option of transport i.e. family member or friend. This must be arranged with the Primary Options team.  

Additional claiming guidelines  

If there are any issues with claiming, the team may amend the invoice and indicate the reason why they have amended it. This will appear on the remittance advice, so adjustments can be made at the practice. Where additional information is required, the case will be declined and a request for further information made.  

All invoices will be held for processing until the outcome of the case has been lodged.

Any cases that have been inactive for more than two months will not be funded. 

Please be aware: 

• any claim exceeding $300 (GST incl.), including ALL costs incurred by a practice, will be reviewed by the Primary Options team and the full claim may not be paid 
• should a claim be declined, the initiating provider is responsible for all in-clinic charges
• where third party referral providers have delivered a service against a declined claim, please be aware the cost may be passed on to the patient by the third-party provider  
• where demand for POAC services exceeds funded contract volumes, Pinnacle MHN reserves the right to restrict access to the particular service and/or revise the service schedule fees with minimal notice (providers will be advised immediately should this occur).