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FAQs for health professionals

Southern Cross Health Society and Southern Cross Healthcare Group ►

Prior approval

Prior approval is central to how we do things at Southern Cross. It gives our members certainty about reimbursement, which helps to reduce worry at an already stressful time.

Prior approval by Affiliated Providers

If you are a contracted Affiliated Provider, you can apply for prior approval on behalf of a member through our online system.

How can health service providers help with prior approval?

If you provide services for which prior approval is normally required, you can help Southern Cross members in the following ways.

Encourage your patient to seek prior approval from Southern Cross as soon as the procedure is planned.
Provide your patient with a written quote and breakdown of costs (e.g. surgeon fee, anaesthetist fee, prosthesis, hospital costs) and the specific name of the procedure.
Ensure the member knows the name and address of the surgeon/specialist and the hospital/facility where the surgery/procedure will take place.

Please note, only Southern Cross can confirm cover for a procedure. This confirmation will be based on a person's entitlements under their specific policy and cover status in relation to any pre-existing health conditions.

How does prior approval work?

Prior approval is required for any healthcare service that is likely to cost more than $1,000 or which involves any kind of hospitalisation (including day stay or in-patient surgery) regardless of cost.
A request for prior approval should be submitted to Southern Cross four working days before the scheduled procedure/service. If prior approval is required in less than three working days, the member should call Southern Cross immediately with as much of the required information as possible and we will do what we can to help.
Prior approval is officially given in writing, confirming the member's eligibility for cover, whether part payment by the member is necessary (because of excesses, estimated costs exceeding policy limits or reasonable charges) and any other applicable conditions.
Usually, presenting this prior approval letter to the health service provider means the member won’t have to pay upfront. Instead, the member can submit the relevant invoice to Southern Cross with a claim form and we pay the health service provider directly.
The member is responsible for paying any difference between the amount charged and the amount Southern Cross has agreed it will pay.
If the member doesn’t receive prior approval before the surgery/procedure, they will need to pay the full cost themselves and lodge a claim with itemised receipts for reimbursement from Southern Cross.

If you are an Affiliated Provider to Southern Cross Health Society, you don't need to go through this prior approval process. Just apply on the member's behalf using our online system.

Why might a member’s prior approval application or claim be declined?

Members can be declined for a number of reasons. Here are some of the most common reasons.

Premiums haven’t been paid. If the member attends to this within 90 days of non-payment, we will reinstate the plan and allow the approval to proceed in accordance with normal business rules.
There is no benefit available under the member’s plan for the procedure.
The procedure relates to one of the plan’s general exclusions, eg it is for treatment of a congenital condition.
The procedure relates to a pre-existing condition that has been excluded from the member’s cover.
The procedure is being performed at a time that suggests the member had an undeclared pre-existing condition and after investigation the pre-existing condition is confirmed.

If we decline a claim or prior approval application it will not be because we dispute a health service provider's diagnosis or recommended treatment.

Can you help a patient who has been declined?

If you think a patient of yours has had a claim or prior approval application unfairly declined, you can contact us, preferably in writing, to outline the situation. Please provide the following information:

the patient’s name and Southern Cross membership number
the procedure to be undertaken
the circumstances or information you believe should be brought to the attention of Southern Cross.

Submit your information to provider@southerncross.co.nz or Clinical Manager, Southern Cross Health Society, Private Bag 99934, Newmarket, Auckland 1149.

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New technology and procedures

Many recent advances in elective surgery have resulted in better patient oucomes, lower treatment costs, or both. In these instances, Southern Cross will often confirm cover for these new procedures or techniques.

However, there are some new medical technologies that appear to add significant cost to treatment, without a commensurate benefit for the patient. In these instances Southern Cross takes a more circumspect view. An example, discussed in our December 2009 provider newsletter, is robotically assisted prostatectomy surgery.

So how does Southern Cross assess a new surgical technique or technology so that it can be “approved”? For the majority of our plans, “approved healthcare services” are those that are listed in the coverage tables, List of Surgical Procedures or the Schedule of Surgical Maximums.

In general terms, we will approve new techniques / technologies where there is a demonstrable clinical benefit to the members at an acceptable cost. Our goal is to ensure the best possible value for our members while maintaining the affordability of their premiums.

As a general guide, we do not cover new health technologies or complex procedures where these are adequately provided by the public health system. We will also typically require a body of New Zealand experience with the new technology for us to review it adequately.

To have a new procedure or technology assessed for approval by Southern Cross phone Conal Edwards on 0800 770 843, email newtechnology@southerncross.co.nz or write to Health Technology Assessment Manager, Southern Cross Health Society, Private Bag 99934, Newmarket, Auckland 1149.

What can you do if the procedure your patient needs is not covered?

If you’ve been told that your patient's Southern Cross policy doesn’t cover the procedure you’re recommending and you believe that it should be covered, please call 0800 770 843, email provider@southerncross.co.nz or write to Clinical Manager, Southern Cross Health Society, Private Bag 99934, Newmarket, Auckland 1149.

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Pharmac criteria

Pharmac has a robust and professional assessment process designed to achieve the best possible efficacy and value for money from the Government's expenditure on pharmaceuticals.

By using Pharmac funding guidelines as a basis to determine when we will reimburse under Southern Cross policies, we ensure we also achieve the best possible value on behalf of members.

Hence, Southern Cross policies will generally provide cover for drugs that are: listed on the Pharmac schedule, Pharmac approved, medically necessary, prescribed by a medical practitioner in private practice and are not otherwise excluded by a member’s policy terms and conditions.

Change to chemotherapy benefit from 17 October 2011

Included in the 'claims year' limit for chemotherapy treatment is an ability to claim up to 50 per cent of the cost (to a maximum of between $8,000 and $10,000, depending on policy type) for non-Pharmac approved MedSafe indicated chemotherapy drugs.

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Treatment injury and ACC

Very occasionally a patient receives an unexpected injury during treatment or surgery. ACC defines an injury caused as a result of treatment from a registered health professional as a "treatment injury". ACC is the "first insurer" in relation to such injuries. For more information visit ACC's Treatment Injury page.

In these cases Southern Cross is prepared to pay for the claim and deal with recovery of costs from ACC provided the following criteria are met:

the member must have been actually injured during treatment, not just had their safety threatened
the treatment was eligible for cover under the member’s plan benefits
the health service provider has filed a potential treatment injury claim
the member has returned a member consent form which allows Southern Cross to process the claim on their behalf, and
ACC has confirmed to Southern Cross that the potential treatment injury claim has been received.

If you have any questions about this process, please contact provider@southerncross.co.nz or call 0800 770 843.

If ACC declines the treatment injury claim

Depending on the circumstances, ACC might decline to fund your patient’s treatment injury. Southern Cross will fund a treatment injury-related procedure if it falls within the normal coverage of the member's policy. Make sure your patient sends us a copy of the decline letter, because we might want to appeal the decision with ACC.

Seeking review of ACC declines for elective surgery

In recent years, we have supported members seeking review of ACC decisions by ACC not to fund their surgery. This process has recently changed. We now require members to undertake a review in those cases where it appears that the surgery is causally linked to a personal injury caused by an accident (as opposed to degeneration or other factors). Southern Cross will help members through all stages of the review process.

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Southern Cross Health Society and the Southern Cross Healthcare Group

The Southern Cross Health Society, New Zealand's largest health insurer, is a part of the Southern Cross Healthcare Group. It operates independently and at arms length from other parts of the Southern Cross Healthcare Group, such as Southern Cross Hospitals Limited, Southern Cross Primary Care and Southern Cross Travel Insurance. Follow this link for more information.