HNZ: Updated claiming guidance for primary care clinical assessments of COVID-19 patients

HNZ: Updated claiming guidance for primary care clinical assessments of COVID-19 patients

Kia Ora Koutou,

The COVID-19 Care in the Community team has been reviewing the clinical guidance and funding model for COVID-19 clinical assessments in primary care. This has involved engagement with primary care leadership.

This review is now complete. The guidance and funding model has been simplified and updated to align with Pharmac’s COVID-19 antivirals eligibility criteria, as well as general COVID-19 and Care in the Community policy. This reflects the commitment to ensuring resources are available for those with the highest clinical risk, rather than providing proactive initial assessments to all COVID-19 positive patients. As a result, this should reduce some of the pressure on the general practice workforce.

The transition out of the current funding arrangement also reflects the end of the winter period and declining case numbers.

Changes to the funding model for COVID-19 clinical assessments in primary care

The following changes will come into effect from Monday 12 September:

  • Providers are funded to undertake a desktop review, where necessary, for COVID-19 cases to determine whether they meet the COVID-19 therapeutics eligibility criteria set by Pharmac. A desktop review claim can still be submitted when the Pharmac criteria is not met. There is no longer a requirement to contact the patient if they do not meet the therapeutics criteria by text or otherwise when the criteria is not met.
  • Proactive initial assessments are only funded for those who
    • meet the COVID-19 therapeutics eligibility criteria set by Pharmac, or
    • are not enrolled with a primary care provider
  • Clinical escalation consultations can be claimed either when a person who is self-managing becomes unwell and contacts a provider for advice and treatment, or when a clinician needs to escalate a case to another clinician.
  • A transfer-of-care review following hospital discharge for COVID-19 care is still available.
  • Funding for in-clinic reviews is retained for COVID-19 related consults only. A person with COVID-19 who requires assessment during the isolation period can be charged any usual co-payments when presenting with a condition unrelated to their COVID infection.
  • Discharging a person from isolation is no longer required, as patients are automatically notified of when they are due to finish their isolation period. The discharge payment is no longer available.

Some elements of the guidance and funding model have not changed.

  • The timing and frequency of regular reviews is clinically determined at an initial assessment, or clinical escalation encounter. This is still the case.
  • Claiming for post-COVID review remains. If a person still feels unwell from COVID-19 (up to six weeks from their day 0), they can access a free consult with their GP.

The full amended guidance and funding model, as well as supporting information, is attached.

Timing and next steps

These changes come into effect from Monday 12 September. We would appreciate you sharing this information and the attached guidance with your networks.

It is anticipated that the time between now and implementation will give PHOs and their practices time to amend their claiming systems.

We appreciate the pressure that primary care continues to experience and will endeavour to keep COVID-19 process changes to a minimum. It is likely that where possible, any further updates will be linked to changes in the COVID-19 public health mandates.

The amended guidance and model were agreed and developed following consultation with primary care representatives. Thank you to those who provided advice and feedback.

If you have any questions about these changes, please feel free to get in touch with the Care in the Community team:

Ngā mihi,


Matt Hannant

Director Outbreak Response

Dr Joe Bourne

Covid Care in the Community | Outbreak Response

133 Molesworth Street, Wellington | PO Box 5013, Wellington 6140

Te Whatu Ora – Health New Zealand