NHS Complex Care Pathways Claiming Guidance
Overview
NHS Complex Care Pathways provide additional funding for patients who meet specific clinical criteria.
Practices submit multiple claims throughout the pathway, with NHS remuneration being received across a series of submissions. There are three available pathways, each with specific eligibility criteria and claim structures. Although pathway claims are submitted over multiple stages, all pathway types attract a Band 2 patient charge.
Practices are strongly advised to collect the patient charge at the commencement of the pathway, as the NHS will continue to recover the patient charge even if the patient fails to attend future appointments.
Pathway Selection
Pathway 1 – Complex Caries
Eligibility Criteria
The patient must:
The patient must:
- Be aged 16 years or over.
- Have 5 or more teeth with caries extending into dentine at the initial examination.
Pathway Payment
- Total pathway value: £293.40
- Number of claims: 6
Pathway 2 – Complex Caries and Periodontal Disease
Eligibility Criteria
The patient must:
The patient must:
- Be aged 16 years or over.
- Have 5 or more teeth with caries extending into dentine.
- Have generalised unstable periodontal disease affecting more than 30% of teeth at the initial examination.
Evidence must include either:
- A periodontal probing depth of 5mm or greater, or
- A periodontal probing depth of 4mm or greater with bleeding on probing.
The diagnosis must be classified as one of the following:
- Stage II Grade B
- Stage II Grade C
- Stage I Grade C
- Stage III Grade B
- Stage III Grade C
- Stage IV Grade B
- Stage IV Grade C
Pathway Payment
- Total pathway value: £732.47
- Number of claims: 12
Pathway 3 – Advanced Periodontal Disease
Eligibility Criteria
The patient must:
The patient must:
- Be aged 16 years or over.
- Have a first diagnosis of Stage III periodontal disease or unstable Grade C periodontal disease (or above).
- Have generalised disease affecting more than 30% of teeth at the initial examination.
Evidence must include either:
- A periodontal probing depth of 5mm or greater, or
- A periodontal probing depth of 4mm or greater with bleeding on probing.
Eligible classifications include:
Stage III
Stage III
- Grade A
- Grade B
- Grade C
Grade C or Above
- Stage I Grade C
- Stage II Grade C
- Stage IV Grade A
- Stage IV Grade B
- Stage IV Grade C
Pathway Payment
- Total pathway value: £256.21
- Number of claims: 6
Creating a Complex Care Pathway in EXACT
A Complex Care Pathway Course of Treatment (COT) can be created from the Exemptions and Charges window.
If a COT has already been created, select:
Chart > Exemptions
and choose the relevant pathway to apply.
Chart > Exemptions
and choose the relevant pathway to apply.
Initial Claim Values
When a pathway is selected, EXACT automatically:
- Sets the claim value to 1, representing the first claim within the pathway.
- Applies the appropriate NHS band.
- Applies the correct patient charge.
UDA Values
Practices are paid a fixed monetary value for each pathway. This value is converted into UDAs using the practice’s individual UDA rate.
As EXACT does not initially know the practice-specific UDA rate, an estimated UDA value is applied using a national average.
For example:
- An initial estimate may display approximately 1.3 UDAs.
Once the first pathway claim is returned in an NHS schedule, the NHS provides the practice-specific UDA value. EXACT will then automatically update future pathway claims using the correct UDA calculation.
Important
The first pathway claim may show a discrepancy between:
The first pathway claim may show a discrepancy between:
- The UDA value displayed within EXACT.
- The UDA value ultimately paid by the NHS.
This is expected behaviour and will automatically correct once the practice-specific UDA value has been returned by the NHS.
Additional Information
Complex Care Pathways consist of either 6 or 12 claims depending on the pathway selected.
As claims are submitted throughout the pathway, practices will receive UDAs incrementally rather than as a single allocation at the start of treatment. This is why each pathway claim attracts a relatively small UDA value.
As claims are submitted throughout the pathway, practices will receive UDAs incrementally rather than as a single allocation at the start of treatment. This is why each pathway claim attracts a relatively small UDA value.
Patient Charges
All Complex Care Pathways attract a Band 2 patient charge, regardless of pathway type.
Important
Important
We strongly recommend collecting the Band 2 patient charge at the first pathway appointment.
If a patient subsequently fails to attend future appointments, the NHS may still recover the patient charge from the practice. Collecting the charge at the outset helps protect practices from this potential loss of income.
In most cases, Band 2 treatment will also be carried out during the initial appointment, making collection of the charge at this stage appropriate.
Declarations
1st Pathway Claim
The user will not be prompted for this declaration when TCing but the declaration can be viewed using the 'Pathway Declarations' button.
Interim or Completion Pathway Claims
If the provider does not select the "Pathway Declarations" button on the TC dialog before trying to send the claim, EXACT will automatically display them so the provider does not miss the opportunity to review them. The declarations displayed will differ by claim type and the options with checkboxes are optional.
Key Points
- Pathways are available for eligible patients aged 16 and over.
- Pathways contain either 6 or 12 claims depending on the pathway selected.
- EXACT automatically creates the first claim when a pathway is selected.
- All pathways attract a Band 2 patient charge.
- Practices should collect the patient charge at the commencement of the pathway.
- Initial UDA values are estimates until the first pathway claim is returned by the NHS.
- Any discrepancy between displayed and paid UDAs on the first claim is expected and will be corrected automatically once the NHS returns the practice-specific UDA value.
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