Member Guide - RACT

Important informationIMPORTANT INFORMATIONYou’ll also be required to provide additional documentationwith claims for the services/items including:• A doctor’s letter of recommendation is required to be lodgedwith claims for the following items/services: blood glucosemonitor, extremity pump, nebuliser pump, appliances, sleepapnoea monitor, pressure garments, approved orthopaedicappliances by us, non-surgical prostheses, TENS monitor,nicotine replacement therapy patches, learn to swimlessons, blood pressure monitors and joint supports.• An orthodontic treatment plan certificate, completed by thetreating orthodontist/dentist, is required before orthodonticbenefits can commence. You can obtain an orthodontictreatment plan certificate by calling us on 13 27 22. For thepurpose of benefit payments, orthodontic treatment isregarded as commencing on the date the appliance isoriginally fitted. Limits apply every calendar year.• Weight loss program is only payable when recommended inwriting by a doctor for the purpose of preventing orimproving a specific health condition/s. The weight lossprovider must be a member of the Weight ManagementCouncil of Australia and agree to abide by the WeightManagement Code of Practice, including: Weight WatchersAustralia – Jenny Craig Weight Loss Centres Pty Ltd –Fernwood – Simplicity Weight Loss. Benefits are onlypayable for weight loss program fees and not meals orexercise components.Upon claiming, members are required to provide the followingin support of their claim for weight loss program benefits:• A report from the weight loss provider or photocopy of yourmembership record of fees paid at the time that themilestone is reached.• A report from the weight loss provider or photocopy of yourmembership record of weight loss achieved fromcommencement of the program.An initial benefit of $100 is payable upon membersachieving a 10% loss of their start weight. Another benefit ofup to $100 is payable on members achieving their goalweight where achieved within 24 months and up to the totalof program fees not already reimbursed. Where program feesare less than $100 at each of these milestones, RACT HealthInsurance will pay the total of the program fees only and not$100. A 2 month waiting period for commencement ofweight loss program applies.• RACT Health Insurance reserves the right to take thefollowing actions against any policy holder or persons whereimproper, fraudulent or indiscretion occurs while makingclaims against the fund. Actions that may be taken are:- Suspension of electronic claiming with the period of timedetermined by the fund depending on the severity of theincident- Restitution (voluntary or negotiated)- Prosecution- No extras benefit will be payable unless a medical reason/condition is present- Services for both extras and hospital benefits must bevalidated by clinical notes. No benefit is payable wherethere are no clinical notes outlining the service provided.The clinical notes must be legible, written in English andbe understandable by a peer.Physiotherapy consultation must be for a minimum of 15-20minutes to qualify for one-on-one physiotherapy benefits.Unpaid accounts (other than hospital accounts)Claims for unpaid accounts will be paid by direct credit (whereavailable) or cheque. The benefit cheque will be made payableto the health care provider. The cheque should be immediatelyforwarded to the health care provider, together with yourpayment for any account balance.Paid accountsBenefits for paid accounts will be paid:• by exception cheque, made payable to the fund member• directly credited into the member's financial institutionaccount• to RACT Health Insurance, where the member requests thatthe benefit refund is, either in part or full, used to pay RACTHealth Insurance premiums.Medical benefitsClaims for medical benefits can only be paid after your claimfor medical services has been assessed by Medicare (except inthe case of claims made through our medical gap cover – seepage 22 for details) and your claim for hospital benefits hasbeen assessed and paid. Our benefits are not payable forservices rendered when the patient is not a hospital inpatient.Agent’s authorityYou may authorise another person to collect benefits on yourbehalf by completing the Agent’s Authority section of the claimform. The fund member and the agent (the person who is beingauthorised to collect the benefits) must sign the authority. Theagent will be requested to sign the claim form again whenbenefits are paid.Item numbers included under Preventative Dental limit:ItemNumber011012013014015016017ADA ScheduleComprehensive oral examinationPeriodic oral examinationOral examination – limitedConsultationConsultation – extended (30 minutes or more)Consultation by referralConsultation by referral – extended(30 minutes or more)Simplified definitionEvaluation of all teeth, also includes recording medicalhistoryFollow-up consult, records all changes to patient's teethsince previous consultA "problem focused" consult done immediately prior torequired treatmentA consult to seek advice/discuss treatment regarding aspecific conditionA consult to seek advice/discuss treatment regarding aspecific condition – 30 minutes or moreA consult with a patient referred by a dental or medicalpractioner for the management/opinion of a specific dentalconditionA consult with a patient referred by a dentalor medical practitioner for the management/opinion of aspecific dental condition – for 30 minutes or more018 Written report (not elsewhere included) A written report of the patient's care111Removal of plaque and/or stainRemoval of plaque/stain from all surfacesof the teeth113 Recontouring of pre-existing restoration(s) Reshaping/repolishing of existing fillings114 Removal of calculus – first visit Removal of tartar from the surfaces of the teeth115121Removal of calculus – subsequent visitTopical application of remineralizing and/orcariostatic agents, one treatmentFollow-up consult to remove all tartar from the surfaces ofthe teethAn application of an agent to the surfacesof the teeth eg: calcium salts, fluorideIMPORTANT INFORMATION48 49