We are committed to the purpose of striving for better health outcomes for our private health insurance members. As part of this commitment, GapCover aims to reduce or eliminate the out-of-pocket medical expenses paid by our members when they have a hospital stay.
This page explains what you need to know about becoming a GapCover provider and participating in the GapCover scheme. If you’d like more detailed information, please download our GapCover Provider Guide.
- How GapCover works »
- How to register to participate in GapCover »
- How to claim »
- Resources and forms »
How GapCover works
The ‘gap’ is the difference between the fees charged by you and the Medicare Benefits Schedule (MBS) fees for the services you provide to our members. This difference can leave our members with out-of-pocket expenses. With GapCover, you can help close this gap.
Please be aware that some levels of cover have excluded services. GapCover will not apply for an excluded service.
Schedule of Benefits
The GapCover Schedule of Benefits shows the amount we’ll pay for a particular service under GapCover. The amounts shown in the Schedule include the MBS fee plus the additional amount that we pay for a particular service.
Download the current GapCover Schedule of Benefits »
As long as your fees do not exceed the relevant amount in the GapCover Schedule of Benefits, the account will be paid in full and there will be ‘no gap’ for our members.
However, you may wish to charge a Known Gap (an out-of-pocket expense that the member pays). This is any amount you charge that exceeds the amount shown in the GapCover Schedule of Benefits, up to a maximum of $500 per claiming provider (ie. per doctor’s account).
If you submit an account where the Known Gap exceeds $500 per claiming provider, the benefit payable for that claim will be reduced to the MBS fee. In other words, the claim cannot be paid as a GapCover claim.
If the gap amount is to be charged to our member you must have obtained Informed Financial Consent (IFC).
As you can see from the following example, the out-of-pocket cost can be significantly reduced for our member when you choose to participate in GapCover.
|Doctor’s total charge||$800|
|GapCover Schedule fee (the higher fee that will be paid up to for treatment covered by GapCover)
|MBS fee for all items
|MEDICARE PAYS||WE PAY||MEMBER PAYS|
|$300 (75% of the MBS fee)||$100 (25% of the MBS fee)
$200 (the difference between the MBS Schedule fee and the GapCover Schedule fee)
|$200 (the difference between the GapCover Schedule fee and the Doctor’s charge)|
In this case, Medicare will pay 75% of the $400 MBS fee. We will pay the remaining 25% of the MBS fee plus an extra $200 up to the GapCover Schedule fee of $600. The out-of-pocket cost for the member is $200.
This treatment can be covered under GapCover because the doctor has charged the agreed GapCover fee and the out-of-pocket for the member is less than $500 per claiming provider.
How to register to participate in GapCover
To join GapCover, simply fill out the GapCover Application Form and return by fax to (03) 8456 6250.
Terms and conditions
To participate in GapCover you must agree to and abide by the following Terms and Conditions:
- You must be registered with ahm Health Insurance to participate in GapCover.
- You must provide our members with a written estimate of fees (informed financial consent) indicating any out-of-pocket expenses they will have to pay. Where possible, ensure the member has given their informed financial consent to these charges prior to treatment.
- A maximum $500 member out-of-pocket cap per claiming provider is allowed (i.e. per doctor account). This is regardless of the number of items or claim lines on the account.
- If more than a $500 out-of-pocket is charged to the member, the account does not qualify as a GapCover claim and only the fund gap amount will be paid, i.e. the MBS fee.
- You must include the total cost of treatment on the account including the full amount the member will have to pay.
- All claims must be submitted by you directly to ahm Health Insurance. Claims submitted by members or claims already paid by the member will not be eligible for GapCover, i.e. no additional amount above the MBS fee will be paid.
- Benefits will only be paid by Electronic Funds Transfer (EFT) only to your nominated account.
- You will be included in our published list of participating GapCover providers, unless you advise us otherwise.
How to claim
Claiming is easy and quick through Eclipse, the in-patient claiming system developed by Medicare Australia that enables providers, health insurers and Medicare to exchange and pay claims electronically. To claim through Eclipse simply send your claims for our members to ahm Health Insurance using Fund ID ‘ahm’ and Claim Type ‘SC’.
If you don’t have eclipse you can also claim manually by using a batch header.
The benefit we pay you will be based on the MBS item numbers provided by you on your account. We use our best endeavours to process accounts within 21 days, provided they satisfy our requirements (see the GapCover Provider Guide for more information). The benefit will be paid in accordance with the GapCover Schedule of Benefits and the Medicare Australia assessing rules, which are subject to change.
How to register
To register for Eclipse or if you want more information about how it works, contact the Medicare Australia eBusiness Service Centre on 1800 700 199 or email firstname.lastname@example.org.
Already an Eclipse user?
If you’re already an Eclipse user and want to start transacting with us, simply register to participate in GapCover and start sending your bills via Eclipse by using Fund ID ‘ahm’ for our members and Claim Type ‘SC’.
Have a question about claiming? Why not give us a call on 1300 309 438.