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Last Updated on 7 October 2019

How to Make a Health Insurance Claim

Private hospital insurance should provide cover for treatments received when you need hospital care, while Extras cover will pay for your routine expenditures.  In order for your health fund to pay bills for medical treatments, you need to understand how to make a health insurance claim. The process can differ depending upon your specific fund and the type of treatment you receive, so it is important to understand exactly what you need to do in order to covered.

Determine Your Eligibility

The first thing you need to do is determine if the type of treatments you will receive, or have received, are actually covered by your health fund. In order to determine this:

  • Review your written policy information. This should specify the types of coverage that you have.
  • Determine if you are within a waiting period. There is a waiting period that is between two and 12 months for many types of care when you sign up for hospital cover. There is also a waiting period for many kinds of extras cover (these waiting periods can vary more from fund to fund because there are no maximum wait times set by law). If you are within a waiting period, you will not be covered.
  • Determine if you are above the benefits limit. Some health funds limit the benefits you can receive for certain kinds of care. For example, when you sign up for extras cover, you may be limited to $250 in dental services for the first year that you have coverage. If you are above the limit, you will not be eligible to have additional care covered.

You should also check with your health insurance fund to determine if they have a network of providers. If they do, and you see an in-network provider, the claims process can be very simple. You may never see a bill and won’t need to do anything if you visit an in-network hospital or provider and be covered.

How to Make a Hospital Claim

You can make a hospital claim for treatment at hospitals that your health fund has an agreement with. You will need to first pay any excess or any bills that fall within the gap.  For treatments that are supposed to be covered by your health fund, the bills may be automatically forwarded to your insurer.  This occurs if the insurance fund participates with that hospital or if the hospital is in the fund’s network.

If the hospital does not send the bills automatically to the insurer, you will need to obtain a claim form from the fund that should cover your care.   Depending upon the provider, you may be eligible to mail your claim, fax it, submit it online, or email it. You will generally need to provide information when making your hospital claim including:

  • Your membership number
  • Your full name
  • Your home telephone number
  • The full name of the patient (for family policies or couple’s policies, this may be different than the member information)
  • The date and location of the accident or incident that resulted in hospitalization
  • Details about the circumstances leading to the hospitalization, as well as the injuries or conditions for which medical care was sought.
  • What hospital the care was received at, and whether the hospital was public or private
  • The dates of hospitalization
  • The name of treating doctors
  • Verification from the treating hospital or physician
  • Details on how payment should be made
  • A declaration that all information submitted on the claim form is true and accurate.

It is important to provide comprehensive and detailed information and to fill out all claim forms in full in order to receive prompt payment of claims.

How to Make an Extras Claim

When you have Extras cover or general cover, you will also need to make a claim with the health fund to get bills paid.

The easiest way to get your Extras benefits paid for is to seek treatment from a provider who allows you to swipe your insurance card at the time of service.  Many providers and Extras health funds participate in Health Industry Claims and Payment Service (HICAPS).  HICAPS is used by a wide variety of different providers.

When HICAPS or other point-of-service systems are used, you swipe your insurance card and the amount your health fund pays is automatically deducted from the money due for services. You will not need to make a separate claim and you will only pay for the portion of medical services that is your responsibility to cover.

If you cannot use HICAPS or another point-of-service system, then you can make a claim by phone, fax, email or mail. Most insures have claim forms available online that you can download. You can type into some of these forms right on the computer and email them, or you can print and complete them.

Again, it is imperative to provide detailed information on the form about the provider, the date and type of service, and your membership information.   You also need to make sure that the services you are making a claim for are covered.

Where Can I Get a Claims Form?

You can obtain a claims form from your health fund.

You can contact your health fund to find out more information about where to obtain a claim form if you cannot find the forms you are looking for online.

What if Medicare Pays a Portion of the Claim?

When Medicare pays a portion of the costs and your health fund also pays a portion of the cover, you can first take your claim to the Medicare office. Medicare will pay some of the Medicare Benefits Schedule (MBS) fee. You can submit the claim to the healthfund for payment of the remainder.

If you don’t have time to first visit Medicare and then submit a claim to your health fund, you may also be able to use a two-way claim form. This means you submit the forms to Medicare and Medicare sends them on to your insurance fund on your behalf. You will receive a benefit from both Medicare and your health fund provider.

Best Practices for Making Health Fund Claims

When making a claim, it is important to submit receipts as well as an original copy of an itemized account. The receipt and claims forms should be itemised, with each individual service listed individually.

What Should You Do If Your Claim is Rejected?

If your claim is rejected, you should reach out to your health fund and find out why. The health fund should provide details about why your claim was rejected. Possible reasons your claim may not be paid include:

  • You are within a waiting period.
  • The service was not covered.
  • You have exceeded your maximum benefits.

If you believe you should have been covered and you were not, you can contact the Private Health Insurance Ombudsman (PHIO) in order to make a complaint. This guide  will tell you how to reach out to the PHIO and this template letter can be used to make a complaint when there is a dispute over whether a certain type of treatment should be covered.

You deserve to get the insurance cover you pay for. Follow best practices for submission of a claim, and take action if your fund denies you the benefits you need.

Frequently Asked Questions About Health Insurance

There are three types of health insurance in Australia. They are:

  • Hospital Cover
  • Extras Cover (also known as general or ancillary cover)
  • Ambulance Cover

Hospital cover can ensure any unexpected surgeries, treatments or hospital stays you may require will be covered. With appropriate cover you will have the flexibility to choose your own doctor and the option of receiving treatment in a private hospital.  Most hospital covers allow you to stay in a private room. One other perk is skipping the public hospital systems’ waiting list, which can be lengthy for non emergency treatment.

Extras cover pays benefits for a a range of services, often including treatments and procedures related to the fullowing:

  • Dental/oral health
  • Glasses and contact lenses
  • Podiatry
  • Physiotherapy
  • Psychulogy
  • Acupuncture
  • Remedial massage
  • Chiropractic
  • Hearing aids
  • Travel vaccinations

Ambulance cover, as the name suggests, will cover you should you require emergency ambulance transport. In an emergency, there is enough to worry about. Having the expenses covered for provides security and peace of mind. Many hospital covers include emergency ambulance transport If yours doesn’t, you will need to shop for this separately.

Life is unpredictable. You never know when you might need cover. No matter what life stage you’re in, there’s a policy out there for everyone. You can select as much or as little cover as you want, depending on your health needs and requirements. It’s a small price to pay for the peace of mind health cover provides.

There is no one answer here. Costs vary across providers and policy types. Just because a policy is cheap, that does not mean it is ‘value for money’ and vise versa. Make sure you check what’s included and excluded in a policy before signing up, as you want to purchase a policy that best fits your specific needs.

Premium: A premium is the price you pay for your insurance policy (it may be paid annually or on an ongoing basis).

Policy: An insurance plan. In other words, it is the type of insurance you choose to select.

Policy Holder: The owner, or ‘holder’ of a policy.

Claim: In the event that you require treatment for a service covered by your policy, you can lodge a claim for reimbursement of all or part of the cost of that treatment.. These days, most claims are submitted electronically by the health care provider (dentist, physio etc)

Lifetime Health Cover: Lifetime Health Cover was put in place to encourage young Australians to seek out and maintain ownership of private health insurance early in their lives. If you do not take out a policy before you turn 31, extra charges will be applied should you take out a policy at a later time.

This means you will pay a 2% loading on top of your premium for every year that passes after you turn 30. For example, if you take out a policy for the first time at age 32, you will be charged 4% of your premium as an extra, then at age 40, 20% and so on, up to a maximum loading of 70%.

The loading is payable for 10 consecutive years of cover - after which it is removed and you premiums will be reduced.

Pharmaceutical Benefits Scheme (PBS): Medicare offers assistance for Australians with many of their their prescribed medication costs through the PBS. This assistance is in the form of subsidies towards the cost of many medications. You can check if your prescribed medication is on the list of subsidised items here.

Medicare Levy Surcharge: The Medicare Levy Surcharge is an additional charge (tax) applied to single Australian taxpayers who earn over the income threshold of $90,000 per year, or families/couples who earn over $180,000 per year. This surcharge is only applied to those who choose not to have a private health insurance policy.

The surcharge is designed to reduce pressure on the public health system by encouraging those with higher incomes to invest in private health cover.

Private Health Insurance Rebate: The government’s Private Health Insurance rebate lowers premiums for most Australians with private health insurance Older Australians may enjoy an even higher rebate. Our calculator can help you estimate the Government health insurance rebate you may receive.

Disclaimer: The above information is correct and current at the time of publication

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