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 up to $400 online for many extras services through Online Member Services claiming.
For hospital services or larger extras claims, you'll need to complete a claims form, which can be emailed to firstname.lastname@example.org.
What is HICAPS and CSC HealthPoint?
HICAPS or CSC 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?
We've made it easier to claim for a range of services when on-the-spot HICAPS claiming isn't available.
Through Online Member Services you can claim on services like:
- Dental - general services (orthodontics and major dental aren't available)
- Occupational therapy
- Podiatry consultations (orthotics and appliances aren't available online)
- Speech therapy.
You don't need to submit your receipts with your online claim, but we may request them so you'll need to keep your receipts for 12 months.
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.
Bnefiits 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 are 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.