Page last updated: 7 August 2025

Where a customer’s health insurance product excludes the clinical category ‘plastic and reconstructive surgery’, we will still pay a benefit towards procedures if:

  • the plastic and reconstructive procedure is medically necessary, 
  • it relates to a procedure in the ‘skin’ or ‘breast surgery’ clinical category, 
  • the ‘skin’ or ‘breast surgery’ procedure is covered under the patient’s product, and 
  • all other claim eligibility requirements are met (e.g. waiting periods met, premium payments are up to date). 
How to assess eligibility
More information
Given the system constraint with Eclipse only allowing a single MBS or presenting illness item code to be submitted with each eligibility check, we are unable to assess as part of the check, whether a 'skin' or 'breast surgery' item is also being performed. Therefore, you will receive an Eclipse message for any plastic and reconstructive items on products that normally exclude this category that states: "2036 ELIGIBILITY CONDITIONAL...".


In these circumstances, use the following to determine eligibility.
  • Process the eligibility check for the ‘skin’ or ‘breast surgery’ item/s.

  • If the response is ELIGIBLE, the plastic and reconstructive item/s are automatically covered.
  • Confirm the prior admission was:

    • Performed at your hospital, and
    • Claimed through Bupa

  • Process an eligibility check for the ‘skin’ or ‘breast surgery’ item/s that were performed previously to confirm the customer remains on a product that covers that procedure and meets other claim requirements.

  • If the result is ELIGIBLE, the customer is automatically covered for the plastic and reconstructive item/s.
  • If the previous related admission was performed at a different hospital or was claimed through a different insurer, we may need further information from the customer and their treating surgeon to help assess eligibility.

  • Bupa may contact the customer to obtain this detail.

  • While this process is being finalised:

    • We will pay these admissions on an ex-gratia basis provided it is related to a ‘skin’ or ‘breast surgery’ item.
    • Please confirm with the treating surgeon that the current procedure is related to the previous ‘skin’ or ‘breast surgery’, and
    • Process an eligibility check for the ‘skin’ or ‘breast surgery’ item/s from the previous admission to confirm the customer remains on a product that covers that procedure and meets other claim requirements.
    • If you receive an ELIGIBLE response for these items, the customer is automatically covered for the plastic and reconstructive item/s.
    • We recommend that you regularly check back to this page to check if we have launched the updated process.
How to claim
  • If the plastic and reconstructive item is being performed in the same admission as ‘skin’ or ‘breast surgery’ item:

  • Submit the claim through Eclipse as you would normally.

  • Ensure the ‘skin’ or ‘breast surgery’ items are appropriately coded on the claim.

  • The system will automatically manage the rest of the claim assessment process.
  • Submit the claim through Eclipse as you would normally.

  • The claim will either be automatically suspended, or the transaction will decline. You may see a response of 8888 CLAIM HAS BEEN SUSPENDED or 2029 ELIGIBILITY CONDITIONAL.

  • In these cases, if the prior admission was claimed through Bupa, our assessors will:

    • Confirm a benefit was paid for a ‘skin’ or ‘breast surgery’ item;
    • Check the patient remains eligible; and
    • Release or reassess the claim to pay benefits towards these items. This usually occurs within 5 working days.
  • If Bupa did not pay the prior admission, we currently rely on your claim submission as confirmation that:

    • A related ‘skin’ or ‘breast surgery’ procedure was previously performed, and
    • The current admission is directly related to that procedure.
  • In these cases, we will pay the claim as an ex-gratia payment while we formalise the new process. This includes where the transaction declines and you see the ‘eligibility conditional’ response. Our exception reporting will identify and correct these claims within 5 days.

  • Once the updated process is live, we will confirm that the eligibility steps outlined in the third scenario above have been followed.

Please regularly check back to this page if you have admissions that fall into this category to understand when the new process has launched.