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How to Make a Claim on Your Health Insurance
How to Make a Claim on Your Health Insurance
Written by
Madeline Pettet
Edited by
Ellie Garran
Reviewed by
Andres GutierrezCompare health insurance policies the easy way
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Understanding the health insurance claims process
Long story short
Health insurance helps cover your health care costs – but only if you make a claim!
If you don’t make a claim for a service, you won’t get money back.
Making a claim has never been simpler; often you can do it on the spot or online
How you claim can depend on the service you’re claiming for and your health fund’s preferences.
You’ll need specific details, like the provider number, to make your claim
Luckily, everything you need is usually on the service receipt.
Understanding the health insurance claims process
If you’ve ever been to the optometrist or dentist, or visited another type of medical professional or specialist, then you may have been asked if you have private health insurance.
While it might initially sound like a snooze-fest, having health cover could actually be an incredibly helpful and cost-effective way to manage your medical bills.
However, in order to get any money back from your health fund, you’ll need to ensure the service used is covered under your policy and then make a claim. Basically, making a claim is the process of contacting your private health insurer about the health or medical service you accessed in order to receive a rebate (or money back) from them.
Ultimately, having health cover can help take the sting out of a pricey medical or health treatment bill by covering some (or all) of the cost, thanks to those handy medical claims. Ka-ching!
When should I make a claim?
You should generally make a claim as soon as you have all the information you need for the service you accessed.
It’s also a good idea to read through your policy documents to understand any claim deadlines or time limits that you need to be aware of before making any claims. You don’t want to miss out!
What can I make a claim on?
In Australia, private health cover is generally divided into three categories: hospital, extras, and ambulance cover (if your state or territory doesn’t already provide it for you).
Hospital cover
Hospital cover insures you against all or part of the treatment costs as a private patient in either a public or private hospital, including doctors’ fees and hospital accommodation. Private hospital cover can allow you to:
- skip public waiting lists at participating private hospitals
- choose the hospital where you receive your treatment
- choose the doctor or specialist who performs the treatment.
What you’re covered for will depend on your level of cover, your insurance provider, and your policy. As with most things in life, the more you pay for your policy, the more things you’ll likely be covered for.
In general, if you have coverage for a particular treatment, it’ll be covered up to the amount set for it on the Medicare Benefits Schedule, by a combo of Medicare and your health insurance. Different policies will have different exclusions and restrictions.
Extras cover
Extras cover, also known as general treatment or ancillaries cover, insures you against all or part of the cost of out-of-hospital health and wellbeing treatments that generally aren’t funded by Medicare. The services you’re covered for will depend on your policy and may include treatments like:
- dental services
- chiropractic treatment
- podiatry
- physiotherapy
- occupational and speech therapy
- glasses and contact lenses.
In most cases, extras cover isn’t unlimited, so you’ll find that the amount you can claim per service, per year, or over the lifetime of your policy is capped. It’s also worth noting that some services may not be covered by your policy at all. Again, the more you spend on a policy, the more bells and whistles it’s likely to come with.
Ambulance cover
Ambulance cover is often included as part of your hospital or extras policy.
The level of cover can differ depending on the policy you choose and the state you live in. In some cases, and depending on which state you live in, ambulance costs are covered by your state government.
Helpful tip
Some health funds have partner agreements with certain health providers, like dentists and physiotherapists. By visiting these partner providers, you may be able to claim 100% of the bill on the spot for some services, meaning you won’t have to pay any extra out-of-pocket expenses.
Dr. Jill Gamberg
GP, Coach, and Lifestyle Medicine Physician
Ways to claim on health insurance
There are many ways to lodge a claim through your health cover policy. The available options for your claim will depend on your insurer, and the type of claim you’re making. Remember, whichever way you choose to claim, your health insurer will need to know your bank details to give you that sweet money back!
On the spot
If a healthcare provider has a device called a HICAPS machine, you’ll simply need to swipe your fund membership card when paying for the service.
Your rebate is automatically deducted from the provider’s fee, so you’ll only be charged the difference between that fee and the amount covered by your policy for the service (also known as the ‘gap’ fee).
The great news is that 100% of private health funds use the HICAPS system, making claiming on the spot really easy.
Online
With most funds, you can lodge a claim directly through their website, but it’s likely you’ll first need to set up an online account.
When you’re ready to make a claim, simply log in and follow the steps from your insurer to lodge. It’s a pretty easy-breezy process from there!
Depending on your insurer, you may need to enter the healthcare provider’s number, item code, and amount you paid for the service. You might also be required to upload your receipts (taking a photo of them is usually fine), so hold onto any paperwork you’re given. And, as always, ask your insurer if you’re unsure!
Via an app
Some health insurers may offer a dedicated app that you can use to submit your claim, making the process super simple. This works similarly to lodging your claim online, but, in this case, you can download your health insurer’s app on your smartphone, log in to your member account, and away you go. It also makes it super easy to upload photos of doctors’ receipts and other important files to support your claim.
By post or in person
If the above methods don’t tickle your fancy, you can always print out your claim forms and post them or go in person to your insurer’s closest customer service centre (if there’s one nearby; not all funds have physical locations these days).
Just make sure to include the original receipts and an itemised account of the services you accessed. Then, you might need to wait for a couple of weeks (or sooner, depending on your insurer’s abilities) for your rebate amount to come into your nominated bank account.
What details will I need to provide when making a claim?
Hospital cover
When you’re treated in hospital, your costs usually come in two flavours (and even two separate bills): hospital costs and medical costs. As a result, you might need to make two different hospital claims.
The hospital costs are things like accommodation, theatre room fees, and even prostheses. Medical costs cover medical professional fees, like that of your surgeon and anaesthetist.
Often, it’s the hospital who’ll do the heavy lifting of claiming those hospital costs. You’ll likely be given a claim form to fill in and sign, which the hospital will forward onto your health insurer along with the bill for those hospital costs.
Medical costs can be a little different since Medicare is involved, too. In some cases, your doctors will forward their bill to both Medicare and your health insurer. Medicare and your insurer then cover their parts of the bill.
Sometimes, you might need to do the legwork and send the bill to Medicare yourself, though. Once that’s processed and you have your Medicare Benefit Statement, you’ll need to find your health insurer’s claim form and send that plus your Medicare Benefit Statement to your insurer.
FYI, these claim forms may be available in PDF format on your health insurer’s website, which you can download and print. If they don’t provide a claim form, then you may be able to get one from the hospital or day facility where you received your hospital treatment.
Extras cover
Claiming on treatments from extras providers is generally straightforward. As we mentioned earlier, you can make your extras claim on the spot using the HICAPS machine, through a dedicated app, or online through your insurer’s website.
On the spot
If you’re paying on the spot, all you need to bring is your insurance membership card. You can simply swipe it through the HICAPS machine after your treatment and your claim will be processed straight away! You might need to bring your debit or credit card, too, just in case you have any out-of-pocket costs.
Mobile app
Simply take some photos of your receipts and upload them to the app. Make sure you have the following details on your receipt before you lodge your claim:
- your provider’s name
- your provider’s number
- your provider’s practice address
- your provider’s ABN/ACN
- the date of service
- a description of the service and its item number
- the name of the patient
- the cost of the service.
And don’t leave it too long – your claim can’t be processed more than two years after the date of service!
Online
Claiming online through your insurer’s member portal is simple: just log in and submit your claim. We recommend holding onto any invoices or receipts just in case you need to share any more info.
Ambulance cover
In some cases, you won’t receive a bill for your emergency ambulance service, as your insurer will generally liaise with your state or territory’s ambulance provider.
It’s a good idea to check whether or not ambulance services in your state or territory are provided under a state scheme. For example, this is the case in Queensland and Tasmania, so if you live in either of those states, you aren’t required to pay a bill for ambulance services.
If you do need to make a claim, you may be able to log into your member account and upload a photo or scanned copy of your invoice.
Then, your insurer will assess your claim and get back to you with an outcome.
If you have already paid for your ambulance service, then you’ll need to include proof of payment, too.
What happens after I submit my claim?
Once you submit your claim, you may need to wait a few days or a couple of weeks for your insurer to assess it before they reimburse you for any refunds or rebates. This timeframe can vary, so check their website or give them a call and ask exactly how long it will take for them to process your claim.
Assessing your claim can include checking:
- that your policy covers the treatment or service for which you are making a claim
- that you were covered for the date of the treatment
- that the provider or health professional you visited is registered and recognised by Australian Health Practitioner Regulation Agency (APRA)
- that you haven’t reached your annual limits (some policies have a cap on how much you can claim each calendar year per treatment, or per service).
While you’re waiting for those business days to pass by, keep in mind that some claims can be more complicated than others.
For example, if your claim is for preventative health, orthotics, or TENS machines, it’s possible that your health insurer may ask you to provide additional documentation to support your claim. If this is the case for you and your claim has been delayed because they want more information, don’t fret! Get in touch with your service provider and they should be able to help you with any additional documentation required.
What happens if my claim is rejected?
A rejected claim isn’t great news, is it? Unfortunately, it can happen, and there are many reasons why. Here are a few possibilities:
- your health fund doesn’t cover the service
- there’s some information missing from the receipt (oops!)
- the service isn’t included in your level of cover
- the photo of your receipt was too blurry
- the service is covered by Medicare (which means you should submit to Medicare first and then, if applicable, submit to your insurer)
- you haven’t finished your waiting period for the services you’re claiming on.
If your claim was rejected and none of the above reasons apply to you, then it may be time to contact your health fund for an explanation.
You never know, it could be something as small as an administrative error! Whatever the case may be, it’s best to get in touch with your insurer as soon as you can to resolve the issue.
If you aren’t given a satisfactory response, you may need to escalate it further by contacting your insurer’s customer service team to let them know you’d like to lodge a complaint.
If you’re still unhappy with the outcome of your complaint, you may choose to lodge a dispute with the Commonwealth Ombudsman.
Where can I find and compare health insurance?
Private health insurance offers the peace of mind that you’re covered for health care services when you need them (and may not be able to otherwise afford them). What’s more, if you earn over a certain amount of money, you may have to pay the Medicare Levy Surcharge if you don’t have private hospital cover.
iSelect makes it easy for you to compare policies from a range of health funds to help find a policy that’s suitable for you. You can chat with one of our comparison experts on 1800 784 772 or use our online comparison tool.
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