The Bupa Australia Medical Gap Scheme
Bupa Australia Medical Gap Scheme
Bupa Australia is one of Australia’s largest health funds,
insuring over 3 million Australians and is part of world-
wide health and care specialist BUPA, which looks after
the health needs of more than 8 million people world-
wide. Practitioner’s Guide
Bupa Australia comprises HBA, Mutual Community,
MBF and MBF Alliances.
Eliminating the Gap Benefits of the Bupa Australia
Bupa Australia also provides health insurance under
Bupa Australia believes that the care a patient receives Medical Gap Scheme
other brands including, NRMA Health Insurance, SGIO,
is of utmost importance and that part of that care is For Practitioners
SGIC and ANZ Health Insurance.
eliminating the financial pain that may be caused by
medical gaps. No contract with Bupa Australia;
Bupa Australia’s Medical Gap Scheme eliminates the • You are free to use the Medical Gap Scheme on a
case by case basis;
medical gap paid by your patients when they are
hospitalised. It provides gap cover without the need for You maintain complete clinical independence;
a contract between Bupa Australia and the practitioner
and allows the practitioner to participate in the Scheme
• Potential for increased practice volume as members
seek a no gap experience;
on an episode by episode basis.
It makes the process simple for you and your patients –
• One full payment to you representing both the
Medicare and Bupa Australia benefit;
saving you time, reducing your paperwork and reducing
bad debts. Plus, we have an electronic system called • No need to pursue unpaid accounts from Bupa
Australia members - no bad debts;
Eclipse available, which makes claims processing fast
and easy. • No need to write off gap amounts for patients facing
This guide contains everything you need to know
– from becoming a Bupa Australia Medical Gap Scheme • Administratively simpler – one payment deposited to
your nominated bank account;
provider to processing claim payments.
Please read on, or visit our provider websites • Available for all MBS in-patient services at all licensed
hospitals and day surgeries;
- www.bupaproviders.com.au or http://provider.mbf.com.au
for more information on how our partnership can work for • Increased patient satisfaction, as quality care is
delivered without financial concerns;
you and your patients.
A weekly statement detailing all payments will be
available via our secure website.
• Financial certainty of no medical gap for in-patient
CONTENTS • Patients continue to have their choice of medical
Eliminating the Gap
Benefits of the Medical Gap Scheme
• Simplified billing process – no need for patients
to claim through a number of sources;
How to Join the Medical Gap Scheme 4 • Improved value perception of private healthcare,
further supporting the private system.
Patient Eligibility 4
For Bupa Australia
Billing and Payment 5
Restoring the surety to private health by covering
Claim Forms 6 the in-patient medical gap;
Payment and Rejection Reports
Claim Rejection Codes
• Increased member satisfaction and value, leading
to improved retention within private health;
Common Questions Answered
• Enhancing relationships with healthcare
Billing and payment
How to Join the Medical Gap Scheme Patient Eligibility
Eliminate gaps, save time and reduce your paperwork, The Medical Gap Scheme is available under all Bupa
here’s how to join: Australia’s hospital tables, given the following patient
1. Complete the application form which can be There are two ways you can process Medical Gap Scheme payments. You can use
downloaded from any of our provider websites.
2. Attach a bank deposit slip, cancelled cheque or bank
• The patient is a member of a Bupa Australia
Eclipse, which allows you to process payments electronically or you can process your
statement to verify your account details.
• The service is eligible for a Medicare benefit; payments manually by using forms.
3. Return the above to Bupa Australia at the
• The service is not excluded under the patient’s level
following address: of hospital cover;
If you’re using Eclipse, payment can be expected Monday Lower incidence of error and shortened review
Provider Operations The service is not a compensable service, that is,
to Friday within 11 working days of lodgement. Payments times – giving you faster resolutions and immediate
Po Box 14639 Melbourne, Victoria 8001 where compensation , damages or benefits may
submitted manually will take 20 working days. EFT payments knowledge of any rejections
4. Upon receipt you will be issued with: be claimed from another source (e.g. Workers’
are paid into accounts every Wednesday. Read below to No hub transaction fees
i. A Practice ID Number; Compensation, Compulsory Third Party Insurance,
find out more about your billing and payment options.
Common Law Damages, Government Programs and View rejection codes and explanations online
ii. Personalised stationery for claims processing. Agencies, Travel Insurance and Sports Insurance, etc); Payment using Eclipse Payment using forms
Once you have joined the Bupa Australia Medical Gap
• The patient is up to date with fund payments; Not interested in all the forms and paperwork? Then this If you haven’t got Eclipse, you can still process your
Scheme, it’s important to brief your staff and advise
your patients that you now use the Medical Gap • The patient has served applicable waiting periods,
including the 12 months waiting periods for
is the option for you. Eclipse is the in-patient claiming
tool that can be used by your practice to send the Bupa
Medical Gap Scheme payments manually. It’s easy,
simply follow our step-by-step guide.
Scheme system. pre-existing ailments and obstetrics. Australia Medical Gap Scheme claims electronically. This
means no more paper claims and improved payment Step 1: Capture the correct details
If these criteria are not met, the claim may be rejected.
turnaround times. To ensure quick processing use this checklist for all the
If you wish to check your patients’ eligibility, please information you need.
Eclipse enables providers and practices to exchange
call 131 243 during business hours, or preferably,
and settle claims electronically, safely and securely over Patient’s name, address and date of birth
if you have access, you may do so via Eclipse.
the Internet. Current Medicare card number and patient suffix
The benefits of Eclipse • Correct health fund name and membership number
Eclipse will save you time and money, here’s how: • Hospital Provider number and the name of the
hospital where the patient was admitted
You’ll get 98% of your claim outcomes within
12 minutes • All service details: Date of service, Medical Benefit
Schedule item number, fee charged per item, the
• There’s no limit to the amount of claims or batches
you can submit
account total and special exemptions (time of
operation, not normal aftercare etc)
• Improved financial management through faster
resolution of claims and quicker payment times
Step 2: Submit your accounts for payment
You can submit your payments by using the Batch Header
• Better data integrity, less manual intervention and
improved claiming automation
Form and your own account forms (if you do not have any
of your own forms please use our Doctor Account Forms)
• Online patient verification of Medicare enrolment
and health fund membership within 4 seconds
Step 3: Batch
We recommend that you submit up to 20 accounts daily
• Online viewing of payments per batch, together with a Batch Header Form. Once we
• One single point of contact and one system for
all health funds
receive your accounts we’ll validate the data and forward
it onto Medicare for processing.
Step 4: Payment
How do I become an Eclipse user? We’ll raise a payment for your claim. This includes the
If you would like to register for Eclipse or want to know 75% Medicare Schedule fee benefit, the 25% Medical
more about electronic claiming or software vendors, gap benefit, and any additional Medical Gap Scheme
please contact the Australia Medicare eBusiness Service amount. You’ll receive reports from us detailing the
Centre on 1800 700 199, alternatively you can email outcome of your payment. Approved payments will be
email@example.com or call the Provider credited to your nominated bank account.
Operations team (see inside back cover for details).
If you’re processing claim payments manually (not electronically), there are two
main forms that you’ll need to use. Here’s an overview of each form and a glossary
Batch Header Form
list to help you complete them. 1. Please complete your practice details:
Practice Name: Practice ID:
Batch Header Form Batch header number – This is the date the batch
of claims leave your rooms, with an alphabetical 2. Complete this form, attach all accounts and send to the address below
The Batch Header Form summarises the number of
character signifying the number of batches for that day. Bupa Australia
claims for an individual provider and the total amount Medical Claims
that all the claims add up to. It will help you to track For example, if three batches were sent for 1 January PO Box 9809
2010 the format would be: Brisbane Qld 4001
and reconcile your weekly or fortnightly submission of
claims. There’s a space for staff to make comments and 1 January 2010
This medical practice agrees to bill the health fund directly for the services attached and accepts the Medical Gap Scheme
it includes your declaration that services provided are
Batch 1 = 01012010A (ddmmyyyyA) Terms and Conditions as supplied by the fund. The members have been advised that no further payment is required in relation
for a private in-patient or day patient of a hospital or an to the services specified in the attached claims.
Batch 2 = 01012010B (ddmmyyyyB)
approved day hospital facility. It also confirms that the
benefits are not claimable from any other source. By Batch 3 = 01012010C (ddmmyyyyC) Provider name:
submitting this form you accept the the Medical Gap It’s important that this number is unique per batch – this
Scheme Terms and Conditions. A Batch Header Form number plus your provider number help us to identify
Telephone number: Date:
must accompany all medical claims. your batches. If you have a query with one of your Batch header number: Total number of claims:
Total fee charged: Total amount claimable:
batches, all you need to do is quote the batch header
How is the Batch Header Form used?
number together with your provider number to enable
A Batch Header Form is to be completed for each Declaration
us to locate it quickly.
provider within a practice and the original must be The professional services specified on the attached forms were provided by me or on my behalf.
stapled to the claims submitted in that batch. Keep a Total amount claimable – This is the total amount These services were rendered as an inpatient of a hospital or approved day hospital facility.
photocopy of the completed form to use when you are expecting to claim back from Bupa Australia.
reconciling the Medical Payment Summary Report Our Medical Claims Summary Report will total both the Comments
you will receive from us. amount of claims approved for payment and the rejections.
This total should equal your total amount claimed.
We have included a list of key terms to assist This will assist you in reconciling claim payments.
you in completing your Batch Header Form: Total fee charged – This is the total fee charged
Practice ID – Your Practice ID is the number given for all claims submitted in the batch. This figure is used
to you by Bupa Australia to identify the Medical Gap to verify that the assessor has entered all claims for
Scheme practice location. To ensure your payment is that batch.
deposited into the correct bank account, your Practice
Total number of claims – This is the total number of
ID must be visible on the Batch Header and Doctor
claims submitted in the batch. Remember that the number
Account Forms. This form can be downloaded from our provider websites:
of claims submitted per batch cannot exceed 20.
www.bupaproviders.com.au or http://provider.mbf.com.au
Provider number – The provider number for your
practice or location is given to you by Medicare
Australia. This helps us and Medicare to identify you. Please note: Printable versions of the Medical Gap
Scheme forms can be downloaded from our websites -
www.bupaproviders.com.au or http://provider.mbf.com.au.
Please ensure that you include your Practice ID.
Bupa Australia Pty Ltd ABN 81 000 057 590 trading as HBA, Mutual Community, MBF and provider of insurance under the brands NRMA Insurance, SGIO, SGIC and ANZ Health Insurance. 02846-05-10S
Doctor Account Form Health fund card/membership number –
Bupa Australia and Medicare use the information sup- The patient’s health fund card or membership number
plied on the Doctor Account Form to assess medical must be provided. This information can be obtained
from the patient or by contacting Provider Services. See
Doctor Account Form
claims. You may use your own account form as long as
you provide us with the health fund number, current inside back cover for details.
Medicare number and hospital name. Health fund name – The name of the health fund
or plan that the patient belongs to must be quoted. This medical practice agrees to bill the health fund directly for the services outlined below and accepts the Medical Gap Scheme
How is the Doctor Account Form used? Funds and plans include HBA, Mutual Community, MBF, Terms and Conditions as supplied by the health fund. The fund member has been advised that no further payment is required
in relation to the services specified on this account form.
Completed Doctor Account Forms should be collated NRMA Insurance, SGIO, SGIC and ANZ Health Insurance.
into batches (20 maximum) and forwarded to Bupa
Medicare number and suffix – The current Medicare Please complete your practice details:
Australia with a Batch Header Form. All fields on the
card number and suffix must be obtained from the
Doctor Account Form must be completed.
patient. This can be found on the patients card and is Practice name: Practice ID:
We have included a list of key terms to assist you in used by Medicare to uniquely identify the person within
completing your Doctor Account Form: their records. Doctor Account Details
Account reference – The account reference is Practice name:
Suffix number – This is the two digit number found
assigned by you and should match your patient’s Provider name:
before the patients name on their membership card (eg.
accounting record. This information is recorded as part Health fund card/membership no: Health fund name:
01) that helps the fund to identify which dependant on
of the claim. This will enable us to quote your account Member’s name: Account reference:
the membership the claim is for. If you do not know this
(claim) reference on the Medical Payment Detail Report information leave this field blank. Patient’s name: Date of birth: / / Suffix no:
for reconciliation. Address: Postcode:
Ordering Medical Gap Scheme Stationery
Facility at which the service was provided:
Applicable service conditions – This section on the
reverse of the Doctor Account Form must be completed. If at any stage you need more Medical Gap Scheme Patient’s Medicare number: Medicare suffix number:
If you answer YES to any of the seven questions listed stationery, simply call or email your order to us.
Alternatively, you can visit our provider websites
please use the space provided to make comments and MBS/MBAC
Description of service
Number of Date of
Provider number Charge
Item No. patients seen service
indicate which item it relates to.
Facility at which the service was provided – $
The name and provider number of the hospital or $
approved day care facility must be entered in this field. $
Any claims submitted without this information will be $
rejected and will need to be re-submitted with the cor- $
rect information. $
Referral Account Details
Referral date: / / Referral period: 3 months 12 months Indefinite
Provider name: Provider number:
Bupa Australia Pty Ltd ABN 81 000 057 590 trading as HBA, Mutual Community, MBF and provider of insurance under the brands NRMA Insurance, SGIO, SGIC and ANZ Health Insurance. 02845-05-10S
Payment and rejection reports
Medical Rejection Detail Report
This is a breakdown of all the rejected payments for each provider in your practice. It provides you with a code and reason as
to why the payment could not be processed. You’ll receive this report when Bupa Australia rejects a batch of claims or items.
See page 12 for more information on claim rejections.
To assist you in reconciling your submitted claim batches, we’ll send you the
following reports. If you are using Eclipse release 4.0 or later, you can view your BUPA AUSTRALIA HEALTH INSURANCE
payment reports online via your software package. You can also view these reports
via our secure provider websites.
Medical Payment Detail Report
This is a breakdown of all the approved and rejected claims in each batch per provider, and the total benefit being paid.
You will receive this report once a batch of claims has been paid for by Medicare or Bupa Australia.
BUPA AUSTRALIA HEALTH INSURANCE
Medical Rejection Summary Report
This reference number This report will be forwarded to you with the Medical Rejection Detail Report and summarises the total amount rejected for
relating to your payment each provider within the practice.
is found here and will
appear on your bank
BUPA AUSTRALIA HEALTH INSURANCE
Medical Payment Summary Report
This report provides you with an overview detailing the total benefits paid to each provider within your practice.
You’ll receive this report once funds have been credited into your account.
BUPA AUSTRALIA HEALTH INSURANCE
Claim rejections Medicare rejection codes
Code Description When a claim is rejected
What occurs when a claim is rejected?
• If the member is not up-to-date with membership
124 Item is restricted to person of opposite sex to patient
• Please check in the MBS book that the item number selected is
the correct one.
There can be many reasons why a payment has not
been made. When a claim is rejected it can relate to
payments at the time of treatment or service
If the claim is covered by another source
Check that the correct patient has been selected.
If you have selected the wrong patient, please correct the de-
tails and re-submit the claim in a seperate batch and mark
either Medicare and/or Bupa Australia assessment. Where any waiting periods have not been served
‘re-submit’ in red
Any rejected claims will be listed in your Bupa Australia at the time of the procedure
Medical Gap Scheme reports with a rejection code. 137 Details of requesting provider not shown on Please check that all the referral details have been included on
Where the hospital cover excludes benefits for account/receipt your account.
Please refer to the following tables for a list of rejection specific treatments and procedures
• If eligible, re-submit the claim in a separate batch and mark
codes, what they mean and what action is required. ‘re-submit’ in red.
Where a Medicare benefit is not payable or where
When are the Medical Gap Scheme benefits Medicare has rejected the claim 162 A benefit for this service has been previously paid
• Check your payment reports or patient accounts for a previous
payment for this item.
Bupa Australia will not pay any medical insurance
Where the claim has not been lodged within two
years of the date of service • If you believe you have not been notified of this, please contact
Medical Claims Assist.
benefits in the following situations:
• Where the member is not on a hospital cover
171 Benefit not payable - provider may only act in
• This means that the provider has already been paid for another
• If the service was not performed whilst the
member was an in-patient of a recognised hospital
Please refer to the Medical Gap Scheme Terms and
Conditions for further information
service. Please check the servicing provider details.
If you believe these details are correct, please contact Medical
or a recognised day hospital facility
179 Benefit not payable - associated service already paid Please refer to the Medical Benefit Schedule or call Medicare
• These claims will require you to submit clinical details (theatre
notes) to the fund for Medicare Adviser’s review.
Bupa Australia rejection codes
Code Description When a claim is rejected
252 Service possibly after care
• Insufficient details on the account (not normal aftercare) - please
include the required Medicare information and re-submit the
claim in a separate batch and mark ‘re-submit’ in red.
L06 Contributor has no hospital cover
• Check with the member that you have the correct personal
and membership details.
320 Expired Medicare card - benefit not payable
• Incorrect card details. Please re-submit your claim with the
correct card number and mark ‘re-submit’ in red.
Check with the fund to verify that the patient is not on
another membership. 414 Provider practice location is closed at the date
Please check the provider number with Medicare.
of service If the provider details need to be updated, please do so and
If the patient is not a member, no benefit is payable from the
re-submit your claim with the updated details and mark
fund. Please bill the member in your normal manner.
‘re-submit’ in red.
L19 Dependant ceased at date of service Please call the patient to see if they have another
membership with us. If yes, re-submit the account as a 415 Referral details same as rendering provider
- self deemed? • Please check the referring provider number, should it be
separate batch and mark ‘re-submit’ in red.
If self-deemed, please make this clear on your account and
L22 Dependant over 20 years on a family table Check if the patient has his or her own cover. If yes, re-submit the claim in a separate batch and mark ‘re-submit’ in
please re-submit the account as a separate batch and red.
mark ‘re-submit’ in red.
429 Patient cannot be identified from the This patient cannot be identified by Medicare. Please check the
L24 Date of the service is after the date paid to The member is not financial, please contact the patient to information supplied spelling of the patient’s name, their date of birth and Medicare
Check with the fund for patient eligibility.
If eligible re-submit the claim in a separate batch and mark • Once you have made the correct alterations please re-submit
the claim in a separate batch and mark ‘re-submit’ in red.
L29 Duplicate claim exists on the database
‘re-submit’ in red.
Check your reports and accounts for a previous payment
or rejection for this claim, as it has been submitted before.
430 Conflicting referral details
• Please check that the referral provider number is current,
and that the referral date and referral period are correct (eg
specialist to specialist can only refer 3 months).
If you believe you have not been notified of this,
please contact Medical Claims Assist.. • Once this has been amended on the account please re-submit
the claim in a separate batch and mark ‘re-submit’ in red.
12 month Waiting Period not served or not waived
Please call us for patient eligibility.
If eligible re-submit the claim in a separate batch and mark
432 Item indicated as not part of multi-op
Please check that these items are part of a multiple operation.
Once this has been amended on the account please re-submit
‘re-submit’ in red.
the claim in a separate batch and mark ‘re-submit’ in red.
If not eligible please bill the member in your normal manner.
L35 Endorsements codes not found at date of service
• Same as L32 The rejection codes listed are subject to change. If you are still unsure why a claim has been rejected please call our Medical Claims Assist team.
See inside back cover for contact details.
Common questions answered Provider support
Q Why should I use Eclipse? batch has been finalised. Administration procedures Call Provider Operations: 1800 060 239
A. Because Eclipse is electronic, it’s a great system for Q Who should we contact for an explanation of This includes any change of details which will affect the Facsimile: (03) 9937 4419
processing the Medical Gap Scheme payments. It will rejection or error description? practice ID number, such as: Email: firstname.lastname@example.org
improve your financial management through faster A. For further clarification on a Medical Gap Scheme
• The appointment of a new doctor Web:
resolution of claims and quicker payment times. rejection, please refer to page 12. If you’re still A doctor leaves your practice
Plus it gives you improved data integrity, with less unsure, contact the Medical Claims Assist team. www.bupaproviders.com.au or
manual intervention and better claiming automation A change to your bank account details http://provider.mbf.com.au
– putting you in control of the process.
Q What are the main features of the Bupa
Q When can a payment be expected?
A. If you’re using Eclipse, payment can be expected
• A change of your address
Please note: If there is a change of doctors at your
Provider Operations , Bupa Australia
within 11 working days of lodgement. Payments sub- Medical Claims practice you’ll need to notify us prior to
Australia Medical Gap Scheme and why PO Box 14639, Melbourne VIC, 8001
mitted manually will take up to 20 working days. EFT sending in claims, so that we can update your details.
should I use it?
payments are paid into accounts every Wednesday.
A. Please refer to page 3 for the many favourable
benefits of using the the Medical Gap Scheme. Q How do I link a claim with a payment?
A. To identify the claim and the payment it relates to, Stationery supplies
Q Why is it important to supply the Medicare
check your Medical Payment Detail Report. This Batch Header forms
number and fund membership number?
report will list:
• Doctor Account forms
A. The Medicare number is required to identify the
patient once the claim details have reached Medi-
The provider batch reference number Benefit Schedule guide
care Australia for processing. The fund membership (your reference number)
• Medical Claims Administration Booklet
number is required to confirm policy details and eligi-
bility. The patient is required to supply you with their • The Bupa Australia batch reference
current Medicare number and fund membership
• The amount charged and benefit paid Medical Gap Claim agreement & reconciliation Call: 1800 060 237 or (03) 9937 4138
details at the time of consultation.
Q How do anaesthetists source patient • A list of patients and the benefits relating to
Q Why are some items paid and others not?
A. To complete accounts, anaesthetists can obtain Patient eligibility For HBA/Mutual Community patients: 131 243
patient details from the doctor of the first refer- A. All claims submitted via the Medical Gap Scheme and choose the provider option
ral or hospital. We have taken steps to ensure that are subject to the normal Medicare Australia rulings.
For MBF/MBF Alliances patients: 1800 111 623
hospitals have all the necessary information required If there are restrictions on medical items, some
and choose the member eligibility option
on the ‘Bradmar’ labels for anaesthetists to complete benefits are not payable.
their accounts. Q How often will the fees or benefits change?
Q If there has been no payment for a patient or A. The fees and benefits are revised in line with the
an item, how is this recognised? Where can the Medicare Australia MBS reviews in November
payment amount be found? each year. Claim assessment & payment Call Medical Claims Assist:
A. If there is a rejection for any reason, this will show Q Can the practice account forms be used? For claim assessment and payment enquiries HBA/Mutual Community patient claims: 1300 367 877
on the Medical Payment Detail Report with an error MBF/MBF Alliances patient claims: 1800 111 623
A. Yes, these forms can be used instead of our Doctor
code and explanation. Payment amounts are listed in Email: email@example.com
Account Forms. It’s important to note, however,
detail on a payment report, which is sent each time a
that a Batch Header Form must be attached and Facsimile: 1300 130 623
your Practice ID number must be written on the
Bupa Australia, Medical Claims,
GPO Box 9809 Brisbane, QLD 4001
Call 1800 060 239
Bupa Australia Pty Ltd ABN 81 000 057 590 trading as HBA, Mutual Community, MBF and provider of insurance
under the brands NRMA Insurance, SGIO, SGIC and ANZ Health Insurance. 02888-05-10S