Using your Health Cover

Things to do when you are going to hospital 

• Check your health cover 
• Things you might discuss with your doctor before going to hospital 
• Which hospital when it is a private hospital? 
• Other important things you need to know when you go to hospital

Using ancillary services 

• What we pay benefits for
• Convenient claiming

Making claims 

• Is your bill claimable? 
• Hospital cover claims 
• Extras or ancillary service claims 
• General principles for claims 
• Submitting claims

Things to do when you are going to hospital
Thinking about all the right things to make your hospital visit as smooth as possible isn’t easy. We hope this section provides you with some useful tips on questions to ask, helps in making decisions and clarifies the processes for payment for the hospital and medical services you receive.

Being informed is important. If you need any assistance please don’t hesitate to contact our Customer Service team on 1800 226 126 or info@doctorshealthfund.com.au. You should also feel free to ask your doctor and the hospital for any information you would like about your treatment, in-hospital and post-hospital care.

Check your health cover

Consider the following questions; read the product information for your hospital cover in the Product web pages and the Making claims section below. The Customer Service team is also available on 1800 226 126 or info@doctorshealthfund.com.au to assist you. 

• Have you completed any waiting periods relevant to your condition? Remember, you are covered for accidents as soon as you become a Fund member. 
• What financial outlays can you expect
  • Do you have an excess to pay on your hospital accommodation before you will receive any benefits? 
  • How much will your gap cover pay for? 
  • Does your cover have any treatment exclusions or benefit restrictions that will affect how much you have to pay for your treatment? 
• What information and documentation will you need to have to make claims for your treatment? 
• Does your cover require any specific processes be followed to claim benefits?

Things you might discuss with your doctor before going to hospital: 

• Timing – when you can expect to be admitted, how long you will be in hospital, recovery time after leaving hospital and the length of time of any restrictions on normal activities 
• If there a surgically implanted prosthesis involved in the treatment, is it a no gap item on the government Prostheses List? 
• Whether any aspect of the treatment may not be eligible for Medicare or health fund benefits
• The other doctors who will be involved in your treatment for instance an assistant surgeon, anaesthetist, radiology, or pathology
• Your private health cover and the estimated cost of the treatment – your doctor may refer to ‘informed financial consent’. This is a process being encouraged by the government where doctors provide information to you about the costs of treatment proposed for you
• How you can reduce the risk of any complications
• Any changes that need to be made to your medications before or after going to hospital

Which hospital when it is a private hospital?

The Doctors’ Health Fund has contract arrangements with private hospitals in every State, the ACT and the Northern Territory. Our network of contracted hospitals is larger than those of some of the biggest health funds, offering greater choice and more convenient options. Using a contracted private hospital provides you with greater cover of the costs of your hospitalisation. If you go to a non-contract private hospital you can expect significant out-of-pocket expenses for your hospital costs.

You can check if the hospital your doctor has suggested is a contracted hospital through this search facility. If the hospital you have discussed with your doctor is not a contracted hospital you should ask if you can be treated in a contracted hospital.

Other important things you need to know about when going to hospital

1. When you are admitted the hospital will give you a National Private Patient Claim form to complete and ask for your ‘informed financial consent’ to the treatment and the costs involved. Your signature is required for claims to be processed for your hospitalisation.

At least two bills are generated for hospital treatment: – 

• one from the hospital which is usually sent directly to The Doctors’ Health Fund, we issue a statement to you after the claim is processed as your record of the transaction
• the other bills come from the doctors, read the Making claims section below for specific information about processes for claims under your hospital cover

2. If you are in hospital for more than 35 days in succession you can be reclassified as a Nursing Home Type Patient, unless your doctor specifies otherwise. This is important because being a Nursing Home Type Patient significantly reduces the amount of benefits you can claim, and you could incur significant out-of-pocket expenses.

3. The Private Patients' Hospital Charter is a guide to what it means to be a private patient in a public hospital, a private hospital or day hospital facility. It sets out what you can expect from: 

• the doctor(s) providing your treatment
• the hospital in which you receive your treatment; and 
• your health insurance fund

You can obtain a copy of the charter from the Department of Health & Ageing


Using ancillary services – and convenient claiming

What we pay benefits for
The Fund’s rules define the services of the following ancillary service providers as eligible for benefit payments where a member has cover for their services –

Convenient claiming

The Doctors’ Health Fund member card is your ticket to convenient claiming if you have Extras cover. Any ancillary service provider who is connected to the HICAPS network can simply swipe your card to process your claim, and you simply pay any remaining amount owing.

You can find HICAPS providers for all types of ancillary services.

If you change your cover or the family members on your cover you don’t need a new card. The system links back to your records with The Doctors’ Health Fund to verify your claims.

Making claims

Is your bill claimable?

Check the product information for your cover in the product pages for Top Cover, Prime Choice, Smart Starter, Total Extras and Essential Extras to see if you have an eligible claim. For old products contact the Fund on 1800 226 126 to see if you have an eligible claim. It should be if the service you received: - 

• is covered and not excluded under your cover 
• is unaffected by any benefit restrictions 
• you had completed any waiting periods when the service was delivered 
• your cover was financial when the service was delivered 
• the bill is less than two years old 
• and you have not exceeded any claims limits on your cover

If you have any doubts about the eligibility of your claim contact the Customer Service team on 1800 226 126 or info@doctorshealthfund.com.au

Hospital cover claims

The hospital will usually submit their bill for your claim directly to the Fund. You will receive a statement showing the claim that has been paid. You will need to pay the hospital directly for any excess amount or co-payments which are included in your cover or services which are not included in your cover.

Depending on your hospital cover different rules apply for claiming on doctors bills for your treatment in hospital. 

• If you have Top Cover, Prime Choice or Smart Starter hospital cover or have added AMA Gap cover to our old products Graduate, Intermediate and Maximum hospital cover, you or your doctor(s) must submit the bills or the receipts to The Doctors’ Health Fund. If they are submitted to Medicare, you may only receive 25% of the Medicare Schedule Fee for the medical services
• Claims under standard Graduate, Intermediate and Maximum hospital cover should be made first to Medicare, then the Medicare Statement of Benefit should be submitted to the Fund with your claim

Extras or ancillary services claims

Seek the convenience of one of more than 18,000 providers connected to HICAPS and claim when you as you leave. The provider swipes your Fund membership card, the claim is made without any form filling or waiting for payments. You simply pay the provider any difference between their bill and the amount claimed.

You can also pay the provider their whole fee. Then claim by submitting a form to the Fund with the receipts for the provider’s services.

General principles for claims 

• Claims must be lodged within two years of the date of the service
• You cannot claim 
  • If you provide false or inaccurate information on your claim form 
  • If you are more than 2 months behind with your contributions 
  • If the service was provided while your membership was suspended 
  • If the service provider is directly related to you 
  • If the service provider is not qualified under the fund rules 
  • If you will be paid compensation or damages by a third party

When a claim for compensation or damages to a third party to cover your healthcare costs fails you can claim against your health cover. If two years have passed since the healthcare costs were incurred you will need to supply documentation that shows the rejection of your compensation or damages claims and the time it has taken for those claims to be decided.

Submitting Claims

Ask your extras or ancillary providers if they are connected to HICAPS. They can process your claim on the spot, and you only pay them any difference between the amount of the claim and the amount of their bill.

Download a claim form

Attach the relevant original receipts or the Medicare Benefits Statement, and check the eligibility of your claim and the procedures for claiming under Making claims.

Fax your claim to   (02) 9437 9326
or
Mail your claim to The Doctors’ Health Fund 
                                PO Box 482
                                St Leonards NSW 1590