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Medical Practitioners

Benefit Statements Online

Use Bupa's secure provider website for quick and easy access to your weekly medical benefit statements. If you haven't already registered, simply complete the online medical benefit statement access form (249kb PDF).

For further information, contact Bupa on 1800 060 239.

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What is the Bupa Medical Gap Scheme?

Bupa believes that the care a patient receives is of utmost importance and that part of that care is reducing or eliminating the financial expenses that may be caused by medical gaps.

Bupa's Medical Gap Scheme (Medical Gap Scheme) can eliminate the medical gap paid by your patients when they are hospitalised. It provides gap cover without the need for a contract between Bupa and the practitioner and allows the practitioner to participate in the Scheme on an episode by episode basis. It makes the process simple for you and your patients - saving you time, reducing your paperwork and reducing bad debts. Plus, we have an electronic system called ECLIPSE, which makes claims processing fast and easy.

Benefits of the Medical Gap Scheme:

For Practitioners

  • Potential for increased practice volume as members seek a no gap experience;
  • One full payment to you representing both the Medicare and Bupa benefit;
  • No need to pursue unpaid accounts from Bupa members;
  • Administratively simpler - one payment deposited to your nominated bank account;
  • Available for all Medicare Benefits Schedule (MBS) inpatient services at all licensed hospitals and day surgeries;
  • Increased patient satisfaction as quality care is delivered without financial concerns;
  • A weekly benefit statement detailing all payments will be available via our secure website.

For Patients

  • Financial certainty of no or known medical gap for inpatient services;
  • Patients continue to have their choice of medical practitioner;
  • Simplified billing process - no need for patients to claim through a number of sources;
  • Improved value perception of private healthcare, further supporting the private system.

Additional information

How to join the Medical Gap Scheme

Eliminate gaps, save time and reduce your paperwork. Here's how to join:

  1. Print and complete the Medical Gap Scheme application form (237kb PDF).
  2. Attach a bank deposit slip, cancelled cheque or bank statement to verify your bank account details.
  3. Return the above to Bupa at the following address:
  4. Bupa Provider Operations
    PO Box 14639
    MELBOURNE VIC 8001

  5. Upon receipt you will be issued with:
    • i. A Practice Identification (ID) Number;
      ii. Personalised stationery for claims processing.

Once you have joined the Medical Gap Scheme, it's important to brief your staff and advise your patients that you now use the Medical Gap Scheme system.

How to use the Medical Gap Scheme

  • Check patient eligibility - please call 134 135
  • Submit your accounts or doctor account forms together with a completed batch header to Bupa or electronically via ECLIPSE
  • Reconcile your accounts. A weekly benefit statement that will cover all payments will be mailed to your postal address, or will be available online.
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Medical Gap Scheme Schedules

The Bupa Medical Gap Scheme Schedules are now available to view or download.

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Medical Gap claims

Billing and payment

There are two ways you can process Medical Gap Scheme payments.

The most efficient way is for you to use ECLIPSE, which allows you to process payments electronically or you can process your payments manually by using forms. If you're using ECLIPSE, payment can be expected Monday to Friday within 11 working days of lodgement. Payments submitted manually will take 20 working days. EFT payments are paid directly into your nominated bank account every Wednesday.

Read below to find out more about your billing and payment options.

Payment using ECLIPSE

Not interested in all the forms and paperwork? Then this is the option for you. ECLIPSE is the inpatient claiming tool that can be used by your practice to send the Medical Gap Scheme claims electronically. This means no more paper claims and improved payment turnaround times. ECLIPSE enables providers and practices to exchange and settle claims electronically, safely and securely over the Internet.

The benefits of ECLIPSE

ECLIPSE will save you time and money. Here's how:

  • There's no limit to the amount of claims or batches you can submit
  • Improved financial management through faster resolution of claims and quicker payment times
  • Better data integrity, less manual intervention and improved claiming automation
  • Online patient verification of Medicare enrolment and health fund membership
  • Online viewing of payments
  • One single point of contact and one system for all health funds
  • Lower incidence of error and shortened review times - giving you faster resolutions and immediate knowledge of any rejections
  • No hub transaction fees
  • View rejection codes and explanations online

How do I become an ECLIPSE user?

If you would like to register for ECLIPSE or want to know more about electronic claiming or software vendors, please contact the Australia Medicare eBusiness Service Centre on 1800 700 199. Alternatively you can email co.eclipse@medicareaustralia.gov.au or eclipse@bupa.com.au

Payment using forms

If you haven't got ECLIPSE, you can still process your Medical Gap Scheme payments manually. It's easy, simply follow our step-by-step guide.

Step 1: Capture the correct details

To ensure quick processing use this checklist for all the information you need:

  • Correct spelling of the patient's name,
  • Patient's address
  • Date of birth (DDMMCCYY)
  • Current Medicare card number and Medicare patient suffix
  • Eight digit Bupa membership number
  • Hospital provider number and name of the hospital where the patient was admitted
  • All service details, including but not limited to: date of service, MBS item number, fee charged per item, referral provider details, the account total and special exemptions (eg: time of operation, not normal aftercare, etc)

Step 2: Submit your accounts for payment

You can submit your payments by using the Bupa Batch Header form (222kb PDF) and your own account forms.  If you do not have any of your own forms please use our Doctor Account Forms.

Please ensure you include your unique Bupa Practice Identification (ID) number on the Batch Header form.  This is to ensure Bupa benefits are paid into the correct bank account.

Step 3: Batch

We recommend that you submit up to 20 accounts daily per batch, together with a Bupa Batch Header form (222kb PDF). Once we receive your accounts we'll validate the data and forward it on to Medicare for processing.

Step 4: Payment

We'll raise a payment for your claim. This includes the 75% MBS benefit, the 25% MBS benefit, and any additional Medical Gap Scheme amount. You'll receive a weekly benefit statement from us detailing the outcome of your payment. Approved payments will be credited to your nominated bank account.

Claims rejections

What occurs when a claim is rejected?

There can be many reasons why a payment has not been made. When a claim is rejected it can relate to either a Medicare and/or Bupa assessment. Any rejected claims will be listed in your Medical Gap Scheme reports with a rejection code. Please refer to the following tables for a list of rejection codes, what they mean and what action is required.

When are Medical Gap Scheme benefits not payable?

Bupa will not pay any medical insurance benefits in the following situations:

  • If the service was not performed whilst the member was an inpatient of a recognised hospital or a recognised day hospital facility
  • If the member is not up-to-date with payments at the time of treatment or service
  • If the claim is covered by another source
  • Where any waiting periods had not been served at the time of the procedure
  • Where the hospital cover excludes benefits for specific treatments and procedures
  • Where a Medicare benefit is not payable or where Medicare has rejected the claim
  • Where the claim has not been lodged within two years of the date of service
  • Where the member is not on a hospital cover

Please refer to the Medical Gap Scheme terms and conditions for further information.

Bupa rejection codes

Code Description When a claim is rejected
L06 Contributor has no hospital cover
  • Check with the member that you have the correct personal and membership details.
  • Check with the fund to verify that the patient is not on another membership.
  • If the patient is not a member, no benefit is payable from the fund. Please bill the member in your normal manner.
L19 Dependant ceased at date of service
  • Please call the patient to see if they have another membership with us. If yes, re-submit the account as a separate batch and mark "re-submit".
L22 Dependant over 20 years on a family table
  • Check if the patient has his or her own cover. If yes, please re-submit the account as a separate batch and mark "re-submit".
L24 Date of the service is after the date paid to
  • The member is not financial, please contact the patient to discuss payment.
  • Check with the fund for patient eligibility.
  • If eligible re-submit the claim in a separate batch and mark "re-submit".
L29 Duplicate claim exists on the database
  • Check your reports and accounts for a previous payment or rejection for this claim, as it has been submitted before.
  • If you believe you have not been notified of this, please contact Provider Operations.
L32
L36
12 month Waiting Period not served or not waived
  • Please call us for patient eligibility.
  • If eligible re-submit the claim in a separate batch and mark "re-submit".
  • If not eligible please bill the member in your normal manner.
L35 Endorsements codes not found at date of service
  • Confirm patient details

Medicare rejection codes

Code Description When a claim is rejected
124 Item is restricted to person of opposite sex to patient
  • Please check in the MBS book that the item number selected is the correct one.
  • Check that the correct patient has been selected.
  • If you have selected the wrong patient, please correct the details and re-submit the claim in a separate batch and mark "re-submit".
137 Details of requesting provider not shown on account/receipt
  • Please check that all the referral details have been included on your account.
  • If eligible, re-submit the claim in a separate batch and mark "re-submit".
162 A benefit for this service has been previously paid
  • Check your payment reports or patient accounts for a previous payment for this item.
  • If you believe you have not been notified of this, please contact Medical Claims Assist.
171 Benefit not payable - provider may only act in one capacity
  • This means that the provider has already been paid for another service. Please check the servicing provider details.
  • If you believe these details are correct, please contact Provider Operations.
179 Benefit not payable - associated service already paid
  • Please refer to the Medical Benefit Schedule or call Medicare Claims Interpretation.
  • These claims will require you to submit clinical details (theatre notes) to the fund for Medicare Adviser's review.
252 Service possibly after care
  • Insufficient details on the account (not normal aftercare) - please include the required Medicare information and re-submit the claim in a separate batch and mark "re-submit".
320 Expired Medicare card - benefit not payable
  • Incorrect card details. Please re-submit your claim with the correct card number and mark "re-submit".
414 Provider practice location is closed at the date of service
  • Please check the provider number with Medicare.
  • If the provider details need to be updated, please do so and re-submit your claim with the updated details and mark "re-submit.
415 Referral details same as rendering provider - self deemed?
  • Please check the referring provider number, should it be self-deemed?
  • If self-deemed, please make this clear on your account and re-submit the claim in a separate batch and mark "re-submit" in red.
429 Patient cannot be identified from the information supplied
  • This patient cannot be identified by Medicare. Please check the spelling of the patient's name, their date of birth and Medicare card number.
  • Once you have made the correct alterations please re-submit the claim in a separate batch and mark "re-submit".
430 Conflicting referral details
  • Please check that the referral provider number is current, and that the referral date and referral period are correct (eg specialist to specialist can only refer 3 months).
  • Once this has been amended on the account please re-submit the claim in a separate batch and mark "re-submit".
432 Item indicated as not part of multi-op
  • Please check that these items are part of a multiple operation.
  • Once this has been amended on the account please re-submit the claim in a separate batch and mark "re-submit".
606 Referring provider number not open at date of referral
  • Medicare have advised referring doctor's provider number is not open at date of referral.
  • Verify with referring doctor that the provider number was valid at date of referral.

The rejection codes listed are subject to change. If you are still unsure why a claim has been rejected please call our Provider Support team.

Claims enquiries

If you wish to enquire about a claim, please call Provider Support on 134 135.

Medical Gap Scheme downloads

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ECLIPSE Patient Eligibility Checking

Confirming patient hospital eligibility for benefits prior to admission is now easier than ever.  Register for ECLIPSE and you will be able to confirm online 24 hours per day, 7 days per week.

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Topic Useful links
Bupa hospital listing

List of private hospitals and day surgeries (124kb PDF)

A list of private hospitals and day surgeries at which members will experience certainty about the costs associated with their hospital treatment.

Claiming / Financial

Medicare Benefits Schedule (MBS)

MBS Online contains the latest MBS information and is updates as changes to MBS occur.

Quality

The Australian Council for Safety and Quality in Healthcare

For the latest updates in issues of safety and quality of healthcare provision in Australia.

National Institute of Clinical Studies

This body seeks to close the gaps between best available evidence and current clinical practice, providing a wealth of information for healthcare workers.

The Australian Council on Healthcare Standards

This independent, not-for-profit organisation is dedicated to improving the quality of healthcare in Australia through continually reviewing of performance, assessment and accreditation.

Australian Prescriber

Free access to current and back issues of this independent publication, providing readily accessible information about drugs and therapeutics.

Professional Organisations

The Royal Australian and New Zealand College of Psychiatrists

This site contains a range of information about the College and psychiatry in Australia and New Zealand.  It also has links to more information about mental health.

Royal College of Pathologists of Australasia

This site contains useful information about pathology and pathologists.

Royal Australian and New Zealand College of Radiologists

Access information about radiology and radiation oncology, the structure of the College, news items, media releases and policy and position statements.

Government

Department of Health and Ageing

For the latest news, programs and resources from this Government department.

Australian Institute of Health and Welfare

Access statistics, publications and information about the state of Australia's health and healthcare systems.

Medicare Australia

For programs, services and health payment information and forms.

Circulars

Department of Health and Ageing Private Health Insurance circulars

Produces private health insurance circulars on various topics.

Private Health Insurance Administration Council (PHIAC)

An independent statutory authority that regulates the private health insurance industry.

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Medical provider login

Login to Bupa's secure provider website for quick and easy access to your benefits statements information