Eligibility criteria

As specified in Southern Cross policy documents, certain healthcare services have eligibility criteria which need to be met before a healthcare service will be covered under a member's policy

If you have an Affiliated Provider (AP) agreement with Southern Cross, you are required to ensure that the contracted service you provide meets the applicable eligibility criteria as set out in your AP agreement. Over the coming year the eligibility criteria found in the links below will replace those set out in your AP agreement, starting in March 2015.

Please also ensure you are familiar with all the general policy exclusions including:

Cosmetic treatment - means any surgery, procedure or treatment that improves, alters or enhances appearance, whether or not undertaken for medical, physical, functional, psychological or emotional reasons.

Health screening - means diagnostic tests, investigations, or consultations in the absence of any sign or symptom suggesting the presence of the illness, disease or medical condition the screening is designed to detect.

Treatment of any condition not detrimental to health
- means treatment of a medical condition that is not causing significant problems for the physical health of an individual.

Healthcare services that are not yet approved
- means a healthcare service that is:

  • not necessary for treatment of the health condition involved.
  • experimental or unorthodox.
  • not widely accepted professionally as effective, appropriate and essential based upon recognised standards of the healthcare specialty involved.

Acute care - means care provided in response to a sign, symptom, condition or disease that requires immediate treatment or monitoring.

That means Southern Cross will not reimburse you for a service you provide that is for or relates to any of the above, or any of the other general exclusions listed in the policy documents.

The following eligibility criteria has been updated:

Cardiology (heart disorder diagnosis& treatment)

Endoscopy (digestive tract examination)

General surgery (breast, gall bladder, hernia)

Gynaecology (reproductive system)

Imaging (scans)

Internal medicine

Interventional radiotherapy

Oncology (cancer diagnosis & treatment)

Ophthalmology (eyes)

Other

Orthopaedic

Otolaryngology (ear, nose & throat)

Respiratory (lung function tests & sleep studies)

Skin

Urology (kidney, bladder, prostate and/or vasectomy)

Vascular surgery (artery & vein surgery)