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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:
|Medicare||75% of MBS Schedule Fee||100% of MBS Schedule Fee|
|Medibank||25% of MBS Schedule Fee for eligible inpatient hospital services||100% of MBS Schedule Fee|
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 via the link below.
We have recently made some improvements to our Provider EFT form to make this process easier for you. The new form can now be filled in digitally and contains a verify button that checks and ensures all mandatory fields have been completed. Forms are then submitted to a dedicated mailbox Medical_AncillaryProviders@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.
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:
GPO Box 9999
MELBOURNE VIC 3001
Registration, Accounts & Patient Eligibility Queries
Phone: Medical Enquiry Line - 1300 130 460
Post: Medical Billing
GPO Box 9999
MELBOURNE VIC 3001
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