Provider FAQs
Yes. The member provides the permission for TUH to request this information each time a claim is made. For claims submitted through HICAPS, the receipt that is printed requires the customer’s signature and includes the declaration:
I certify the above products and services have been provided and received by the person(s) listed above on the specified dates, and
a) This claim is not subject to any other form of compensation or reimbursement including Medicare Australia; and
b) The claim does not knowingly breach Fund rules; and
c) Where this claim is for optical or orthotic appliances, it is based on a relevant clinical prescription.
I authorise the Fund to pay proceeds direct to the provider and to verify any aspect of this claim.
Section 4.2 of the HICAPS Provider agreement also stipulates the requirement for providers to supply a fund with evidence to support the claim including treatment plans, appointment schedules, signed receipts and other supporting documentation as requested.
Section IV and VII (c) of our Fund rules also state that that we may request information from a member or their health service provider before or after a benefit is paid.
TUH has a restriction on Providers treating Family members. Section III (C) of our Fund rules prohibits us from paying a benefit for treatments conducted by a provider to the provider’s family members. This is further noted in our Important Information Guide under the heading 'What is not covered?' being “treatment by a provider who is a family member, including (but not restricted to) treatment by yourself or your partner, parent, sibling, child, or other insured person on the policy”.
Health fund benefits can only be claimed once the crown has been inserted. We understand that it is business practice to take a deposit or take a payment upfront to minimise the financial burden for both patient and dentist. However, claims can only be submitted through HICAPS after the service has been provided to the member.
Health fund benefits can only be claimed once the orthotics have been received by the member. Please note that claims for cast and orthotics cannot be claimed via HICAPS on the same day.
We acknowledge that at times our requests may cause some concerns for providers. As custodians of our members’ contributions, TUH has an obligation to all of our members to manage benefit outlays. Therefore, TUH regularly undertakes a review of the claims we have paid. When assessing any claim for benefit, a Private Health Fund is obliged to ensure there is a relevant disease, injury or condition, for which the patient is receiving general treatment. Our reviews are to ensure that we are adhering to the above obligation and that the services have been provided and are being claimed correctly and appropriately.
You play an important role in our member's health and we are therefore mindful of the time a benefit review can take. To enable us to conduct an efficient review please ensure that clinical notes are kept for each treatment being claimed. Treatment notes must demonstrate clear evidence of the medical condition being treated, the patient’s clinical goals, recorded results and anticipated end date of the treatment.
