Information on 25% Fund Gap

 

Notice Board

What is 25% Fund Gap?
General Information for Recognised Providers

How Do I Claim?
Online Claiming with Medibank via Eclipse
What happens if an account is rejected?
Where do I send resubmitted accounts?
Contact us

 

Notice Board

 

What is 25% Fund Gap?

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

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 for assessment. Currently, Medibank provides payment to providers via our Members in the form of a cheque.

 

General Information for Recognised Providers

What is a Recognised Provider?

To be a Recognised Provider of Medibank, you need first to be registered as a provider (e.g. a doctor) with Medicare Australia. If your provider number is not on our system, you’ll need to provide us with a letter from Medicare Australia which confirms that it recognises you as a provider. This will enable us to add your provider number to our system and process your claims.

If you’re a Recognised Provider of Medibank, you’re eligible to claim the 25% fund gap for in-hospital medical services. Please contact us on 1300 130 460 to determine if you are a Medibank Recognised Provider.

Once we have established that you are eligible to receive the 25% fund gap benefit from us, you can elect to receive this benefit via EFT by completing our Provider EFT Form.

How Do I Claim?

Simply submit your account to Medicare using a Two-Way claim form completed by the patient and let Medicare and Medibank take care of the rest for you.

Two-Way claim forms can be obtained from Medicare.

Online Claiming with Medibank via Eclipse

 

Medibank now has the capability to accept 25% Fund Gap Medical claims via ECLIPSE for Two-Way Fund Gap claims. 

 

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 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 Medibank Private for further information.

 

What happens if an account is rejected?

 

A 25% Fund Gap account can be rejected by Medibank or Medicare for a number of reasons. If you believe that a claim has been rejected by Medibank in error, underpaid or overpaid, please return the claim to Medibank for re-assessment by re-submitting the invoice and a brief explanation as to the problem with the payment.

If you believe that a claim has been rejected by Medicare Australia in error, underpaid or overpaid, please contact Medicare Australia.

To query a claim payment, contact our Medical Enquiry Line


Where do I send resubmitted accounts?

Resubmissions can be sent to:

Medical Billing
Medibank
GPO Box 9999
MELBOURNE  VIC   3001

 

Contact Us

Registration, Accounts & Patient Eligibility Queries
Phone: Medical Enquiry Line - 1300 130 460
Email:  Medical_Provider@medibank.com.au
Post:  Medical Billing
          Medibank
          GPO Box 9999
          MELBOURNE  VIC  3001