How can I submit a claim?
There are a couple of ways you can claim on services.
For most extras services you can claim at the time of your treatment by swiping your Membership Card in the provider's HICAPS machine.
You can also submit claims for many Extras services through the Mobile App.
For hospital services or larger extras claims, you can claim through the mobile app or by completing a digital claims form, or completing a printable version which can be emailed to email@example.com.
What is HICAPS and HealthPoint?
HICAPS or HealthPoint is a service available to many providers of extras services. It looks just like an EFTPOS machine, and you can swipe your Membership Card to instantly claim the amount that's covered on that service. It deducts that amount from the total cost of the treatment, and then you only have to pay the difference.
What services can I claim on with HICAPS?
You can claim on-the-spot using HICAPS for a range of treatments, like:
- Dentists, endodontists, periodontists, dental prosthetists, advanced dental technicians, prosthodontists, paediatric dentists
- Dispensing optometrists, optical dispensers
- Occupational therapists
- Massage therapy
To find out if your provider has HICAPS, you can search for them on www.hicaps.com.au.
What services can I claim for online?
Online Member Services (OMS)
Online Claiming through Online Member Services is currently not available. We are in the process of updating our Online Member Service portal. Claiming can still be completed online via the Mobile App.
You can also lodge most claims directly to Territory Health Fund through the mobile app by simply taking a photo of your receipt/s and pressing submit. You will need to be registered for OMS before being able to access the app.
How do I claim if I have to go into hospital?
In most cases, when you're discharged from hospital, your account will be settled directly by Territory Health Fund.
Before going into hospital, you'll need to pay the excess that applies to your policy. If your hospital stay was subject to any waiting periods, or if you had any personal expenses, like telephone calls, then you'll be responsible for those expensese. The hospital will usually require settlement for these when you're discharged.
How do I receive benefits when I've claimed for a service?
Benefits are the payments you get back when claiming for hospital and extras services.
There are a couple of different payment options available for receiving benefits.
Deducted from the cost of treatment on the day
If your medical practitioner has HICAPS, your claim is processed on the spot, and any benefit amount is immediately deducted from the cost of your treatment, so you’ll only have to pay any difference.
Paid into your bank account
Your benefit can be paid directly into your nominated financial institution account. All you need to do is provide us with your account details on your application or claim form (including account name, BSB and account number), and we’ll pay the benefits directly to your account, usually within two business days of the claim being processed.
Benefits are payable when:
- The treatment or service is covered by your level of cover, all conditions are met and the waiting period for that service has been served
- A service or treatment is medically necessary, clinically relevant and is a treatment recognised by us
- The service or treatment is delivered in Australia by a recognised practitioner or therapist
- No benefits are payable from another source (e.g. compensation payment or Government benefit).
We calculate the benefit based on the cost of the treatment or aid, taking into account any allowances or discounts that you may get from the provider. None of the benefits we pay will be higher than the actual charge of the service or appliance.
What is a benefit limit?
Limits are the maximum amount we'll pay on certain services in a single Membership Year.
To make cover affordable, limits apply to Extras cover. Limits are in place to set the number of times you can claim on a particular service, or combination of services, and to set monetary limits on total claims within any one Membership Year.
Some services also attract a sub-limit. This is the maximum amount we'll pay on a single type of service. For example, Premium Extras has an overall limit of $1,400 per person per Membership Year, but diagnostic dental has a sub-limit of $600. This means you can claim up to $600 on check-ups at the dentist, and the remaining $800 can be used on other types of dental services.
When you make a claim, the amount we pay for that service (your benefit) is deducted from your cover's benefit limits.
Most of our limits are per person, per Membership year (unless stated otherwise). Unused benefits can't be transferred to anyone else on your policy.