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Changes to In-patient Medical Claims (IMC) submitted as a GapCover claim through ECLIPSE’s Scheme (SC) channel

Medibank Providers

Changes to In-patient Medical Claims (IMC) submitted as a GapCover claim through ECLIPSE’s Scheme (SC) channel

The Department of Human Services (the Department) will implement changes in the way they pay Private Health Insurers. The objective for this change is to align with their simplified billing process that aims to reduce the number of accounts a private patient receives after being in hospital. 

Presently, if you submit a GapCover claim to us and the total assessment results in a $0 benefit payable, Medibank will still pay you the eligible Medicare portion (75% of Medicare Benefit Schedule).

Effective 21 July 2018, the Department’s process will change whereby you will no longer receive the eligible Medicare portion if Medibank’s total assessment results in a $ 0 benefit payable.

The common reasons for a $0 benefit assessment includes the customer’s health insurance policy is not current, is within a waiting period or doesn’t include the services rendered.

What this means for you

  • These changes will impact a small number of your GapCover claims.
  • If Medibank’s total assessment results in a $0 benefit, then the Department will reject the GapCover claim and you will receive the following notification, HEALTH_FUND_REJECTED. 
  • If the customer’s health insurance cover is resolved, then you can resubmit the claim through the original claims channel to receive the Medicare benefit.
  • Alternatively, you can claim through alternate claiming channels such as IMC Patient Claims (PC) or Medicare Online to receive the Medicare benefit.
  • To minimise the occurrence of rejected claims and ensure prompt payments for your services, please ensure the hospital has performed an eligibility check for services to be provided for our customers.

If you require further information please call our contact centre on 1300 130 460.