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FAQs for healthcare providers

Affiliated Providers (APs) include doctors, specialists and facilities who provide Southern Cross members with certain healthcare services at agreed prices. APs arrange prior approval for members and submit invoices on behalf of the member to Southern Cross through a web based system.
 
Southern Cross promotes the use of APs to more than 867,593 members. An online directory of APs is available for members and referrers to use and they are encouraged to ask their referrer to send them to an AP for treatment.
The Affiliated Provider programme was first established in 1997 and continues to grow year on year.
Benefits for Affiliated Providers
  • Certainty of payment. Prices for services are agreed upon during the contracting process so you are clear about what you will be paid.
  • Improved cash flows. Payment is generally made within two days of the provider requesting payment. 
  • Online administration. The online system makes applying for prior approval and requesting payments easy.
  • Dedicated support. Partnership Managers provide a direct point of contact at Southern Cross. They deal with queries you have about your Affiliated Provider agreement and any day-to-day issues.
  • Promotion. We encourage our members to seek referral to Affiliated Providers whenever possible. Affiliated Providers are listed on Healthcare Finder, an online directory that members and referrers can use to easily find information and contract details.

Benefits for patients who are Southern Cross members

  • Easy prior approval and claiming. As an Affiliated Provider, you take care of the prior approval and claiming processes on behalf of the member. This means the member does not have to submit a claim, and is not out of pocket while the claim is being processed.
  • Certainty of cost. Agreed prices means that, in most cases, the member knows up-front how much, if anything, they will have to pay for their treatment.

'Affiliated Provider-only' refers to healthcare services that are only reimbursed by Southern Cross if the provider has an Affiliated Provider agreement for them. 

Our aim is to provide health insurance that helps our members receive sustainable, accessible and affordable quality healthcare services through our Affiliated Provider programme. We aim to achieve this by making reimbursement of certain healthcare services contingent on an Affiliated Provider agreement being in place with the provider of those services.
 
The simplicity of accessing healthcare services through our Affiliated Providers is a key benefit Southern Cross members enjoy from the programme. That’s because an Affiliated Provider takes care of approvals and claims for Southern Cross members through an online system.
 
It makes life so much easier from your patient’s point of view and it’s equally attractive to healthcare providers like you (see the benefits listed on the previous page).
Click here to check if a provider is an Affiliated Provider.
No, providers are welcome to discuss contracting for any healthcare services carried out that Southern Cross currently funds. When contracting for other healthcare services, we take into account: member demand for your services, your location, the services you offer / areas of expertise, national coverage and price.
Pricing outlined in your Affiliated Provider agreement is intended to provide certainty and consistency. On rare occasions, healthcare services performed under the Affiliated Provider agreement may be much more time-consuming, complex or highly priced than usual.
 
In these cases, we will consider providing a reasonable, additional reimbursement but this is the exception rather than the rule. You will need to provide us with the clinical rationale for the extra costs incurred. Decisions are made on a case by case basis.
We have dedicated team members who provide support to Affiliated Providers and we sometimes conduct regular audits.
 
Partnership Managers
Our Partnership Managers build and maintain relationships with Affiliated Providers. They work with healthcare professionals and providers to agree on and define the services to be provided under the Affiliated Provider agreement, and the prices payable. The Partnership Managers will also be in touch to review, amend or expand agreements.
  
Audits
As per the terms of an Affiliated Provider agreement, Southern Cross audits Affiliated Providers to ensure they are meeting their contractual obligations. As an Affiliated Provider, you are required to keep proper financial information and medical records for the services provided. You also need to keep evidence of compliance with eligibility criteria. We share the outcomes of audits with you, including any ‘best practice’ identified during the audit.
 
In a recent survey, 91 per cent of Affiliated Providers rated the performance of the Southern Cross Affiliated Provider programme as either ‘above average’ or ‘excellent’.

In order to be covered under a Southern Cross health insurance policy the treatment needs to be an ‘approved treatment’. This means a healthcare service that is necessary for treatment of the health condition involved, is not experimental or unorthodox, and is widely accepted professionally as effective, appropriate and essential based upon recognised standards of the healthcare specialty involved. Where there are no signs or symptoms that would indicate that it’s an approved treatment, the member can still have the service, but it will not be covered by health insurance. The member will need to pay the full cost themselves.

It’s important to note there are a number of exclusions that apply, including cover for pre-existing conditions and unapproved healthcare services. They are set out in the policy document.

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Consultations and rooms-based services
Individual providers can call Southern Cross’ Provider line on 0800 770 843 to discuss an Affiliated Provider agreement.
 
Surgical services
Generally, the hospital or facility holds the contract with Southern Cross. Individual providers should contact the hospitals or facilities they work at, and speak to the person who looks after Affiliated Provider agreements with Southern Cross. That hospital or facility will then negotiate an Affiliated Provider agreement with Southern Cross. The Affiliated Provider agreement includes the healthcare services, providers, location(s) and pricing.
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There are five ways for Southern Cross policyholders to claim:

  • through an Affiliated Provider
  • through an Easy-claim provider
  • submitting an online claim through My Southern Cross
  • via the My Southern Cross mobile app
  • sending a claim form by post

If you think a member who is 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 healthcare service to be undertaken
  • circumstances or information you believe should be brought to the attention of Southern Cross
Submit your information to provider@southerncross.co.nz, Southern Cross Health Society, Private Bag 99934, Newmarket, Auckland 1149.
If you've been told your patient's Southern Cross policy doesn't cover the healthcare service you're recommending and you believe that it should be covered, please call 0800 770 843, email provider@southerncross.co.nz or write to Southern Cross Health Society, Private Bag 99934, Newmarket, Auckland 1149.

Under fee for service:

Members must contact us for prior approval if the cost of their healthcare service is likely to be over $1,000 or if they need to be hospitalised - including day stay or in-patient surgery regardless of the cost.

Members should do this at least four working days before the healthcare service being provided.

Southern Cross will provide written confirmation advising 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.

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.

Healthcare providers can help Southern Cross members with prior approval by:

  • encouraging the member to seek prior approval from Southern Cross as soon as the healthcare service is planned

  • providing the member with a written quote and breakdown of costs (eg surgeon fee, anaesthetist fee, prosthesis, hospital costs) and the specific name of the healthcare service

  • ensuring the member knows the name and address of the surgeon/specialist and the hospital/facility where the healthcare service will take place.

Under the Affiliated Provider programme:

The Affiliated Provider applies for prior approval on behalf of a member through an online system. If confirmed, the Affiliated Provider will let the member know upfront how much, if anything, they need to pay towards the healthcare service.

Prior approval can be declined for a number of reasons. Some of the most common reasons are:

  • there is no benefit available under the member's policy for the healthcare service

  • the healthcare service relates to one of the policy's general exclusions, eg screen or cosmetic treatment

  • the healthcare service relates to a pre-existing condition

  • premiums haven't been paid. If the member attends to this within 90 days of non-payment, we will reinstate the policy and allow the approval to proceed.