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 the contracted service you provide meets the applicable eligibility criteria as set out in your AP agreement or found in the links below. 

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


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


Certain oral surgery or dental treatments, including:

  • implantation of teeth and/or titanium dental implants
  • surgery designed to assist or allow the implementation of orthodontic healthcare services
  • diagnosis, management and treatment of developmental or congenital deformities or abnormalities of the facial skeleton and associated structures
  • extraction of teeth unless impacted/unerupted.

Congenital conditions
means congenital anomalies or defects which are present at birth and for which the policyholder or dependant had either: (a) signs or symptoms of the condition prior to the original date of joining, or (b) signs or symptoms of the condition within 3 months of birth, as reasonably determined by Southern Cross. Except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis and squint.


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.


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.

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.


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.


Current eligibility criteria

Cardiac services (heart disorder diagnosis & treatment)

Gastroenterology (digestive tract examination)

General surgery (breast, gall bladder, hernia)

Gynaecology (reproductive system)

Imaging (scans)

Internal medicine

Interventional radiology 

Neurosurgery

Oncology (cancer diagnosis & treatment)

Ophthalmology (eyes)

Oral & Maxillofacial

Orthopaedic

Other

Otolaryngology (ear, nose & throat)

Respiratory (lung function tests & sleep studies)

Skin

Urology (kidney, bladder, and prostate)

Vascular surgery (artery & vein surgery)