Find out more about Bupa Medical Gap Scheme patient eligibility and how to make a claim on the scheme.

An eligible Bupa health insurance customer is a person who at the time of receiving hospital care:

  • is a financial customer and holds an appropriate level of hospital cover with Bupa
  • is eligible for Bupa Medical Gap Scheme benefits
  • is covered for, and has served applicable waiting periods for the service provided, including the 12 month waiting periods for pre-existing conditions, ailments or illnesses and pregnancy (including childbirth)
  • is a patient as defined by section 3(1) of the Health Insurance Act 1973 (Cth).

Bupa will only pay benefits where the services received by an eligible Bupa health insurance customer are:

  • eligible for Medicare benefits
    • claimed within 2 years from the date of service
  • not compensable services, that is, where compensation, damages or benefits may be claimed from another source (e.g. Workers' Compensation, Compulsory Third-Party Insurance, Common Law Damages, Government Programs and Agencies, Travel Insurance, Sports Insurance, etc.)
  • not related to cosmetic surgery
  • not subject to exclusion under the customer's level of hospital cover.

Specialists can check a patient's eligibility electronically via ECLIPSE or by calling 134 135 and pressing 3 for the provider option.

As some covers may contain exclusions or offer restricted benefits on some services, we strongly recommend that you encourage customers to contact Bupa directly to confirm their eligibility entitlements on 134 135.

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

If you are submitting claims under the terms of the Bupa Medical Gap Scheme via ECLIPSE, please submit the claims using claim type AG for Agreement Claims. Bupa does not currently accept claim type SC for Scheme Claims.

If you elect not to bill a claim under the terms of the Bupa Medical Gap Scheme and still wish to submit the claim via ECLIPSE, the claim can be submitted to Bupa using claim type PC for Patient Claims. In this case, benefits will be paid up to 100% of the MBS Schedule Fee (Bupa pays 25% of this fee, and Medicare pays 75%).

Other important elements of ECLIPSE claiming include:

  • Fund BRAND ID: please ensure all claims are submitted using the correct Bupa FUND BRAND ID: BUP
  • Fund Payee ID: this is your Bupa Practice ID number. It is important you include your Bupa Practice ID number in the Fund Payee ID field, as this will ensure all payments are directed to the correct nominated bank account.

If you would like to register for ECLIPSE or want to know more about electronic claiming or software vendors, please contact the Medicare Australia eBusiness Service Centre on 1800 700 199.

Alternatively, you can email ebusiness@humanservices.gov.au or eclipse@bupa.com.au.

There are factors to be aware of where a customer is admitted to hospital for multiple treatments. If at least one of those treatments is covered by the customer’s policy, but one or more of those treatments is not covered, Bupa will generally only pay a benefit towards the covered treatment, as long as the customer has served the applicable waiting periods and meets eligibility requirements. Bupa will not pay a benefit toward excluded treatments.

For domestic customers, Bupa will also cover treatment as required under the legislation related to paying benefits. This includes paying benefits towards Associated Treatments for Complications, Associated Unplanned Treatments, Common Treatments, and Support Treatments.

Outside of these situations, if a customer receives hospital treatment during an admission to hospital that is both included and excluded, we will pay for all the included treatment and may pay any element of treatment that cannot be appropriately allocated to the excluded treatment on an ex-gratia basis. Otherwise, the customer will be responsible for all expenses related to the treatment which is excluded on their policy.

If you submit a partial coverage medical claim on ECLIPSE you may receive a message indicating that benefits are not payable, including the following message: "2009 Benefit not payable under this level of cover".

This may be an error if the customer is covered for at least one treatment submitted as part of the partial coverage claim.

If you do receive messaging indicating that benefits are not payable for a partial coverage hospital claim, please contact Bupa so that we can urgently reassess the covered treatments of the claim:

Whilst we recommend the use of ECLIPSE, we realise there will be instances where Bupa Medical Gap Scheme specialists may need to submit a claim manually.

On these occasions, you MUST attach a current 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
  • The Bupa Batch Header must be signed and legible
  • Please accompany with a Doctor Account form if you do not have your own invoice
  • All manual claims can be submitted to Bupa either by post or email:

    Bupa
    Medical Claims
    GPO Box 4338
    Melbourne 3001

    Email: gapscheme@bupa.com.au

If you are submitting claims for pathology services that are subject to the Medicare Rule 3 exemption, you must include the time of service in order for Bupa to submit your claims to Medicare.

Your accompanying invoices must be legible and preferably not handwritten.

Claims that do not provide the required information or lack a legible Batch Header and/or invoice will result in your claim being rejected, requiring it to be resubmitted.

The Bupa Medical Gap Scheme is also available to overseas students and visitors. Claims can be submitted via ECLIPSE if your software has OVS claiming functionality. Alternatively, claims can be submitted for manual assessment.

When submitting for manual assessment, you MUST attach a current Batch Header form and include:

  • Your Bupa Practice ID number and Practice name
  • Full details relating to the patient, including 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.
  • The Bupa Batch Header must be signed and legible
  • Please accompany with a Doctor Account form if you do not have your own invoice.
  • All manual claims can be submitted to Bupa either by post or email:

    Bupa
    Medical Claims
    GPO Box 9809
    BRISBANE QLD 4001

    Email: gapscheme@bupa.com.au

If you are submitting claims for pathology services that are subject to the Medicare Rule 3 exemption, you must include the time of service.

Benefits for manually assessed overseas student or visitor claims will be paid via cheque.

Your accompanying invoices must be legible and preferably not handwritten.

Claims that do not provide the required information or lack a legible Batch Header and/or invoice will result in your claim being rejected, requiring it to be resubmitted.

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 Bupa rejection code, Medicare reason code, or Medicare return code.

If you wish to enquire about a claim, please call the Bupa Medical Claims Provider Support on 134 135 and press 3 for the provider option.

All claims submitted to Bupa are subject to the normal Medicare Australia rulings. If there are restrictions for the medical items, some benefits are not payable.

Please also refer to the Medical Gap Scheme Terms and Conditions for further information including patient eligibility and payment of benefits.

Bupa rejection codes and Medicare reason and return codes are subject to change. If you are still unsure why a claim has been rejected, please call the Bupa Medical Claims Provider Support team on 134 135 and press 3 for the provider option.

Use Bupa's secure Partner Portal for quick and easy access to your weekly medical benefit Statements. If you haven't already registered, simply complete the online Bupa Partner Portal Access Form.

For further information, please contact our Provider Operations Team on 1800 060 239.