Health Insurance Claim

Find out about the process of making a health insurance claim and how it works through Savvy. 

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, updated on July 10th, 2023       

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Health Insurance Banner - A young woman receiving a neck and back massage from a physio

There are multiple ways to claim back some of the money you’ve spent on health treatment, both through Medicare and your private health insurance company. Health insurers generally make it easy to make a claim on your health insurance policy, but it’s still important to know what options you have available.  

Find out all about health insurance claims and the many ways you can submit them to your insurer, as well as what you may be able to claim for under your policy, right here with Savvy.

How do I make a claim on my private health insurance policy?

There are various ways you can make a claim on your health insurance policy. These include: 

On the spot, using HICAPS terminal 

This is one of the easiest options to use if you wish to claim back money on your extras policy. If your health care provider (such as your dentist or physio) has a HICAPS terminal in their office, all you have to do is to swipe your health fund membership card when you’re paying. Your allowable rebate will automatically be taken off the total and you can pay the gap with your standard credit or debit card.  

Online 

When you first buy a health care policy, you’ll set up an online account with your insurer. When you’re ready to make a claim, simply log into your health fund’s website and follow the prompts to make a claim. You may need to quote the healthcare provider’s number, item code and the amount charged for services, so make sure you have all your receipts handy before you log in.  

On the go using a mobile app 

Many health funds also have a mobile app which allows you to make a claim on the go using your phone or tablet. Just log into the app and follow the instructions to make a claim. Again, you may need to quote a provider’s number and item codes, so make sure you have your receipts available when making a claim. 

Through your hospital (for hospital cover) 

Most insurers pay the hospital directly for inpatient services, so you don’t have to pay the whole hospital bill, just the gap (if there is one). You’ll need your health fund’s membership card and your normal debit or credit card when you approach the hospital service desk to pay your bill. The receptionist may be able to settle the account using a HICAPS terminal or submit the claim to your health fund on your behalf. 

Via mail or in person 

Although online apps and on-the-spot claims have now overtaken paper forms as the main ways Aussies make claims on their health insurance, there may still be circumstances when you receive a bill through the mail for treatment. This may happen if you required ambulance transport to hospital, for instance; you may receive a bill from the ambulance provider. If so, you can either visit an office of your health provider or go onto their website and download the relevant claim forms to submit by post.  

This may be your preference if you aren’t comfortable using online methods, but HICAPS remains the most convenient and preferred way to make a claim for most Australians where it’s available. 

What can I claim for under hospital and extras policies?

The areas of treatment that are covered by health insurance vary depending on the type of policy you’re buying and your insurer. Some of the areas you can claim for include: 

Hospital cover 

This type of health insurance can cover you in full or partly for treatment provided when you’re a private inpatient in hospital. Hospital cover may include:

  • The cost of admission to a private hospital as a private patient, or to a public hospital as a private patient 
  • The costs associated with staying in a single room if available 
  • Theatre, recovery ward and other accommodation fees 
  • The cost of consultations with doctors and surgeons after you’ve been admitted 
  • Surgeon and anaesthetist's fees 
  • Any tests performed while an inpatient, such as blood tests, x-rays or CT scans 
  • The cost of any medications and pharmacy items provided to you while you’re an inpatient (such as bandages, slings, wound dressings and pain-killing medication)

Extras cover 

These are some of the healthcare services that can be covered by an extras policy:

  • Dental 
  • Optical
  • Physio and chiropractic services 
  • Hearing aids 
  • Podiatry 
  • Speech services 
  • Remedial massage 
  • Psychology 
  • Dietetics 
  • Non-PBS medications

When comparing policies to help you find the best health insurance for your needs, it's crucial to consider what each policy offers in the way of inclusions and exclusions. This can help you pick out one which may offer the protection you're looking for with more confidence.

How do I find out how much Medicare will pay for my treatment?

All medical services covered by the Australian Government through Medicare are listed on the Medicare Benefits Schedule (MBS) list. This comprehensive list clearly shows how much Medicare is prepared to reimburse you for the healthcare provider delivering that service. This is commonly referred to as the MBS fees and benefits. You can look up the MBS schedule fee for any medical treatment you’re about to receive as long as you know the item number, which is an individual code identifying which treatment is to be provided. 

If a healthcare provider bulk bills, they charge an amount equal to the MBS benefit with no additional costs to pay. However, many practitioners charge an amount above this amount. If this is the case, you will have to pay the ‘gap’ between the MBS fee and what your practitioner charges.  

Extras cover can assist you with the cost of paying fees for out of hospital services like dentists, which is one of the main advantages of private health insurance. The amount you’ll be able to claim from your health fund will depend on the level of cover you’ve chosen to buy, with cheaper policies covering less of the fee. 

Frequently asked questions about health insurance claims

How can I find out how much is left to claim on my extras policy?

Extras policies typically have benefit limits for each category of treatment provided. For example, you may be able to claim $300 on general dental and $500 on major dental treatment per year. You can find out how much of your annual or policy limit you’ve used so far that year by logging into your account on your health fund’s website or mobile app. 

Can I make a claim on my health insurance over the phone?

It isn’t usually possible to make a claim on your health insurance policy over the phone, as your health fund will need to see the receipt issued by your healthcare provider.  

If I get a bill for ambulance transport, how can I claim it on my health insurance?

Ambulance cover is offered either bundled with hospital cover or as a standalone policy. To make a claim on your ambulance insurance, it’s often necessary to fill out a claim form and send it, along with the bill for ambulance transport, to your health fund. Your health fund can then pay the ambulance company directly.  

How long will it take to be reimbursed after a health insurance claim?

HICAPS claims are often deposited instantly into your bank account. If you make a Medicare claim, you'll usually be reimbursed within two to three working days. Submitting a claim via post will likely take longer, as you’ll have to allow time for the claim form to be delivered and processed before you can receive your reimbursement. 

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