Medibank GapCover Scheme Information

Important information

Medibank are working towards moving away from accepting provider refunds via cheque and from issuing cheques to providers for claim benefits. Instead, we’ll use Electronic Funds Transfer (EFT) to get payments to you faster – 2 to 3 business days.

What happens next?

You’ll need to provide your EFT details, which can be done in 3 simple steps:

Go to GapCover Application and Change of Details Form
Complete the registration form
Save and send the completed form to GapCoverForms@medibank.com.au

August 2021 GAPCOVER RATES

Following the 1 July 2021 changes to the Medicare Benefits Schedule and a review of our GapCover schedule and customer out of pocket costs, Medibank is increasing rates for certain MBS items within Orthopaedics, Obstetrics, Ophthalmology, Cardiology & Neurosurgical. These new rates will be effective from 16 August 2021. To view and download the GapCover rates, please see the ‘Current GapCover Rates’ section below. If you have any questions about changes to Medibank’s GapCover schedule, please contact us on 1300 130 460. If you have any questions about the Medicare Benefits Schedule please go to MBS online.

Changes to Information Published for GapCover Providers

We know that our customers are concerned about the cost of their hospital admission and we are supporting them to have better conversations with their treating doctor about out-of-pocket costs.

We are including additional information about GapCover participation for most doctors and specialists that have not opted out to being published on the Medibank Find a Provider website. Customers will be able to find out the percentage of hospital claims the doctor or specialist charged no out-of-pocket, charged an out-of-pocket of up to $500 or charged an out-of-pocket of more than $500.

This information is published in accordance with the GapCover Terms and Conditions.

The information on GapCover participation will support our customers to make the best decisions about their health and about what, if any, out-of-pocket costs they might face when admitted to the hospital.

Please contact us for further information about GapCover on 1300 130 460.

Changes to In-patient Medical Claims (IMC) submitted as a GapCover claim

The Department of Human Services (the Department) will implement changes to the way they pay Private Health Insurers. Learn more

GapCover Application and Change of Details form

For GapCover registrations and any other change of details you want to make, simply fill out the GapCover Application and Change of Details forms and email to our dedicated mailbox GapCoverForms@medibank.com.au.

What do you need to do?

You may need to download Adobe Acrobat Reader DC before you start
Click here to view the new form and some brief instructions on how to complete.

Revised Terms and Conditions for Medibank's GapCover Scheme

We have recently made some changes to our GapCover terms and conditions to help improve the delivery of private healthcare to our customers and strengthen our partnership with GapCover participants.

Click here to view the updated Terms and Conditions of our GapCover scheme that took effect on 1 May 2017. Please note, the revised Terms and Conditions do not affect any payment terms (i.e. the timeframe in which claims for benefits are assessed and paid) or the current schedule of GapCover fees.

We have also updated the GapCover Provider Guide which includes useful operational information like registration and claims management processes.

What do you need to do?

The updated GapCover Terms and Conditions will apply in respect of any claims for benefit payments submitted via GapCover processes on and from 1 May 2017. You can continue to submit GapCover claims as you usually do, and you will continue to be recognised and promoted as a GapCover provider.

Please refer to the GapCover Information section below and complete the GapCover Application and Change of Details form if you wish to:

update your contact information, and/or
opt out of being included in the lists we or others publish of Medibank GapCover providers.

You can update these details or opt-out of publication at any time. Please note that even if you have previously opted-out prior to 1 Jan 2017, you will need to do so again to continue that exclusion

Note: if you wish at any stage to opt in to being published as a GapCover participant, you will need to complete and submit the GapCover Application and Change of Details Form (even if you are not changing any of your contact or other details) and leave the opt-out from publication un-selected.

More Information

For more information you can contact us on 1300 130 460.

GapCover Schedule of Benefits

The GapCover Schedule of Benefits is indexed in line with the Medicare Benefits Schedule (MBS).

Please refer to the Department of Human Services website for further information on the MBS - www.mbsonline.gov.au

Patient Eligibility Checks for the GapCover Scheme

Interactive Voice Response (IVR) is used to interact with health providers through a series of voice commands. Medibank uses the IVR technology on its Medical Enquiry Line to enable prompt patient eligibility checks of private health insurance cover for proposed medical procedures and suitability for the GapCover scheme. As a provider, we know this service is important to you in providing access to timely patient eligibility information.

You can now conduct patient eligibility checks at any time as the Medical Enquiry Line is available 24 hours a day.

Follow these simple steps to use the IVR system

Call the Medical Enquiry Line on 1300 130 460

Select the relevant option on IVR

Enter the GapCover Access Code – 540 300

Follow the prompts to enter patient details

Please ensure the admitting hospital has completed a separate check to confirm a member’s eligibility for private health insurance benefits in relation to the proposed hospital admission.

For further information, please refer to ‘Payment of Benefits’ in the GapCover Provider Guide (click here).

Doctors and their staff

Access our most recent notifications on our Notice Board or download useful forms and information (pdf) under GapCover Information.

Gapcover claims processing system

Medibank has implemented a GapCover claim processing system. This system enables faster processing of claims submitted directly to us by doctors. However, the system can only process claims that use our current standard format. Please follow these simple requirements so your claims can be processed using the current system:

Use the latest batch header form which can be downloaded from this website;
Attach up to 20 accounts per batch header; and
Print each account on a separate page.

The system cannot process claims submitted in the following previously used formats:

Previous versions of our batch header forms;
Accounts presented on old Medibank Private doctor account forms; or
Multiple accounts printed on a single page.

We recommend that GapCover claims are submitted directly to Medibank Private rather than given to your patient. As a provider, you are required to submit all GapCover accounts directly to Medibank. We are unable to process GapCover accounts submitted by patients.

Ceasing patient-submitted GapCover claims

Ceasing patient-submitted GapCover claims from 31 December 2010

To improve our members’ experience we will no longer require them to submit their GapCover claims to us. Effective 1 January 2011, only claims submitted by providers will be accepted. We would like your cooperation with this and ask that you submit all Medibank GapCover claims on behalf of your patients directly to us which will enable more efficient claims processing. Refer to the Provider Information Booklet and Schedule of Benefits for instructions on how to do this.

GapCover Accounts - Medicare and Referring Provider Numbers

In order to ensure your account is processed quickly and correctly, please ensure that your account includes the following:

Correct Medicare number. If the Medicare number is incorrect or not provided, the account will be rejected. Please put the UPI (Unique Patient Identifier) at the end of the Medicare number. If the UDI is at the start of the Medicare number, the account may be rejected.
Referring Provider Number. Although our requirement is only for referring provider details, including the referring provider number ensures that the account is processed correctly and removes any confusion that may arise from providers with multiple locations.

Known Gap

Changes to GapCover - effective 1 June 2010

From 1 June 2010, we changed the maximum GapCover out- of-pocket to $500 per doctor, per claim.

What will this mean for Doctors using GapCover?

When submitting a claim, doctors must ensure that the ‘known gap’ does not exceed $500;
A fully itemised account must be submitted for all GapCover claims to Medibank which outlines all charges for the member per claim, including any charge not covered by Medibank;
Where the ‘known gap’ amount exceeds $500, the claim should be submitted under the Fund Gap arrangement; and
As has been the case previously, doctors must obtain Informed Financial Consent from the member prior to admission explaining all out of pocket costs.

Please note, any other conditions associated with using GapCover continue to apply.

Payment for Online Claiming via ECLIPSE

Providers wishing to submit Gapcover claims via Eclipse will need to ensure EFT details have been provided to Medibank to facilitate payment of funds. You can update your EFT details by completing the GapCover Application Form which can be downloaded from the Medibank website: www.medibank.com.au >choose ‘Providers’ link, then ‘GapCover Information’ and scroll down to 'GapCover Application Form'. Please allow 5 business days for your EFT details to be activated.

GapCover claims to be paid by EFT only

From 1 November 2011, as an improvement to our claiming process, GapCover claims will only be paid by EFT and no longer by cheque.

To register your EFT details please submit a GapCover Application Form found under GapCover Information.

Informed Financial Consent and Eclipse Claims

Medibank has recently sought clarity from the ECLIPSE Reference Group on conflicting information regarding Claim Type=SC and Informed Financial Consent options. As a result, from Wednesday 29th June Medibank will accept Gapcover medical claims via ECLIPSE with the informed financial consent field set to X for SC type claims where there is no Gap. Where there is a gap and the member has been provided with written financial consent for a known gap the informed financial consent field must be set to W.