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Bupa Medical Gap Scheme

Bupa's Medical Gap Scheme 2018

Bupa recently wrote to all Providers regarding changes to a number of services covered under selected Bupa products, including how we describe some categories of services, and important changes to the Bupa Medical Gap Scheme (Scheme).

A copy of the letter is available here and further information on these changes and other useful links can be found below.

Q. What are the key messages being communicated to Scheme Providers?

There are 6 key messages including:

  1. Changes to the services covered under some Hospital products as well as updates to our terminology and definitions relating to how we describe some services.
  2. The higher Scheme rates will only apply in Hospitals that have an agreement with Bupa, including Members First, Network and Fixed Fee Hospitals.
  3. Bupa’s minimum requirements for the submission of manual claims.
  4. Providers will no longer be able to opt out of being promoted on bupa.com.au/find-a-provider.
  5. Confirmation of the Providers Scheme registration status.
  6. We have updated the Scheme Terms and Conditions.

Q. Where can I find out more information about Bupa Hospital products?

Information about the services covered under each Bupa Hospital Product from 1 April 2018 can be found in our Hospital Covers at a Glance document.

Q. When do the Scheme changes take effect?

The Scheme changes will take effect from 1 August 2018. Bupa recommends all Providers familiarise themselves with these new Terms and Conditions.

The current Medical Gap Scheme Terms and Conditions and Medical Known Gap Terms and Conditions will continue to apply until 31 July 2018.

Q. What is a Bupa Members First, Network or Fixed Fee Hospital?

Bupa has agreements with many private Hospitals and Day Surgeries around Australia to provide customers with certainty about the hospital costs associated with treatment. At most agreement Hospitals, customers will have a 'no gap' experience for hospital costs associated with their stay (except for any excess or co-payment or exclusions that may apply to their level of cover). These Hospitals will also forward the hospital charges directly to Bupa, saving our customers the inconvenience of having to submit a claim.

Q. Where can I find a Bupa Members First, Network or Fixed Fee Hospital?

You can search for a Bupa Members First, Network or Fixed Fee Hospital via our Hospital search function or by downloading a Bupa Hospital Listing.

Q. What happens if a customer is treated in a Hospital that doesn’t have an agreement with Bupa?

Customers can still choose to be treated in a Hospital that does not have an agreement with Bupa, however where this occurs medical benefits will be limited to 25% of the MBS Schedule Fee.

Q. Can I use the Scheme and still charge a Gap?

The Scheme allows Providers the option to register as either a No Gap or Known Gap Provider:

  • No Gap Providers accept the Scheme benefit as full payment for the entire/whole episode of care, with no additional out of pocket costs to be charged to the patient.
  • Known Gap Providers accept the Scheme benefit in full, but can elect to charge the patient a maximum out of pocket cost of no more than $500 for the entire/whole episode of care.

If you are unsure of your Scheme registration status, please contact the Health & Benefits Operations team on 1800 060 239 or at provopsmedical@bupa.com.au. Please ensure you have your Bupa Practice Identification (ID) number available, as this will assist us to identify your Practice.

Q. Is this the start of Bupa moving to a managed care system similar to the US?

The direct answer is absolutely not.

Australia does not require customers or doctors to seek pre-approval prior to treatment. This continues to be the case today. Doctors, never health insurers, will always determine patients' treatment and care options as they do today; nothing has changed.

However, customers have been asking for greater clarity on costs especially at locations where mixed arrangements were in place, and this change to the medical gap scheme is designed to support this. Managed care cannot and will not occur in Australia. This is complete misinformation. The only change, applicable only at a very small number of locations, actually means that doctors must advise a patient if they are going to a contracted hospital or not, and then must advise what their medical costs will be for the service.

The patient then will have full informed consent and can decide how they wish to proceed either at the recommended non-contracted facility or anywhere else they choose to go. Of course, most doctors have multiple admitting rights across Australia and if they operate at a contracted facility, which they can choose to do, then not only will the hospital bill be covered but also they can also use the gap scheme to help customers minimise their medical costs.

Q. Can I change my Scheme registration status to either No Gap or Known Gap?

Yes. The Scheme continues to allow Providers to register as either No Gap or Known Gap. To change your Scheme registration status, simply complete a Change of Details form and email the completed form to provopsmedical@bupa.com.au.

Please ensure you include your Bupa Practice ID number and Practice name in Section A of the Change of Details form. Failure to supply this information will result in the Change of Details form being returned to the Practice.

Q. As a Scheme Provider, can I still opt out of the Scheme on a case by case basis?

Yes. Whilst Bupa encourages Providers to use the Scheme for all customers, Bupa appreciates there may be occasions where a Provider chooses not to accept the Scheme benefits. On these occasions, the Provider must:

  • obtain full Informed Financial Consent (IFC) from the eligible Bupa customer at the first consultation leading to the episode of care; and
  • bill the patient directly.

In these cases, Bupa will pay the customer 25% of the MBS Schedule Fee.

Q. How do I update my Practice information?

If you would like to change the current information that we have recorded for your Practice, please complete a Change of Details form and email the completed form to provopsmedical@bupa.com.au.

Please ensure you include your Bupa Practice ID number and Practice name in Section A of the Change of Details form. Failure to supply this information will result in the Change of Details form being returned to the Practice.

Q. How will my status as a participating Scheme Provider be promoted?

To assist Bupa customers and referring Providers to be able to identify Providers who are registered under the Scheme, Bupa may promote details of your Practice including contact details, information about your participation in the Scheme, and the location(s) at which you practice.

This information may appear in any Bupa approved media or materials, including on any Bupa website or Mobile App, via call centres and retail centres or affiliated partner websites.

Bupa may also advise customers to ask you about the Medical Gap Scheme and any Known Gaps when they contact you.

Q. How can I submit In-patient Medical claims?

Bupa encourages the use of ECLIPSE as it provides a secure method for the submission of claims for in-patient medical services. Claims submitted via ECLIPSE are automatically processed through both Medicare and Bupa contributing to a speedier payment cycle.

  1. If you are submitting claims under the Terms of the Scheme via ECLIPSE, please submit the claims using claim type AG for Agreement Claims.
  2. If you elect to not bill a claim under the Terms of the Scheme and still wish to submit the claim via ECLIPSE, the claim can be submitted to Bupa using claim type PC for Patient Claims.

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.

Q. Can I submit claims manually?

Yes. Whilst we recommend the use of ECLIPSE, we realise on occasion there will be instances where Scheme Providers may need to submit a claim manually.

On these occasions, you must attach a Batch Header form and include:

  • Your Bupa Practice ID number and Practice name
  • Full details relating to the patient, including Medicare card number and patient suffix
  • Bupa membership number
  • Full details of the service provided including the total fees charged (inclusive of any gaps)
  • Facility ID, including Name and number (ID) and
  • The referring Provider's details.

Failure to provide the required information will result in the claim being returned to the Practice.

Q.  What is a Batch Header and why is it required?

You are required to complete a Batch Header form for all manual claims you submit to Bupa for assessment.  This form ensures your claims are processed and benefits are paid according to the Scheme agreement you have with Bupa. 

Please ensure you include your Bupa Practice ID number and Practice name on the Batch Header form. Failure to supply this information will result in the claims being returned to the practice.

Q.  What is my Bupa Practice ID number and how can I find out what it is?

The Bupa Practice ID number is a unique identifier used to identify your Practice when submitting claims or making inquiries regarding the individual Practice. To facilitate quicker processing of your claims, please ensure your Bupa Practice ID number is included with all claims including those submitted via ECLIPSE. This will allow Bupa to identify your Practice location and to pay benefits into the correct bank account.

If you are not sure of your Bupa Practice ID number, please contact the Health & Benefits Operations team on 1800 060 239 or at provopsmedical@bupa.com.au.

Q. What is a Facility ID & Name?

The Facility ID and Name refers to the Hospital Provider number and name of where the admission took place. Failure to provide this information will result in the claim being rejected by Bupa.

Q. Where can I find the Scheme Schedules?

The Scheme Schedules can be located here.

Q. Who can I contact to discuss these changes further?

Should you wish to discuss the changes to the Scheme or, would like to update your Practice information, please contact the Health & Benefits Operations team on 1800 060 239 or at provopsmedical@bupa.com.au. Please ensure that you have your Bupa Practice ID number available, as this will assist us to identify your Practice.

Useful Links

Bupa Hospital Listing

Hospital Search Tool

Hospital Covers at a Glance

Medical Gap Scheme Schedules

Change of Details Form

Batch Header Form