FAQ for claims

15 Most Asked Questions about HealthCarePlus Health Insurance Claims

Jun 2, 2021 12:50:56 PM / by HealthCarePlus

Below are some of the most asked questions that our team has received about making claims since we started our monthly Member Surveys. We want you to claim so we thought it would be useful to put them together in a blog post and publish it, so that our Members can refer to it whenever they need to find out more about claims.

1. It has been more than 12 months since my treatment/surgery can I still claim?

Yes.

  • Claims over 12 months old are still eligible so please send them in for processing.  Remember, if you have lost your receipts, you can contact your medical provider to obtain a copy of the invoice that you can then submit for a refund.
  • For surgical claims your insurer typically pays the provider directly. If you have paid and are seeking an excess refund, we suggest that you submit your claim as soon as possible so that you can receive your refund. 

2. I have a number of different claims to make under my ‘day to day’ plan, how will I know if these exceed my benefit maximums?

  • The easiest way is to submit your claim along with receipts. UniMed will advise if any of these services exceed your benefit maximums.

3. Where do I find claim forms?

  • For ‘day to day’ plan claims, please follow the instructions here: https://healthcareplus.org.nz/member-services#claims
  • For Hospital Cover claims visit the claims section of your insurer’s website to find instructions, or contact your HealthCarePlus representative if you are unable to locate the forms.

4. How does the HealthCarePlus Claim Process work? 

  • For 'day to day' expenses including specialist visits or diagnostic testing, you will need to pay the invoice yourself and claim back up to 50% subject to annual limits under your HealthCarePlus ‘day to day’ plans - click here to complete your form & attached copies of the receipts you have paid.
  • If you have a linked Hospital Cover plan, contact your insurer to arrange prior approval. For specialist visits and some testing, you will need to pay invoices and claim reimbursement from the insurer attaching copies of your receipts. If you require surgery or more expensive diagnostic testing, the insurer will usually pay the provider directly less any excess, as long as you have received your prior approval from them first. Claiming will be limited to a maximum of 100% of costs if you have both 'day to day' and hospital cover plans.

5. I’ve been referred to a specialist/undergone diagnostic tests can I claim this?

  • If you have one of HealthCarePlus's ‘day to day’ plans, you can claim back up to 50% of this cost subject to annual maximums – click here to complete your form
  • If you have a Hospital Cover plan you may be able to claim 100% of the cost depending on whether the specialist visit/testing leads to surgery within 6 months, or if you have purchased the optional ‘specialist & test’ option. If you are unsure check with your HealthCarePlus representative. Claiming will be limited to 100% of costs if you have both day to day' and hospital cover plans.

6. My GP has performed some minor surgery, how do I claim this?

  • If you have one of the HealthCarePlus ‘day to day’ plans you can claim back up to 50% of this cost subject to annual maximums –  click here to complete your form
  • If you have a Hospital Cover plan you may be able to claim 100% of the cost without paying an excess, check with your insurer if you are unsure. Claiming will be limited to 100% of costs if you have both day to day' and hospital cover plans.

7. What is an excess?

  • Many people opt to have an 'excess' on their Hospital Cover plans to help keep their premiums lower. Insurers will require you to pay this 'excess' amount directly to your medical provider in the event of surgery/treatment, and the insurer will pay the balance directly to the provider, as long as you have arranged prior approval with the hospital insurer first.
  • If you also have a linked ‘day to day’ care plan you can claim back the excess you have paid to a maximum of $500 – subject to terms and conditions  – to claim this excess click here

8. What does the waiting period in the day to day plans mean?

You must have your plan in place for this period prior to be able to start claiming on the specified benefits. Only healthcare services undertaken after these waiting periods can be claimed.

 

9. I have upgraded from Primary Care or #Care4U to Primary Care Extra. When can I claim the extra benefits?

You will serve the waiting period applicable under Primary Care Extra for all benefits that are not included in Primary Care or #Care4U. These additional waiting periods apply over and above the standard waiting periods for Primary Care or #Care4U. Please refer to Upgrade Policy for full terms and conditions.

 

10. Do the Primary Care plans cover pre-existing conditions? If yes, when can I claim?

Yes, Primary Care plans cover pre-existing conditions after short initial wait periods. You are eligible to claim benefits on your policy. Please refer to your policy document to find out more about waiting periods or call us on 0800 600 666.

 

11. What value of 'day to day' claims should I accumulate before I submit a claim?

Please submit your claim to Unimed at any value. We strongly recommend you claim regularly to get the most out of your day to day plan.

 

12. When will my 'day to day' claim be paid?

Unimed aims to process 'day to day' claims within 3 business days and if you have given them your bank account details, we will direct credit the reimbursement into your bank account on the same day that they process the claim. This time frame may vary over holiday periods. Once your claim has been paid a Claim Advice notification will be sent by email or mail to you outlining how your claim has been assessed.

 

13. If I exhaust my year’s entitlement can I submit receipts in the following year?

No, claims are assessed based on when the healthcare service is undertaken, not when the claim is made. Claims can not be submitted to be deducted from the following year’s entitlement.

 

14. I have a linked and approved HealthCarePlus Hospital Cover plan, how do I claim the excess?

Claims for reimbursement of an excess must be supported by a receipt for the excess paid by you, evidence of the amount paid by your hospital cover provider (claims assessment advice/payment advice letter), copies of invoices from the surgeon, anesthetist (if applicable) and hospital.

Through your HealthCarePlus 'day to day' plan we may reimburse 50% of net expense up to a maximum excess reimbursement of $500. Excess reimbursement for oral surgery is applicable under Primary Care Extra, but excluded under Primary Care and #Care4U.

Please use the same claim form for day to day plans here: https://healthcareplus.org.nz/member-services#claims

 

15. Why is the dental benefit capped at $250?

In order to keep our 'day to day' plans at an affordable level, we need to cap the maximum claim amounts. If we increase the amount you can claim for dental expenses, we will also need to significantly increase the cost of the plans.  So we retain these limits to ensure the 'day to day' plans remain affordable for our members.

 

If you have any other claim queries about our Primary Care Plans and or Hospital Select, please call Claims at UniMed on 0800 600 666 or if your question is about another hospital insurance contact either your HealthCarePlus adviser or your hospital insurer direct.

 

Tags: Claims