SCHEDULE OF BENEFITS - nib

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Rejected Claims nib may reject claims for payment of MediGap benefits on the following grounds: • if insufficient or incorrect details are provided on the account or Batch Header/Account Form; • if the service is not an Eligible service within the meaning of these Rules and the nib Fund Rules; • if the fee charged by the practitioner exceeds the MediGap benefit for the service; or • if the Claim for payment of a Medicare benefit in respect of the service is rejected by Medicare. • nib will return rejected Claims to the practitioner and may require: • accounts to be amended where applicable and re-submitted to nib with the practitioner’s next group of accounts; or • accounts to be claimed from Medicare by the customer directly, then the normal 25% medical gap benefit to be claimed by the customer through nib; or • accounts to be sent to the customer noting that the item shown on the account is not claimable through MediGap or from Medicare. Payment of Benefits MediGap benefits are determined once Medicare has provided confirmation to nib that a claim is payable for the service. nib will pay Benefits to practitioners by direct deposit into the nominated financial institution account or by cheque within 7 days of receipt of the Medicare benefit. Benefits for Claims made through Eclipse can only be paid by direct deposit and therefore practitioners using Eclipse for claiming must provide nib with current bank account details. Benefit amounts are subject to the eligibility requirements set out in these Rules and nib Fund Rules. Payment of Benefits by nib is conditional upon: 1. the provision of all information required by nib as set out in these Rules and any other information reasonably required by nib to facilitate a proper assessment of the Claim; 2. the information supplied to nib being true and correct; 3. the practitioner complying with these Rules; 4. all waiting periods that apply to the nib customer having been served, all premiums paid and other conditions in respect of the services provided to the customer having been satisfied by the customer accordance with the nib Fund Rules; 5. no fraud having been committed or reasonably suspected by nib to have been committed by the practitioner in any respect whatsoever in the making of or surrounding the claim; 6. any other matter which nib, acting reasonably, considers relevant. As part of its assessment of submitted Claims nib may request that the practitioner establish that it provided the treatment or services invoiced under the MediGap Scheme. Practitioners agree to provide nib with any information reasonably required by nib, including, but not limited to: 1. information establishing that a particular surgically implanted prosthesis, human tissue item or other medical device was used as part of the treatment or services; or 2. information to establish that an ICU service or a rehabilitation or a psychiatric service was provided by the practitioner; or 3. information establishing that a cancelled procedure, patient transfer or re-admission occurred; or 4. information enabling nib to reconcile claim forms with medical practitioner records. Errors in Invoicing and Payment and incorrect payment of Benefits nib reserves the right to request that a practitioner refund a Benefit paid by nib to the practitioner if nib or Medicare becomes aware that a Claim has been incorrectly paid or overpaid. If, within 90 days of payment, it is discovered by nib or the practitioner) that the practitioner has invoiced nib incorrectly or that nib has paid the practitioner part or all of a Benefit in error, the practitioner agrees to: 1. refund any amount paid incorrectly by nib against that Claims invoice within 14 days from the date the practitioner is given notice by nib that a refund is required; and 2. reissue an amended invoice as soon as reasonably practicable after becoming aware of the error or overpayment. The practitioner acknowledges and agrees that the payment of Benefit for the Claim submitted by the practitioner to nib will be considered to be in full and final payment of the Claim. Notwithstanding that fact nib will consider reasonable claims adjustments for legitimate claims errors submitted within 90 days of the payment of the Claim. | MediGap 2010 6 If the practitioner establishes to nib’s satisfaction that the practitioner was paid incorrectly, nib will pay the practitioner the correct amount as soon as practical after nib becomes aware of or is notified of the error. If at any time the practitioner fails to pay or refund any amount due to nib as a result of the payment of a Benefit made in error
for any of the reasons set out above or otherwise, the amount owing is a debt owed by the practitioner to nib. nib may choose to offset a debt the practitioner owes it in relation to a nib customer against other amounts that nib owes the practitioner, or may recover the amount as a debt in a court of competent jurisdiction. Audit The practitioner agrees that nib may, through any person acting on behalf of nib, carry out an audit of the practitioner’s patient and treatment records for nib customers without charge, pertaining to a Claim for MediGap benefits or any other matter directly relevant to the practitioner’s obligations under these Rules, provided that nib gives the practitioner at least two business days notice of the audit. The practitioner agrees, at its own cost, to use its best endeavours to assist nib in undertaking the audit including providing nib with access to clinical data and other necessary documentation in a timely manner to nib to enable nib to verify the amounts payable by nib as MediGap benefits in accordance with these Rules. As part of the audit process: 1. the practitioner will, on request, supply nib with copies of invoices relating to the components of services provided to a nib customer and for which a MediGap benefit is sought, and when requested, the practitioner will also provide evidence to nib that the invoices relate to a particular service provided to a nib customer; and 2. the practitioner agrees that nib may conduct periodical evaluations to review all documentation, including certificates associated with certain admissions nominated by nib, subject to nib providing the practitioner with two business days notice. Fraud If a practitioner lodges a claim for services: • where the treatment claimed has not been provided by the practitioner; or • where unnecessary treatment is performed nib may take all action available to it to protect its interest including revoking the practitioner’s participation in the MediGap Scheme, seeking reimbursement of the amounts claimed and if necessary referring the matter to police. Practitioner’s Professional Freedom nib’s MediGap Scheme provides Eligible practitioners with the choice to participate on a patient-by-patient basis, ensuring the practitioner’s professional freedom to identify and recommend appropriate treatment, within the scope of accepted clinical practice, is maintained. nib has no responsibility for treatment provided to its customers by participating practitioners. Informed Financial Consent nib is a ‘No Gap’ fund and the patient must be advised of this. The practitioner has the right to charge a fee outside the MediGap Schedule however, if this is the case, the account should be given to the customer for claiming through Medicare and nib. Only the Medicare schedule fee will be paid for services above the MedGap benefit. Where appropriate, participating practitioners will inform a customer in writing of amounts the customer could reasonably be expected to pay for treatment or services and will obtain written acknowledgement from the customer of receipt of that advice. This information must be given: • if possible before the treatment or services are provided or otherwise as soon as practicable after; and • in accordance with the requirements of the Private Health Insurance Act 2007 and any other relevant legislation; and • including any ‘Gap’ payment associated with the cost of any prosthetic items. Disclosure of Financial Interests Practitioners will disclose to a customer any financial interest the practitioner has in the products or services recommended by the practitioner to the customer. Any such disclosure must be given in accordance with the Private Health Insurance Act 2007 and any other relevant legislation. | MediGap 2010 7
Page 1 and 2: SCHEDULE OF BENEFITS RULES AND GENE
Page 3 and 4: RULES FOR PARTICIPATION IN nib’s
Page 5: Making Claims for MediGap Benefits
Page 9 and 10: Item No Benefit Item No Benefit Ite
Page 33: 1300 853 530 nib.com.au nib health

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