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.


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

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 except as specifically provided by the Keeping Well and Vision and Dental modules (additions to Wellbeing plans)
  • surgery designed to assist or allow the implementation of orthodontic healthcare services except as specifically provided by the Keeping Well and Vision and Dental modules (additions to Wellbeing plans)
  • diagnosis, management and treatment of developmental or congenital abnormalities of the facial skeleton and associated structures
  • extraction of teeth except as specifically provided by extraction of unerupted or impacted teeth (under oral and maxillofacial in Affiliated Provider surgical procedures) benefit, or by the Keeping Well and Vision and Dental modules (additions to Wellbeing plans).

Congenital condition(s) means congenital anomalies or defects which are present at birth and for which the policyholder or dependant had either:

  1. signs or symptoms of the condition prior to the original date of joining, or
  2. signs or symptoms of the condition within three months of birth, as reasonably determined by Southern Cross. Except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis and squint.

Detrimental to Health means a medical condition that is causing significant problems for the physical health of an individual.

Unapproved healthcare services means healthcare services such as specific drugs, devices, techniques, tests and/or other healthcare services that have not been approved by Southern Cross prior to treatment. Please see the list of unapproved healthcare services.

Health screening means diagnostic test(s), investigation(s), or consultation(s) in the absence of any sign or symptom suggesting the presence of the illness, disease or medical condition the screening is designed to detect.


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)