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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 fund to pay bills for treatments, you need to understand how to make a health insurance claim. The process can differ depending on 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 cover 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 health fund to health 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 cover. If you are above the limit, you will not be eligible to have additional care covered.

You should also check with your health 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.

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 them.  This occurs if the health 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, you will also need to make a claim with the insurer.

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 membership card and the amount your insurer 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 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 insurance fund, and this is usually readily available on their website. 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 of cover and your insurance 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 insurance fund for payment of the remaining balance.

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). 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.

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

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