We strive to make it quick and easy to submit an Extras claim and receive benefits back. This is why we have our easy to use app and new-look Online Member Services. Through these channels, you can submit your invoices or receipts in minutes using your mobile or desktop device, and it is our aim to process these within a couple of business days of being received.
Our app is the most frequently used platform for submitting Extras claims. Due to its popularity with members, we have plans to make further enhancements to it in the near future.
We aim to pay every valid claim as efficiently as we can. However, there are instances where a claim cannot be processed. This could be because we don’t have enough information, legislation stops us from covering a service, or the service is simply not covered by your level of cover.
Other than limits being reached, we explain some of the more common reasons why a claim might not be processed -
Outpatient medical services/services billed under a Medicare item number
Legislation prevents private health insurance from covering out of hospital or ‘outpatient’ medical services. These are services received when you are not an admitted patient in hospital, but receive a medical service, which can include:
- GP visits
- consultations with specialists in their rooms
- diagnostic imaging and tests (apart from the selection of tests covered under Extras cover)
These services are usually covered by Medicare, and often have a Medicare item number on the invoice (these can range from 3 to 5 numbers).
For medical services received while in hospital, as an admitted patient, it is common practice that we receive these invoices and claims from your hospital and/or doctor directly.
Not enough information provided
There could be instances when we need to return an Extras claim to you and request further information to ensure service/s can be processed correctly and within our guidelines. There are two main reasons for this:
The invoice is missing important information. To avoid a claim being returned, it is helpful to first check that your receipt has all required information to process your claim, before you submit it to us. Your invoice must clearly show the following important information:
- patient name (person who received the service, cannot be anyone else on the policy),
- details of the treatment received (in the case of dental services, this includes item numbers),
- the provider’s details,
- date of service and,
- the fee paid
Your provider should be issuing you an invoice or receipt with this information as part of their service.
Without these details, a claim cannot be processed, and this delays the receipt of your benefits. In the case of pharmaceutical items, it is important that items are provided on an Official Pharmacy Receipt. The official receipt also provides a script number and other information required to process your benefit.
A letter from your doctor is required. For Aids and Appliances claims, we require a letter from your treating practitioner to compliment your invoice or receipt. This is to ensure the item is being prescribed to you to treat a medical or health condition. Providing this letter in the first instance will streamline the processing of your claim.
Service not covered
Unfortunately, sometimes we need to return your claim as the service is not covered under your particular policy.
Common instances where this might be the case –
- If you are on Essential Extras or Starter Extras claiming for services such as Exercise Physiology or Class Physiotherapy*, which are only claimable on Total Extras under a Health Management Plan;
- A pharmacy item is below the PBS, and therefore not eligible for benefits. Doctors’ Health Fund benefits are paid when the pharmacy item is above the PBS amount of $40.30, and we cover 85% of the cost above this PBS.
To review the services your policy covers, your limits, and your claims history, simply log in to Online Member Services.
More on submitting a valid Extras claim can also be found on our website.
How do I find the status of my claim on the app?
When your claim has been assessed, we will send you a notification to your mobile device that includes your claim outcome and benefit. To ensure you can receive push notifications, you need to be logged into the app (the app can be closed and remain logged in) and have notifications enabled (which can be found in the Settings of your device).
You can also check on the status of your claims by clicking on ‘My Claims’, once the app is open. On this screen you will see the date you submitted the claim, its status and some other information. Further details can be found by clicking into the claim itself.
We are always looking for ways to ensure we are maintaining our high level of customer service and cover for our members. As always, if you have a specific query or concern about your cover or claim, our friendly Member Services Team is available to assist you.