Bupa Update for Medical Gap Scheme Providers

Dear Practice Manager,

We are writing to tell you about some important changes that will shortly occur as part of the new Australian Government Private Health Insurance Reforms (Reforms), as well as important information regarding your participation in the Bupa Medical Gap Scheme (Scheme).
Important changes to some policies as a result of the Australian Government Private Health Insurance Reforms
The Australian Government is introducing a range of Reforms across the private health insurance industry. These Reforms are focused on making it easier for customers to understand private health insurance products, and what they are covered for, and to help customers choose the cover that’s right for them. These Reforms will see some services and benefits removed, adjusted, or added.
Introducing the new Government tiers of cover
A major change is the Australian Government’s new classification of hospital products across four tiers, which all health insurers must adopt. These tiers are gold, silver, bronze and basic. All health insurers must also adopt the same clinical categories across these four tiers. The Australian Government has set the minimum number of clinical categories that need to be covered within each product tier. Under the Reforms, some products will require a name change. Where a product covers more categories than the minimum requirement for the given tier, the new product will have the word ‘plus’ in its name.

Bupa will be introducing these new tiers and clinical categories from 1 July 2019, and in preparation for these changes, some products names will change from 1 April 2019.

A complete summary of Bupa products from 1 April 2019 including any name changes can be found in our “Hospital Covers at a Glance” document which is available for downloading at www.bupa.com.au/for-providers.

We will shortly begin communicating these changes with all Bupa customers, and encourage customers to contact Bupa directly to check their cover entitlements prior to treatment.

To find out more information about these changes, including detailed information about the Australian Government’s Private Health Insurance Reforms go to www.bupa.com.au/for-providers.
Your Scheme Registration
Please see the table below which shows the provider(s) in your practice and their current Scheme registration status.

The Terms and Conditions of Bupa’s Medical Gap Scheme allow No or Known Gap providers two options, namely:
Use the Scheme which provides higher Scheme rates, bill Bupa directly for this amount and charge the patient no gap (for No Gap providers) or a maximum out of pocket of $500 per episode of care (for Known Gap providers). In the case of Known Gap providers, the gap must be included in the total fee charged for both manual claims and electronic claims submitted via ECLIPSE;

Don’t use the Scheme and bill the patient directly.
It is important to note that if you intend to use the Scheme, you may not raise any additional charges (for No Gap providers) or any additional charges above the maximum of $500 (for Known Gap providers) under the guise of other miscellaneous items, such as administration fees, booking fees or any item not being a professional service described by a Medicare MBS item.

You may not use – or represent to customers that you are using – our Scheme if you intend to raise an additional charge.

Bupa undertakes regular audits of our customers and providers to ensure the Terms and Conditions of the Scheme are adhered to. Should additional charges be identified which breach our Scheme Terms and Conditions, you may be asked to refund any over-paid monies. Repeated misuse of the Scheme will result in providers being de-registered from our Scheme.

For details about our Scheme’s Terms and Conditions, please refer to our website at www.bupa.com.au/for-providers
Submission of manual claims
Whilst we encourage the use of ECLIPSE for the processing of Scheme claims, should you need to submit a manual claim, to ensure a streamlined claims process you must attach a current Bupa Batch Header form and include on the invoice both the Hospital Name and Number (Facility ID) where the service took place.
Importantly, the Bupa Batch Header must be signed and be legible. Further, please include your Bupa Practice Identification (ID) number on the Batch Header Form, as this will assist us to identify your practice. Failure to provide this information, or should it not be legible, will mean your claim is rejected, requiring it to be re submitted.
Should you require more information regarding the submission of claims, go to www.bupa.com.au/for-providers.
Yours sincerely,

Andrew Ashcroft
Head of Medical Benefits

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