How to make a Hospital or Extras Health Insurance Claim?
The process can differ depending on your specific fund and type of treatment, so it is important to understand exactly what you need to do in order to claim.
by Gary Andrews
Last update 15 Apr 2021
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.COMPARE & SAVE
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:
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.
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:
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.
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.COMPARE & SAVE
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.
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.
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.
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:
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.COMPARE & SAVE
This guide is opinion only and should not be taken as medical or financial advice. Check with a financial professional before making any decisions.