For Medical Providers

• If you charge at or below the AMA fee, your patient will generally have no out-of-pocket costs.
• If your fee is higher than the AMA fee, your patient pays the difference between your fee and the AMA based benefit.

This model is unique to Doctors’ Health Fund and is designed to recognise the value of specialist services at a level aligned with AMA recommendations.

AMA benefits are not a contracted rate and are paid at the member’s entitlement level only.

To view AMA rates, you will need to have an active subscription with the Australian Medical Association. For copyright and licensing reasons, health funds cannot provide AMA fee schedules to specialists.

For detailed AMA fees, please refer to the AMA List of Medical Services and Fees via your AMA membership. For information regarding specific rates please refer to AMA Fees list.

You can choose whether to participate in AGC per episode of care.

If you charge within the AGC schedule, patients will generally have no gap or a small known gap.

If you charge above the AGC schedule, the patient is responsible for the difference between your fee and the benefit from Medicare and the fund.

Under AGC, you may choose:

1. No Gap You charge the AGC scheduled fee → the patient has no out-of-pocket cost.

2. Known Gap You may charge a capped co-payment of:

• Up to $500 per treating practitioner, per episode; or
• Up to $800 for labour and delivery management items.

Note AGC rules do not permit additional non-clinical fees (e.g., booking fees, administration fees, facility fees).

AGC offers a structured and nationally recognised billing model that:

• Allows funds to pay higher benefits than the standard MBS amount, reducing patient out-of-pocket expenses. Top Cover Gold
• Lets specialists choose per-patient whether to participate allowing you full flexibility to decide per episode.
• Simplifies billing by allowing doctors to bill the fund directly
• Facilitates payments through AHSA processes to the bank details you have registered with AHSA.

If you choose to bill using AGC:

• You must register with the Australian Health Services Alliance (AHSA) to access the official Access Gap fee schedules.
• Health funds, including DHF, cannot provide AGC fee schedules to specialists due to licensing restrictions.

For information regarding specific rates please refer to AHSA Access Gap Cover Scheme.

For almost all providers: No. Doctors’ Health Fund uses the AHSA registration system. If you are registered with AHSA for AGC, we automatically receive your:

• Provider number
• Practice locations
• Contact details
• Direct credit details
• AGC participation choices

You do not need to register with us if:

• You already participate in AGC
• You are registered with AHSA
• You bill using Medicare provider numbers and ECLIPSE
• Your details are current with AHSA

You should contact AHSA if you need to:

• Add or change a practice location
• Update banking or contact details
• Update billing arrangements
• Register for Access Gap Cover

You should contact us directly if:

• A patient specific eligibility or benefit query arises
• You need help with a claim after submission
• AHSA directs you to contact us for fund-specific issues

You can submit medical claims to Doctors’ Health Fund via:

ECLIPSE

Email: providers@doctorshealthfund.com.au

Post:

Doctors' Health Fund
PO Box Q1749
Queen Victoria Building
Sydney NSW 1230

For email and postal claims, please ensure you include the AHSA Batch Header with your submission so we can process your claim promptly.

We are listed under The Doctors’ Health Fund, please look for us under T in the ECLIPSE system.

Manual claims (email or post)

Remittances for manual claims are sent to the postal address supplied to us via AHSA.

You should receive these within normal postal timeframes after the claim has been finalised.

ECLIPSE claims

We are unable to generate remittances for ECLIPSE claims. If you are not receiving electronic remittances, please contact your practice management / billing software provider for support.

We receive provider details directly through:

• Medicare
• AHSA

If your details have been updated with these organisations, there is nothing further you need to do.

If you do not hold an AHSA agreement we can only process a one-off payment. Please email us with confirmation of your current banking details so we can ensure payment is made correctly.

Note: Doctors’ Health Fund cannot issue cheques.

Only members with Top Cover Gold hospital cover and who have served all waiting periods are eligible for AMA‑based benefits.

For all other hospital covers (e.g., Prime Choice Gold, Smart Starter Bronze Plus), AHSA Access Gap Cover (AGC) applies.

Because cover varies, we strongly recommend contacting us before billing or providing a quote to confirm the patient’s entitlements.

No, you do not need a contract or agreement with us to charge AMA rates.

If your patient holds Top Cover Gold, and we have your banking details, we can pay AMA‑based benefits directly to you. Otherwise, the patient may claim eligible benefits themselves.

This depends on your billing software.

Most systems allow you to select a billing scheme, where:

• Scheme (SC) → pre‑fills AGC (AHSA) rates
• Agreement (AG) → pre‑fills AMA rates

If your software does not have this feature, you may need to manually enter the AMA based fee.

If unsure, please check with your software provider regarding your configuration.

You may choose not to participate in AGC for any patient or episode. In this case, we will pay benefits up to the Medicare Benefit Schedule (MBS) rate, and the patient is responsible for the difference between your fee and the MBS benefit.

If your patient holds Top Cover Gold benefits will be paid following the AMA Fee Schedule. AMA benefits are not a contracted rate and are paid at the member’s entitlement level only.

Payment timeframes depend on:

• ECLIPSE processing
• AGC schedule compliance
• Correct and complete account information

Payments are issued directly to you based on the bank details you have registered with AHSA.

There are several possible reasons:

1. Medicare has declined an item

If Medicare does not pay a benefit for an item, we cannot pay a benefit either.

2. Patient waiting periods

Benefits may be reduced or not payable if waiting periods apply.

3. Provider number without an active AHSA agreement

If you bill under a provider number that does not have an active AHSA Access Gap Cover Scheme agreement on the date of service, we can only pay up to the Medicare Benefit Schedule (MBS) rate.

4. AMA vs AHSA eligibility mismatch

If you submit a claim at AMA rates but the patient is covered under an AHSA product, AHSA rules apply.

Under AGC rules, if the out‑of‑pocket exceeds $500, the service becomes ineligible for AGC, and we revert to MBS‑based benefits.

If you require assistance interpreting the benefit outcome, please contact us by phone or email.

• If lodged via ECLIPSE, review the error message and resubmit.
• For manual accounts, resubmit corrected AHSA forms and invoices.

AMA benefits are a member benefit, not a contractual provider benefit.
This means:

• We can only amend the claim if AMA billing was intended at the time of service, and
• You can provide evidence such as an Informed Financial Consent (IFC) or estimate of fees showing the AMA aligned charge.

If no documentation is available, we cannot retrospectively change the benefit.

As Doctors’ Health Fund is the only health fund in Australia offering AMA based benefits, our process may differ from other funds.

We recommend contacting us before submitting the claim to confirm the patient’s level of cover.

On the AHSA Doctors site, which hosts:

• Registration forms
• Change of details
• Additional locations
• Banking updates
• AGC Terms & Conditions
• Billing guides

Please be aware that AMA rates for specific item numbers are copyrighted. We are unable to disclose them. If you wish to confirm these, you will need to refer to the AMA.

More information regarding specific AMA rates