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:
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.
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.
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.
Current eligibility criteria