Patient hospital eligibility checking

If you are trying to process an eligibility check or claim for a plastic and reconstructive item and received an ELIGIBLITY CONDITIONAL response, visit the Plastic and Reconstructive Surgery Eligibility Process page for more detail on how to respond.

Clarifying patient hospital eligibility to benefits prior to being admitted is now easier than ever – register and you will be able to do it online!

If you have any queries or require further information please use the contact appropriate to your query from the list below:

Query / request type	Contact details
Request or Response data	Phone: 1300 663 590
User Guide	Help data on eclipse.civica.com.au
Copy of error messages	Help data on eclipse.civica.com.au
Submit a registration form	Fax: 1300 662 083
Hospital claims queries	Email: hospitalclaims@bupa.com.au Fax: 1300 303 548

Bupa Medical Gap Scheme and patient eligibility

Only eligible services rendered to private inpatients during hospitalisation qualify for the Bupa Australia Medical Gap Scheme benefit.

Any consultations or treatments prior to or after hospitalisation do not form part of this process and need to be billed separately. Please inform the patient that these expenses are claimable through Medicare only.

Payment process

Please inform the patient of the account payment process:

In the majority of cases, the member will receive no accounts for inpatient services. All accounts are to be forwarded directly to us for payment
If you are the Doctor of first referral and have previously registered your intent to charge a co-payment you need to inform the patient of the co-payment amount for you and any other treating medical specialist, who is also using the Bupa Australia Medical Gap Scheme, prior to treatment. This amount is to be billed directly to the patient by you, or an approved Billing Agency, once the service has been rendered. Remember to inform the patient that this amount is not claimable through any other source
Co-payments are only charged in exceptional circumstances, and are dependent on the member’s financial consent. Conditions are available on application.

Membership eligibility

All hospital covers are eligible for the Bupa Australia Medical Gap Scheme benefit. This benefit is provided in addition to the normal 25% inpatient medical ‘gap’ benefit.

Note: Benefits are only paid for members where their payments are up-to-date, and the member has served all Waiting Periods and Benefit Limitation and Exclusion Periods. Please refer to the Products at a Glance section for further information on Waiting Periods and benefit limitations specific to each hospital product. Bupa Australia bears no responsibility for the payment of benefits for services which are not eligible services.