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How is a health insurance claim assessed?

Find out how your claim is assessed and what’s involved

A middle-aged woman typing as she sits at a desk in an office
A middle-aged woman typing as she sits at a desk in an office

You’ve just left your physio appointment and you’re about to pick up the groceries, but before you jump in the car, you upload your receipt to submit your claim on the nib app. You’ve got your life together, you’re feeling limber (thanks to the physio’s exercises) and you’re ready to move on to the next item on your (never-ending) to-do list.

But, while you wait for your benefit to be paid, have you ever wondered how it’s assessed?

We make it as easy as possible to submit your claim, but behind the scenes, our team is working to process your payments as fast as possible. We spoke with nib’s Head of Claims and Policy Admin, Bridget Wilks, about how your claim is assessed and what’s involved.

Ways to claim

Firstly, let’s cover how you can claim. Many registered Extras providers will provide on-the-spot claiming facilities, so you can simply swipe your nib membership card and be on your way. If on-the-spot claiming isn’t available, we’ve also made easy photo claiming available through the nib app or member account – which can be accessed from your computer, phone or tablet. You can also lodge a claim by mail.

You don’t generally need to submit a hospital claim if you attended an nib agreement hospital and used a doctor who participated in MediGap for your admission, however if you did receive a bill, head to our hospital billing and claiming page to find out more.

What you need to claim

All you need to submit your claim is the official receipt from your visit to a specialist or health provider. The receipt should clearly include:

  • The provider’s name and contact details

  • The address where the service was provided

  • The patient’s full name and address

  • The date of appointment

  • The itemised description of services

  • The amount charged

Credit: nib health insurance

What happens then?

Once your claim has been submitted, we start working to process it straight away. We have a system that checks your claim alongside some of your policy details including:

  • That your policy covers this specific treatment/specialist: For example, we’ll only pay claims for your chiro visit if you’ve signed up for an Extras policy that covers chiropractic.

  • That you were covered for the date of the treatment: If you saw your dentist on April 3rd and signed up for private health insurance a week later (on April 10th), you won’t be able to claim on that April 3rd visit.

  • That the provider or specialist you visited is registered: To legally practise in Australia, allied health practitioners must be registered and recognised by AHPRA (Australian Health Practitioner Regulation Agency). To protect our members, we only pay claims for visits to allied health practitioners who are accredited and registered.

  • That you haven’t reached your annual limits: With Extras benefits, there’s a cap on how much you can claim each calendar year for each treatment – we call it your ‘annual limit’. To check your annual limits and how much you have left, head to the ‘My Usage’ tab in Online Services or on the nib app.

Why would a claim get rejected?

There are a number of reasons why a claim may have been rejected and, according to our claims team, here are some of the most common1:

  • We don’t cover the service (e.g. swimming lessons or aromatherapy)

  • There’s some information missing from the receipt provided

  • The service isn’t included on your cover

  • The photo of your receipt was blurry

  • The service is covered by Medicare, which means you must submit to Medicare first, and then if applicable complete your claim with us

  • For prescriptions, the medication is listed on the Pharmaceutical Benefits Scheme (PBS)

If you want to talk to someone about why your claim wasn’t approved, head to our Contact Us page. For more information, tips and tricks on your private health insurance, make sure you check out the Health Cover tab on The Check Up.

1Data from 1 January 2018 to 1 October 2018