What happens when you lodge a health insurance claim?

by Jude Watson
Health Geek
8th May, 2017 | 3 minutes

After you lodge a claim with your health insurer it can sometimes feel like you’re waiting for a bus to arrive, but you don’t have the timetable. When you understand how the claims process works, you’ll have a better idea of how long it could take, and what might influence your insurer’s decision.

The claiming process and who’s involved

How your claim is processed and by who depends largely on your submission method.

On the spot

Many healthcare professionals (also referred to as ‘providers’) have electronic facilities, known as HICAPS machines, so you can simply swipe your health insurance membership card at the point of service. That’s it. When you claim this way, your rebate is automatically deducted from the provider’s fee. You’re only required to pay the difference between the provider’s fee and the amount your insurance covers for that service.

This method is all conducted automatically, computer to computer. Your claim is checked against data held in your insurer’s system and a rebate is calculated and applied immediately.

Online or via an app

If you’ve set up online access with your healthcare provider, you can choose to log in and lodge your claim on their website. Some insurers require you to upload your accounts and receipts, while others just ask for the provider’s number, item code and amount. The rebate is then transferred to your nominated account, usually within 24 hours depending on the amount and fund.

While this method is largely automated, someone from your insurer may be involved in reviewing the lodgement.

By post or in person

If you prefer to submit your claim by mail or in person at a local branch you’ll need to complete a claim form. You’ll then need to post or hand it to the insurer with an itemised account and original receipts from the provider.

This claims method is handled and processed by data entry staff and possibly assessors.

Hospital claims

If you’re making a claim under hospital cover, your fund usually pays the provider directly. You will be asked to present your membership card on admission and the hospital administration staff will check your cover and submit the claim. You may receive a hospital bill for the difference between the fee and the amount your insurance covers.

Determining who’s involved will depend on how your hospital of choice chooses to submit the claim.

What do health insurers look at when making decisions?

These days, most of the claims process is fully automated. The insurer’s system holds data about your account and works out your rebate using information such as the services you’re covered for and whether your premium payments are up-to-date.

If your claim is rejected or the rebate is less than you expect, it could be that:

  • Your premium payments aren’t up-to-date.
  • You’re still serving the waiting period.
  • You’re not covered for that service.
  • You’ve reached the annual limit for that service.

The best way to have your claim processed smoothly is to make sure you understand what your policy covers and how payment can be made to your healthcare provider.

Health insurers might appear similar, but there can be a world of difference in what they actually offer. Take time to compare health insurance providers before making a choice, and read the policy documents carefully.

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