Information on 25% Fund Gap
General Information for Providers
What is 25% Fund Gap?
Information for Simplified Billing Agents
Terms and Conditions for Simplified Billing Agents
How to register with Medibank Private
How to claim 25% Fund Gap as a Simplified Billing Agent
Online Claiming with Medibank Private via Eclipse from September 2010
What happens if an account is rejected?
Where do I send resubmitted accounts?
Contact us
Notice Board
- Medibank Private introduces EFT for 25% Fund Gap from September 2010
From September, you can receive EFT payment. A new corresponding Remittance Advice will be sent to you with the relevant information on your account assessment.
Complete the Provider EFT form to register your EFT details.
Provider EFT Form
- Product Changes effective 1 June 2010
From 1 June 2010, new exclusions and restrictions will apply to some services under some Medibank Private covers. Contact 1300 130 460 to check if a patient has an eligible cover before a service is performed.
The 25% Fund Gap is for medical services for members who receive inpatient hospital treatment. Account payments breakdown is as follows:
| Who pays? |
How much? |
Total |
| Medicare |
75% of MBS Schedule Fee |
100% of MBS Schedule Fee
|
| Medibank Private |
25% of MBS Schedule Fee for eligible
inpatient hospital services
|
To have a claim assessed, the member is required to submit an itemised account to Medicare Australia. The member will then receive a Medicare Australia Statement of Benefit (SOB).
The member is then required to complete a 25% Fund Gap Member Claim Form and attach the Medicare Australia Statement of Benefit and submit to Medibank Private for assessment. Currently, Medibank Private provides payment to providers via our Members in the form of a cheque.
Notice Board
When submitting 25% Fund Gap Claims, you are required to include a completed Medibank Private 'Batch Header'. A 'Resubmission Batch Header' has been introduced for claims requiring review following the initial assessment.
Please ensure the correct Batch Header is attached when submitting new claims or claims requiring resubmission and that they are grouped separately. Copies of the Batch Headers are below.
Batch Header (limit of 40 claims)
Resubmission Batch Header (limit of 10 claims)
View a completed Batch Header or Resubmission Batch Header
- Required information on claims
When submitting claims, please ensure all mandatory and accurate information is included. Mandatory Fields include:
- Patient Membership Number - Charge Amount
- Patient First and Last Name - Medicare Benefits Schedule Item
- Date of Birth - Medicare Schedule Fee
- Date of Service - Medicare Benefit
- Service Provider Name and Service Provider Number - If the claim is accident or compensation related
If a claim is an accident or compensation related, it is a mandatory requirement that Medibank Private is informed. Please ensure that this is clearly marked on the front of the relevant claim/s if this is the case.
- Product Changes effective 1 June 2010
From 1 June 2010, new exclusions and restrictions will apply to some surgical items under some Medibank Private covers. Contact 1300 130 460 to check if a patient has an eligible cover before a service is performed.
- Medibank Private introduces EFT for 25% Fund Gap from September 2010
In September, Medibank Private will introduce EFT payment along with a corresponding Remittance Advice which will provide you with the relevant information on the outcome of your account assessment.
- Online Claiming with Medibank Private via Eclipse from September 2010
From September 2010, Medibank Private is planning to have the capability to accept 25% Fund Gap Medical claims via ECLIPSE. If you are interested in submitting medical claims via ECLIPSE, please contact the Medical Services Manager for further information.
In conjunction with the new EFT payment methods for Simplified Billing Agents, Medibank has introduced Terms and Conditions. These Terms and Conditions will apply from 5 September 2010.
If you wish to submit 25% Fund Gap accounts to Medibank Private as a Simplified Billing Agent, you need to register with Medibank Private. When you register with Medibank Private, you agree to accept the Terms and Conditions that apply when submitting claims as a Simplified Billing Agent for 25% Fund Gap Claims.
To register, complete a Simplified Billing Agent Registration & Change of Details Form and mail to:
Medical Services Manager
Provider Relations
Medibank Private
GPO Box 9999
MELBOURNE VIC 3001
You will then receive confirmation of your registration, together with relevant details to help you claim as a Simplified Billing Agent for 25% Fund Gap.
• Simplified Billing Agent Registration & Change of Details Form
1. As a Simplified Billing Agent, you submit the account to Medicare to receive the 75% Medicare benefit.
2. Once you have received your benefit from Medicare, forward the Medicare Simplified Billing Statement of Benefits and account, together with your completed Batch Header to Medibank Private.
3. Send your completed accounts to:
Medical Billing
Medibank Private
GPO Box 9999
MELBOURNE VIC 3001
4. Once the accounts are received, Medibank Private will process and assess the claim for payment.
5. If a benefit is payable, you will receive Medibank Private's payment by cheque addressed to you. From September 2010, payment will by made via EFT (if you are registered with Medibank Private)
6. If a benefit is not payable, the Statement of Benefits will contain a code explaining the reason.
It is important that the correct information is provided on the Batch Header to ensure timely and accurate processing of accounts.
From September 2010, Medibank Private is planning to have the capability to accept 25% Fund Gap Medical claims via ECLIPSE.
ECLIPSE is an extension to Medicare Australia's online claiming solutions and
• offers a secure connection between practices, public and private hospitals, billing agents, Medicare and Department of Veterans' Affairs and health funds.
• incorporates direct communication for providers with Medicare and health funds, all in the one transaction.
What are the expected benefits of ECLIPSE?
• Faster resolution of claims and faster payment times
• Less manual intervention - fewer errors, speedier resolutions
• Clearer error messages with a single point of contact for problem resolution
• Online patient verification of Medicare enrolment and health fund membership
• No more claims batching
• One system for all health funds
• No transaction costs for medical claiming
• A one stop shop for claiming
You can obtain further information on ECLIPSE from Medicare Australia
If you are interested in submitting medical claims via ECLIPSE, please contact the Medical Services Manager for further information.
A 25% Fund Gap account can be rejected by Medibank Private for a number of reasons.
If you believe that a claim has been rejected in error, underpaid or overpaid, please return the claim to Medibank Private for re-assessment by attaching a Resubmission Batch Header.
Resubmission Batch Header
It is important that Resubmission Batch Headers are included with resubmissions and completed accurately to allow for timely and accurate re-assessment.
Completed batches of resubmissions can be sent to:
Medical Billing
Medibank Private
GPO Box 9999
MELBOURNE VIC 3001
Accounts & Patient Eligibility Queries
Phone: Medical Enquiry Line - 1300 130 460
Email: Medical_Provider@medibank.com.au
Post: Medical Billing
Medibank Private
GPO Box 9999
MELBOURNE VIC 3001
Registration enquires for Simplified Billing Agents
Phone: Medical Services Manager - 03 8622 5947
Fax: 03 8622 5691
Email: Medical_Contract_Administration@medibank.com.au
Post: Medical Services Manager
Provider Relations
Medibank Private
GPO Box 9999
MELBOURNE VIC 3001