HOW TO CLAIM ON HEALTH INSURANCE

Hospital claims follow a different process from extras. In most cases, you don't need to submit anything yourself — the hospital and your insurer handle the billing directly.

Before admission:

1. Inform the hospital that you have private health insurance. Provide your insurer name, membership number, and any pre-approval reference if applicable.
2. Check hospital agreement — confirm the hospital has an agreement with your insurer. At non-agreed hospitals, you may face gap payments of {{NON_AGREED_GAP_RANGE}} even for covered treatments.
3. Pre-approval (if required) — some insurers require pre-approval for elective (planned) admissions. Contact your insurer before your scheduled procedure to confirm coverage and get a pre-approval reference number. Emergency admissions don't require pre-approval.

During admission: 4. Hospital bills your insurer directly for accommodation, theatre fees, nursing care, and prostheses. You don't need to pay these upfront at agreed hospitals. 5. Doctors bill separately — your surgeon, anaesthetist, and any assisting doctors send their own invoices. These may be billed through the hospital or sent to you directly.

After discharge: 6. You pay your excess — {{PROFILE_EXCESS_RANGE}} per admission (once per admission, not per day). 7. You pay any gaps — the difference between what doctors charged and the combined Medicare + insurance benefit. This is the main out-of-pocket cost for most hospital admissions. 8. Explanation of benefits — your insurer sends a statement showing what was claimed, what was paid, and what you owe.

Understanding your hospital bill:

Line item	Who pays	Your out-of-pocket
Hospital accommodation	Your insurer (at agreed hospitals)	$0
Theatre/operating fees	Your insurer (at agreed hospitals)	$0
Prostheses (implants, lenses, etc.)	Your insurer (if on Prostheses List)	Usually $0
Nursing care	Your insurer	$0
Surgeon fees	Medicare (75% of schedule) + insurer (25% of schedule)	Gap above schedule fee: {{TYPICAL_SURGEON_GAP_RANGE}}
Anaesthetist fees	Medicare (75%) + insurer (25%)	Gap above schedule fee: {{TYPICAL_ANAESTHETIST_GAP_RANGE}}
Assistant surgeon	Medicare + insurer (partial)	{{TYPICAL_ASSISTANT_GAP_RANGE}}
Excess	You	{{PROFILE_EXCESS_RANGE}}
Co-payment (if your policy has one)	You	{{COPAYMENT_RANGE}}/day

Extras claims are simpler but managed by you. There are three ways to claim.

Method 1: HICAPS (instant claiming at the provider) Most dentists, optometrists, physios, and other allied health providers have HICAPS terminals. The process:

1. At your appointment, present your health insurance card
2. The provider swipes your card and enters the service details
3. Your claim is processed instantly
4. You pay only the gap (the difference between the provider's fee and your insurer's rebate)
5. No paperwork, no waiting for reimbursement

This is the fastest and most common claiming method. {{HICAPS_PROVIDER_PERCENTAGE}} of extras providers support HICAPS.

Method 2: Insurer mobile app Most insurers offer a mobile app for claims:

1. Take a photo of your receipt at the provider
2. Open your insurer's app and submit the claim
3. Enter the service details (date, provider, item number, amount)
4. Submit — the rebate is deposited into your nominated bank account
5. Processing time: {{APP_CLAIM_PROCESSING_DAYS}} business days typically

Method 3: Online portal or post For providers without HICAPS or if you prefer:

1. Pay the full fee at your appointment and collect a detailed receipt
2. Log into your insurer's online portal or download a claim form
3. Enter the claim details and upload/attach the receipt
4. Online processing: {{ONLINE_CLAIM_PROCESSING_DAYS}} business days
5. Post processing: {{POST_CLAIM_PROCESSING_DAYS}} business days

What you need for an extras claim:

Required	Details
Provider receipt/invoice	Must show: provider name and registration number, date of service, service description and item number, amount charged
Your membership details	Membership number, card — for HICAPS this is automatic
Bank account (for reimbursement)	Registered with your insurer for non-HICAPS claims

Before booking a service, check how much benefit you have left for that category. Most insurers provide this through:

• Mobile app — real-time remaining benefits by category
• Online portal — log in to view current year's claims and remaining limits
• Phone — call your insurer and ask for a benefits check
• At the provider — HICAPS can show your remaining benefit before processing the claim

What to check:

Check	Why
Annual limit remaining	Have you already used your ${{EXAMPLE_DENTAL_LIMIT}} dental limit this year?
Per-service limit	Some policies cap individual services within a category
Waiting period status	Have you passed the 2-month or 12-month waiting period?
Sub-limits	Is your optical limit shared with another category?
Limit reset date	Does your limit reset 1 January or on your policy anniversary?

Understanding the most common rejection reasons helps you avoid them.

Reason	What happened	How to avoid
Service not covered	Your policy doesn't include that service category	Check your PDS or call your insurer before booking
Still in waiting period	You haven't served the required 2 or 12 months	Check your waiting period end dates before claiming
Annual limit reached	You've already claimed up to your annual maximum	Check remaining benefits before booking
Provider not registered	The provider isn't registered with AHPRA or the relevant board	Confirm provider registration before your appointment
Claim submitted late	Most insurers require claims within {{CLAIM_SUBMISSION_DEADLINE}} of the service date	Submit claims promptly — don't let receipts pile up
Incorrect item number	The item number on the receipt doesn't match a covered service	Ask the provider to check the item number before you leave
Pre-existing condition	Treatment relates to a condition within 6 months of joining	Disclose health history honestly when joining; understand waiting periods
Cosmetic procedure	Treatment classified as cosmetic rather than medically necessary	Confirm with your insurer before proceeding; get pre-approval
Non-agreed hospital	You were treated at a hospital without an insurer agreement	Check hospital agreements before booking elective procedures

If your claim is rejected:

1. Read the rejection reason carefully — your insurer must explain why
2. Check your PDS — verify whether the service should be covered
3. Call your insurer — ask for a detailed explanation; sometimes rejections are administrative errors
4. Request a review — if you believe the rejection is wrong, request an internal review in writing
5. Escalate to the Ombudsman — if unresolved, lodge a complaint with the Private Health Insurance Ombudsman (free service)

Gap payments — the difference between what a doctor charges and the combined Medicare + insurance benefit — are the largest out-of-pocket cost for most hospital admissions. Many insurers run gap cover schemes to reduce or eliminate these gaps.

Types of gap cover:

Scheme	How it works	Your out-of-pocket
No gap	Doctor agrees to charge the schedule fee — insurer + Medicare cover 100%	$0 doctor fees
Known gap	Doctor agrees to charge a set amount above schedule — insurer covers the gap up to a limit	Predictable, capped gap (e.g., {{KNOWN_GAP_CAP_RANGE}})
No scheme / out-of-scheme	Doctor charges whatever they choose — you pay the difference	Unpredictable — {{TYPICAL_SURGEON_GAP_RANGE}} or more

How to use gap cover:

1. Ask your insurer which doctors participate in their gap scheme
2. When your GP refers you to a specialist, request a referral to a gap-participating doctor
3. Before scheduling surgery, ask the surgeon: "Do you participate in [insurer name]'s gap cover scheme?"
4. Get a written fee estimate from the surgeon and anaesthetist before your procedure