SCHEDULE OF BENEFITS - nib

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Customer Eligibility A nib customer meets the eligibility criteria for MediGap if: • at the time of receiving the Eligible service the nib customer: ·· is eligible for hospital benefits under an nib product to which MediGap applies; and ·· is a financial customer of nib; and ·· is not subject to a waiting period in respect of the eligible service; and ·· is eligible to receive Medicare benefits; and ·· the nib customer received Eligible services from a participating practitioner: i. in respect of which the customer is not entitled to compensation, damages or any other indemnification; and ii. which are not excluded for Medicare benefit payment. Practitioners will need to obtain the following details from nib customers and provide to nib: • nib Customer number; and • nib Customer name, address and date of birth to ensure identity; and • current Medicare card including the patient reference number; and • confirmation that the customer is not entitled to compensation or payment from another source in respect of the service. If a claim for compensation has been lodged but not settled, practitioners should advise customers to contact nib and provide details relating to the claim. In addition the practitioner must advise nib of the operation item numbers expected in the planned inpatient service for the nib customer. Once the practitioner has all these details, nib will be able to confirm the customer’s eligibility for Benefits under the MediGap Scheme. To assist in ensuring the customer is covered for MediGap benefits please contact the MediGap Hotline 1300 853 530. Eligible Services MediGap is available for chargeable in-patient hospital services rendered in public or private hospitals and registered day facilities to Eligible customers by participating practitioners. All services are subject to Medicare Australia claiming requirements. When MediGap Benefits are Not Payable MediGap benefits are not payable in the following circumstances: • where the Claim is sent directly to Medicare or the customer instead of to nib; • where a Claim is lodged more than 2 years after the date on which the service was provided; • where the date on which the service was provided is prior to the date of the practitioner’s application to participate in nib’s MediGap Scheme; • where the amount of the Claim is more than the MediGap benefits for the relevant service. MediGap is a No Gap scheme and the practitioner must accept the MediGap benefit as full payment for the service; The practitioner must not charge any other fee in respect of that service. This includes ‘booking fees’, administration fees’ and similar charges. If the practitioner intends to charge more that the MediGap benefit for a service, the service is not an eligible MediGap service and the account for those services must be forwarded to the patient directly. • for any service provided to a customer on an outpatient basis; • for any services where the customer , at the time of admission, is classified as a Medicare (public) patient; • for a service for which there is no Benefit payable under the MediGap Schedule of Benefits; • for a service for which there is no Medicare benefit payable; and • Where charges are equal to or below Medicare benefit payment. MediGap Benefits For participating practitioners who provide Eligible services to Eligible customers, nib will pay an amount up to a maximum of the MediGap benefit for that service. For the avoidance of doubt, the MediGap benefits set out in the MediGap Schedule of Benefits are the total amount (including 100% of the Medicare benefit payable for the service) payable to the practitioner for the relevant eligible service. The MediGap benefit will be identified and described by the corresponding MBS item number. | MediGap 2010 4 All claims for payment of MediGap benefits must comply with the Rules of the MediGap Scheme and nib’s Fund Rules.
Making Claims for MediGap Benefits Eclipse Claiming This is a Medicare Australia initiative, which offers an electronic claiming alternative. nib has this claiming functionality available to enable providers to make Claims with a faster claiming experience. When using Eclipse for the MediGap Scheme, Claims should be processed as claim type as SC (Scheme). Manual Claims received via post When a practitioner lodges accounts for MediGap Cover benefits payment, practitioner accounts must be accompanied by the Batch Heade /Account Form (AS-056) per provider. nib MediGap Batch Headers Account forms can be found at www.providers. nib.com.au or via hyperlink http://www.nib.com.au/home/providers/MediGap/Documents/Account_Form.pdf See sample below. There are 2 methods that can be used: Method 1 - Using your own accounts with the nib Batch Header/Account Form Information contained on the Batch Header/Account Form is required by nib and Medicare to assess benefits. If the practitioner account/billing system contains all the information required on the nib Batch Header/Account Form, in particular parts 2 and 3, then only complete parts 1 and 4 and attach to the practitioner own account - it is essential that part 4 is completed and signed. If more than the 4 lines are needed on the form for the same account, use a second page – the second page only requires the patient name, provider name and account number. Please staple multiple pages together. Method 2 - Using the nib Batch Header/Account Form as your account Fully complete all parts of the Batch Header/Account Form. Supplies can be obtained using the stationery request form - AS-056. nib MediGap Batch Headers Account forms can be found at www.providers.nib.com.au or via hyperlink http://www.nib.com.au/ home/providers/MediGap/Documents/Account_Form.pdf abn 83 000 124 381 nib MediGap Department This medical practice agrees to bill nib MediGap directly for the services on this Reply Paid 62208 account and accepts the terms of MediGap as set out in the current Products & NEWCASTLE NSW 2300 Phone 1300 853 530 (option 1) Procedures Guide. The patient/nib customer has been advised of the payment Fax 02 4925 1906 arrangements for the services on this account and no further payment is required. Email medigap@nib.com.au Web providers.nib.com.au nib MediGap is a NO GAP scheme. BATCH HEADER OR ACCOUNT FORM Instructions • Complete parts 1 and 4 if attaching your own accounts. (Your accounts much include all information in parts 2 and 3) • Complete parts 1, 2, 3 and 4 if using this form as your account. PART 1 - BATCH DETAILS Provider’s name Provider’s number Date lodged Number of claims in batch Total value of $ claims in batch PART 2 - ACCOUNT DETAILS Patient’s name *Medicare no. nib customer number *Patient reference no. *Please ensure correct Medicare and Reference No’s are stated Separate forms must be completed for each provider Patient’s date of birth Customer’s name (if not the same as the Patient) Hospital name Hospital provider number Referral details Your reference number Total charge Referral date Referral period: 3 months 6 months 12 months 18 months Indefinite Referring doctor’s name Referring doctor’s provider number PART 3 - SERVICE DETAILS Service conditions - tick () below if applies to each service MBS Item no. Description of service Number of patients Date of Service Full cost of service Part of a multiple procedure Referred within a hospital Designated Considered Performed Self ‘not normal’ ‘not for on separate determined after care comparison’ sites 1 2 3 4 Assisting doctor’s name Surgeon’s name PART 4 - AUTHORISATION • Are the services on this claim related to compensation? Assisting doctor’s provider number Surgeon’s provider number Yes No Ensure all sections are fully completed and authorised • Does your practice have financial interests in any hospital or health insurance product? Yes No • Has the patient/nib customer been provided with informed financial consent? Yes No Declaration The professional services on the attached account were provided by or on behalf of a doctor in this practice and were rendered to a private in-patient of a hospital or registered day hospital facility. I declare that the charges above are full cost for services provided and that no additional charges have been placed on the customer for those services. Signature of authorised person For assistance or more information, please call the MEDIGAP HOTLINE 1300 853 530 (option 1) Date nib0056_0809 | MediGap 2010 5
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Page 3: RULES FOR PARTICIPATION IN nib’s
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