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Using your Health Cover

Things to do when you are going to hospital 

Using Extras services 

Making 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

 

Using Extras 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 –

General dental services registered dentist or specialist dentist
Major dental services registered or recognised orthodontist, endodontist, periodontist, oral surgeon, prosthodontist, pedodontist or other recognised specialist
Optical registered ophthalmologist, registered optometrist or a prescription filled by a registered dispenser
Therapies registered practitioners of orthoptics, occupational therapy, speech therapy, dietetics, podiatry, physiotherapy, and psychology.
Home nursing registered nurse
Non-PBS pharmaceuticals medicine prescribed by a doctor and dispensed by a pharmacist that is not subsidised under the Pharmaceutical Benefits Scheme
Mammography, bone density tests, Thin Prep testing registered medical practitioners
Aids & Appliances click here to see a list of items eligible for benefits
Hearing aids ordered by a medical practitioner or a hearing service provider

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.

Health Management Programs

If you have our Total Extras cover, you can access our Health Management Program benefit to support your return to good health.

What are Health Management Programs?

Health Management Programs are treatments intended to manage a member's specific health condition.

There are strict legal requirements about what can, and cannot, be a Health Management Program.

Our Health Management Program Approval form is designed to ensure we meet all those requirements and needs to be completed by your ordinary medical practitioner, who is not related to you.

The current treatments recognised as Health Management Programs cover services (not goods) and are:

  • Exercise physiology
  • Quit Smoking
  • Acupuncture
  • Weight loss classes
  • Exercise classes conducted at a gym or by a personal trainer
  • Class physiotherapy

We expect your ordinary medical practitioner to prescribe treatments in accordance with accepted clinical practice for your specific condition and alternate treatments cannot receive a benefit at this time.

Where insufficient information has been provided to support the efficacy of the Health Management Program to ameliorate a member’s specific health condition, our medical advisor will deem no benefit is available.

Who can deliver Health Management Programs?

Health Management Programs must be delivered by appropriately trained individuals with current registration, with a national association, to perform the treatment.

Exercise physiologists and Royal Australian College of General Practitioner acupuncturists must have a current Medicare provider number before we can provide a benefit.

When can I claim for my Health Management Program benefit?

Benefits are only payable when the specific health condition was present on, or before, commencing the Health Management Program.

Where the Health Management Program is ongoing, or has been paid in advance, a benefit can only be paid on completion of that treatment.

If the ongoing Health Management Program has distinct stages / consultations, such as visits with an Exercise Physiologist, a benefit is payable on the completion of each stage / consultation.

Receipts need to Evidence of the start and end date of each stage / consultation is required before a benefit is payable.

Where payment has been made but treatment under the Health Management Program is not received, no benefit is payable.

Are wellbeing or preventative treatments covered?

A fundamental element of a Health Management Program is the prescribed treatment is intended to manage a member’s specific health condition.

In the absence of a specific health condition (such as an undiagnosed condition, genetic predisposition and wellbeing) we are prevented from paying a Health Management Program.

For example, personal training to reduce an obese member’s BMI would likely be considered a Health Management Program, while a member with a healthy BMI (and no other specific health condition) would be ineligible to claim.

We would like to reward and recognise our healthy members but are constrained by the law.  Nevertheless, we are always supportive of our members in maintaining their good health and wellbeing and look forward to opportunities to do more in the future.

What is a specific health condition?

A specific health condition is a condition that’s been diagnosed by your ordinary registered medical practitioner, who is not related to you.

The treatment being claimed must be intended to ameliorate that condition.

Examples of specific health conditions are asthma, arthritis, unhealthy BMI, high blood pressure and muscular skeletal disorders. 

Core strengthening, flexibility and wellness are not examples of a specific health condition.

What happens if medical practitioner recommends a program for more than 12 months?

An essential part of living with a specific health condition is ongoing appointments with your ordinary medical practitioner, who is not related to you.  This is vitally important to ensure prescribed treatments are working and nothing adverse has occurred.

This is why the Health Management Program Approval form is only valid for a maximum of 12 months at a time.

How often do I need to complete this form?

To continue claiming for a Health Management Program you must provide a new Approval form on the expiration of the old one.

Can I claim for the cost of getting the Health Management Approval form completed?

No.  Costs incurred for the completion of the Health Management Program Approval form are not claimable.

I have been prescribed a treatment which is also covered elsewhere under my policy, how is this claim paid?

Where a treatment is listed as both a Health Management Program and a standalone service, a benefit will be paid under the standalone service.

Where the limit for the standalone service has been exhausted, no additional benefit is claimable for that treatment as a Health Management Program.

Do I have to complete any other forms?

A completed Health Management Program Approval form is required for every new / renewed program.  A claim form is only required when other services are claimed in conjunction with a Health Management Program.

Health Management Programs are not claimable through HICAPS but can be claimed through our smartphone app.

Claims through the smartphone app need to include a photograph of a completed Health Management Program Approval form.

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. 

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) 9260 9958

or

Mail your claim to The Doctors' Health Fund

PO Box Q1749, Queen Victoria Building, Sydney NSW 1230