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Southern Cross provides cover for treatment which is medically necessary. “Medically necessary” means healthcare services that in the opinion of Southern Cross are necessary for treatment of the health condition involved, are not experimental or unorthodox, and are widely accepted professionally as effective, appropriate and essential based upon recognised standards of the healthcare speciality involved.

Southern Cross does not cover cosmetic treatment. “Cosmetic treatment” means any surgery, procedure or treatment that improves, alters or enhances appearance, whether not undertaken for medical, physical, functional, psychological or emotional reasons.

Southern Cross provides cover for treatment which is medically necessary.

Medically necessary means healthcare services that in the opinion of Southern Cross are necessary for treatment of the health condition involved, are not experimental or unorthodox, and are widely accepted professionally as effective, appropriate and essential based upon recognised standards of the healthcare speciality involved.

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

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.

There are four ways for Southern Cross policyholders to claim:through an Affiliated Provider through an Easy-claim provider submitting an online claim through My Southern Cross sending a claim form by post.

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 screening 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.

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 the circumstances or information you believe should be brought to the attention of Southern Cross. Submit your information to provider@southerncross.co.nz or Clinical Advisor, 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 the Clinical Advisor, Southern Cross Health Society, Private Bag 99934, Newmarket, Auckland 1149.

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