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You can now claim electronically - to do so click on the "Claim Form" icon below and follow the instructions.
The information provided in this document should be read in conjunction with the information contained in the Fund’s latest brochure.
- How to make a claim on general (extras) treatments
- What kind of account or receipt is required?
- How will my claim be paid
- What is Hicaps
- What is Access Gap cover
- What about hospital claims
- How do I pay my excess
- What about doctors accounts
- How do I claim through Medicare
- Can I claim for services provided overseas
- I have some old receipts. Will the Fund pay benefits on these services?
- Can I claim for future services?
- What about orthodontic treatment?
How to make a claim on general (extras) treatments
Most general treatment claims are made by filling out a claim form, attaching the original account you have received from the provider, and submitting the claim to the Fund by post or in person at the Fund's office. You can also e-mail your claim by completing the electronic claim form, scan your original accounts/receipts and attach both to an e-mail to onlineclaims@tuh.com.au. Claim forms can be obtained by contacting the Fund or can be downloaded from our website. If you don’t have a claim form but still wish to lodge a claim, you should send your accounts or receipts with a signed, covering letter which authorises the Fund to pay these claims for you. You may submit more than one service per claim form.
What kind of account or receipt is required?
Accounts or receipts should be on the provider’s official account form or letterhead. All accounts must be itemised and must bear the name and address of the person providing the service. The account must also state the name of the person receiving the service, a description of the service, the date the service was provided and the cost of the service. You must submit original documents, not photocopies or faxes. If you are submitting an electronic claim by e-mail you must scan your original accounts/receipts, save them to your computer and retain these for 6 months after your claim has been paid. If you are claiming inpatient services, please read the section on the next page titled “What about doctor’s accounts?” Cash register dockets or copies of credit card receipts are not acceptable documents for making claims. You should ask the provider to provide you with an itemised receipt as outlined above, to allow you to claim. Providers are accustomed to doing this and are happy to do so if requested. You will often find it will be necessary to request this type of receipt when you are making purchases from chemists, medical equipment suppliers. Claims for some items must be accompanied by a doctor’s letter stating that the item is medically required. These include prosthetics, mechanical appliances, hearing aids (where more than one is required) and to indicate that contraceptives are used for other than contraceptive reasons.
How will my claim be paid?
If you are presenting your claim in person, there are several ways you may be paid. In most cases the Fund will give you a cheque payable either to the provider or yourself, as applicable. If you have already paid the provider and the benefit to be paid on the claim is not over $200, you may request a cash payment. If you are submitting your claim by mail, the Fund will post you a cheque for the benefits. If you have not paid for the service, the Fund will send the member a cheque payable to the provider. If you have already paid for the service, the Fund will send the member a cheque payable to the member. Please allow up to 5 business days after the claim has been processed for the cheque to be processed. If you have already paid the provider, you may also request that the Fund deposit your benefits directly into your bank account. You will need to advise the BSB number of your financial institution, your account number and the name in which the account is held on your claim form. These details will be held on the Fund’s computer so that benefits for all future paid claims will be deposited into your account automatically, unless advised otherwise. The benefits usually appear in your nominated account within 48 hours of the claim being processed.
What is HICAPS?
HICAPS is an electronic system for making claims with providers who participate in the system. It works very similarly to EFTPOS. Once you have had your appointment, simply hand your Health Fund membership card to the provider. They will ’swipe’ your card through a special machine and the claim will be made electronically. There are no forms for you to fill in and no paperwork for you to send to the Fund. You will only need to pay the provider the difference between your benefit entitlement and the charge for the service.
Should you ever encounter a problem when making a HICAPS claim, ask the provider to contact the Fund at that time. Many problems can be fixed over the phone and your claim can continue.
What is Access Gap cover?
TUH aims to close the gap on out of pocket in-hospital medical expenses for all members. Access Gap Cover is available with any level of hospital cover. Participation is the personal choice of your medical practitioner, so check this before commencement of treatment. Also ask your specialist to recommend that any assisting specialist(s) use Access Gap Cover for the billing of services.
How in-patient billing works
As a private in-patient, Medicare will cover 75% of the MBS fee for doctor's charges. TUH will cover the remaining 25%. If your doctor charges above the MBS fee, this is an out of pocket expense.
If your doctor has nominated to bill under the Access Gap Cover scheme you will either:
- Have no out of pocket expenses: or
- Know your out of pocket expenses
Prior to treatment you can request an estimate of possible costs.
If your doctor participates in this scheme, in most cases you will not receive an account as TUH receives the bill and makes any claims on your behalf from Medicare. If your specialist prefers to send the account to you personally, it is important that you submit this account to TUH directly and NOT to Medicare. The account should bear a sticker or other message to advise you to do this. Once your account has been settled, you will receive a statement from TUH confirming the amount paid to your doctor.
A list of some of the doctors who have participated in Access Gap in the past, is located on the TUH’s website and is available by clicking here. This is not an exhaustive list as some professionals do not want their name advertised in this way. If your doctor or specialist has not participated in Access Gap, but is willing to do so for you, please ask them to contact TUH for directions on how to register. Professionals who participate in Access Gap cover typically may include specialists, doctors, radiographers, anaesthetists and pathologists.
What about hospital claims?
In the majority of cases the hospital will submit their claim to the Fund directly. Once the benefit is paid to the hospital, the Fund will send you a payment advice to inform you of this.
How do I pay my excess?
If you are required to pay an excess on a hospital stay, you should pay this directly to the hospital involved NOT to the Fund. The hospital will often ask you to pay your excess prior to your admission. In some cases the Hospital will wait till after the Fund has paid them before sending you an account for your excess.
What about doctors’ accounts
Bills from doctors, anaesthetists, pathologists and other medical professionals which relate to inpatient hospital services should be submitted to Medicare before being sent to the Fund. The only exception to this is where the doctor has billed you through the Access Gap Scheme. These accounts should always be sent to the Fund directly and should have a warning on them advising you to do so. Do not submit these accounts to Medicare.
How do I claim through Medicare?
When you submit accounts for inpatient services to Medicare, you will have two options available to you. Firstly, you can fill in a standard Medicare claim form. If you choose this method, Medicare will pay your benefit over the counter or post you a cheque. Medicare will also issue you with a Statement of Benefit. To claim any additional benefits that may be available through the Fund, attach this Statement of Benefit to a Health Fund claim form together with a receipt from the doctor if you have already paid the account and then submit it to the Fund. Do not send your Medicare cheque to the Health Fund. Alternatively, in addition to the standard Medicare claim form, you may also fill in a ‘two way’ claim form. If you fill in this form, Medicare will pay their benefit and then submit the claim to the Fund on your behalf. The only drawback with the two way system is that it is not usually as quick as the traditional method so, if the doctor is offering you a discount for paying by a certain date, it may be to your advantage to pay the account before submitting it to Medicare.
Can I claim for services provided overseas?
No. Members should be aware that Medicare has very few reciprocal arrangements with other countries. Benefits are not payable by the fund for doctors or in-hospital medical services provided overseas. It is HIGHLY recommended that members take out travel insurance to cover medical expenses while travelling. If you will be overseas for more than one month you may be entitled to suspend your membership. Please contact the Fund for details.
I have some old receipts. Will the Fund pay benefits on these services?
Benefits are not payable for services, which took place two years or more prior to the date of lodgement of the claim. Benefits are paid at the rate which applied to that service at the time the service was provided. Benefits are paid up to the limit that applied to that service in the Calendar Year in which the service was provided. Benefits for services provided in one year cannot be claimed against the limit allowed for that service in the following or preceding year.
Can I claim for future services?
Sometimes members may choose to pay in advance for a series of treatments which will be carried out over a period of time. You should be aware that the Fund will only pay benefits for services as they are carried out and will not pay for services which will be carried out at future date.
What about orthodontic treatment?
Orthodontic limits are different to the limits which apply to other services claimable through the Health Fund because orthodontic limits are lifetime limits. They do not renew at the start of each Calendar Year as most other limits do. Dental impressions, x-rays and consultations which may be provided by an orthodontist in conjunction with orthodontic treatment are paid as normal dental services and are not claimed against your orthodontic limits. Members or their dependants who are embarking on orthodontic treatment may find that their orthodontist offers them the option of paying for the entire course of treatment in a lump sum at the start of treatment. While members are free to take advantage of this offer, it is important to be aware that the Fund will not pay benefits on this lump sum as this would mean paying benefits for services that had not yet been provided. The Fund will pay benefits for the initial application of orthodontic appliances after they are applied and then for each follow up visit at the time the service is provided, subject to the patient’s orthodontic limits. Members should obtain documentation from their orthodontist for each individual service and submit them to the Fund after that service is carried out to enable further benefits to be paid.
