A Guide to Health Insurance Claims

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 be covered.

Determine your eligibility for a health insurance claim

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 hospitalisation

• Details about the circumstances leading to the hospitalisation, 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 hospitalisation

• 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 insurers 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.

Common reasons health insurance claims are denied

Your claim may have been denied for a number of reasons. Here are some of the most common.

Treatment not covered by policy

Never assume that a treatment is covered by your policy. Read the terms and conditions so you know for sure. If you make a claim for a treatment that isn't covered, it will be rejected. For example, many funds do not cover surgical and non-surgical cosmetic procedures.

This could include reconstructive surgery for cleft palates or even burns. Most policies have restrictions and exclusions on benefits and services, so it's important to know what you're covered for.

Treatment from a non-participating hospital

If you were treated at a hospital that doesn't have an agreement with your fund, there's a good chance you won't be covered. Check with your fund to find out which hospitals participate in their scheme, so you know what to expect before you are admitted for treatment.

Benefit cap

Some policies have benefit caps on specific services limiting the amount of benefits that can be paid out each year. These caps should be clearly stated in the terms of your policy. Annual limits may be calculated by calendar year, financial year, or in the 12 months since you took out your policy. Check with your fund for details.

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 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.

Chris Stanley is the sales & operations manager of health insurance at Compare Club. With extensive experience and expertise, Chris is a trusted leader known for his deep understanding of health insurance markets, policies, and coverage options. As the sales & operations manager of health insurance, Chris leads a team of dedicated professionals committed to helping individuals and families make informed decisions about their health insurance needs.

Meet our health insurance expert, Chris Stanley

Chris's top health insurance tips

• 1

  Australia’s public health system is world-class, but wait times for public hospitals can be long, inconvenient - and leave you living in constant pain while you wait.

• 2

  An appropriate private health insurance policy can speed up your surgery, relieving your pain sooner.

• 3

  Family health cover means your children are covered under the same policy as you.

• 4

  Many health insurance policies come with a 12-month waiting period for pregnancy-related cover, so it’s a good idea to get a family policy organized well before starting your family. This means your child will be covered from birth until at least their early twenties (depending on which health fund you select).