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.

APs may also be listed on Healthcare Finder, an online directory that members and referrers can use to easily find information and contact details. Members are encouraged to ask their referrer to send them to an AP for treatment.

Read more about the AP programme.

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.
• Promotion. We encourage our members to seek referral to Affiliated Providers whenever possible. Affiliated Providers may also be 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 healthcare 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 our Affiliated Provider-only healthcare services.

Download the Southern Cross Affiliated Provider Skin Excision Data - Information Requirements (Appendix 5) document.

Yes, we can! Our Patient outcomes and experience team have data for you to review. Please contact your partnership manager or for more information visit Patient Outcome and Experience Surveys.

Consultations and rooms-based services

Individual healthcare providers can email us at [email protected] and a partnership manager will contact you to discuss an Affiliated Provider agreement.

Surgical services

Generally, the hospital or facility holds the contract with Southern Cross. Individual healthcare 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, healthcare providers, location(s) and pricing.

For more information, see Become an Affiliated Provider.

No, you are welcome to discuss contracting for any healthcare service 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.

For more information, see Become an Affiliated Provider.

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. Partnership managers will also be in touch to review, amend or expand agreements.

Relationship managers

Our relationship managers look after the day-to-day workings of the Affiliated Provider relationship and are in regular contact with your administrative and financial staff. They provide any support you may require relating to:

• our web-based claiming system
• prior approvals
• claiming processes.

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.

Southern Cross sometimes conducts audits as needed to ensure Affiliated Providers (APs) are complying with the terms of their agreements. Audits are always carried out within the rights and obligations under an AP agreement.

Checking compliance with an AP agreement is one reason we may ask you to take part in an audit. In other cases, we audit because data analysis or other investigations have helped us identify irregularities with or possible breaches of an agreement.

Sometimes we conduct a second audit to confirm you have made required changes after the first or to establish whether an issue is systemic.

Notice of an audit

APs will be given no fewer than five working days’ notice of an audit. However, if the audit's integrity is at risk of breach or a serious specific incident has occurred, APs will be given 72 hours' notice.

Audit results

Audit results are kept confidential between you and Southern Cross. Identifiable personal information will not be recorded in audit reports. Please direct any questions to [email protected] or contact your partnership manager.

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 and eligibility criteria that apply, including cover for pre-existing conditions and unapproved healthcare services. They are set out in the policy document.

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.
• The circumstances or information you believe should be brought to the attention of Southern Cross.

Submit your information to [email protected], 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 if:

• 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’re a GP and you want to add your expertise to the CareHQ team you can email [email protected].

The benefits of becoming part of CareHQ:

• Enjoy a flexible work/life balance by dictating when you work
• With virtual consultations, you can work from anywhere – your practice, your home or the holiday house, at times that are most convenient to you
• Work with the assurance that CareHQ has strong clinical governance, policies and procedures
• You’ll receive an induction and onboarding, as well as best practice training in virtual consultations
• Leave the finances up to us – CareHQ will manage all your payments, there’s no invoicing or overheads to worry about
• CareHQ has been designed and developed by primary care for primary care, so we talk your language and understand your needs

CareHQ has been created together with the primary care industry and the provider system. We have GPs, the New Zealand medical industry and your patients at the heart of everything we do. We’re designed to be your choice for convenient virtual care that is linked back to you (if your patient chooses) so that we can support you in providing continuity of care.

CareHQ brings Kiwis a trusted, convenient and secure virtual consultation service.

Find out how your practice can offer CareHQ as part of your after-hours care by contacting us at [email protected].

Easy-Claim is a convenient way for Southern Cross members to claim for eligible healthcare services at the time of treatment, without completing a claim form at participating:

• GP’s
• pharmacies
• optometrists
• dental practices
• physiotherapists
• chiropractors
• podiatrists
• osteopaths
• remedial massage therapists
• clinical psychologists
• psychiatry
• Rongoā Māori
• audiologists.

When a Southern Cross member provides their membership details to a participating practice, an electronic claim can be made via the Easy-Claim system. Within seconds the practice can advise the member of the outcome of their claim.

Contact the Easy-Claim team on 0800 700 053 or email [email protected].

Benefits of becoming an Easy-Claim provider include:

• Makes health services more accessible for patients who have Southern Cross Health Insurance
• Enhanced patient loyalty due to the ease of claiming
• Positive brand association with Southern Cross Health Insurance
• Contactless direct credit payments made to the practice
• Your practice details are displayed on our Southern Cross Healthcare finder

Contact the Easy-Claim team on 0800 700 053 or email [email protected].

We have dedicated team members who provide support to Easy-Claim providers. Our Easy-Claim relationship managers build and maintain relationships with our Easy-Claim providers assisting with any training, support or general enquiries.

Contact the Easy-Claim team on 0800 700 053 or email [email protected].

We encourage you to refer to an AP as it benefits Southern Cross members.

1. It's easy. The AP organises prior approval for the member's healthcare service and claims on their behalf.
2. It keeps future premiums more affordable by helping us to manage the cost of claims.
3. Agreed prices mean that, in most cases, members know up-front how much, if anything, their contribution will be.

If you or your patient think that ACC’s decision is incorrect, please encourage them to make contact with the Southern Cross member advocacy team at [email protected]. We will review the decline documentation and offer advice as to whether a review of ACC’s decision is warranted. If the decision is reviewable, the Southern Cross member advocacy team can work with the member to guide them through the review process.

If your Southern Cross patient has already applied for a review of ACC’s decision, we may be able to assist with the process. You or your patient can contact us directly with supporting clinical information at [email protected]. For more information see our How Southern Cross works with ACC.

Applying for review of an ACC decline decision will not delay a member’s healthcare service (provided they are eligible for cover under their Southern Cross Health Insurance policy). They can request approval from us at any time after receiving a decline decision from ACC.

ACC will contact the claimant (the member) and/or the member advocacy team directly to confirm the ACC entitlements now approved. If Southern Cross paid claims for any treatment relating to a covered injury, we will request reimbursement in full from ACC. If the member had to pay a portion of the cost to their healthcare provider, this will be reimbursed once funds are received from ACC. This can take up to three months or occasionally longer from the time of the decision. If the member has received any treatment related to their injury that they have not claimed with Southern Cross, they can now submit these costs to ACC for consideration.

ACC’s decision will remain unchanged. Although Southern Cross does not require members to, they have the right to appeal the decision to the District Court. This is a more formal process than a review hearing. Legal representation is generally required and only a small number of cases are successfully appealed. If a member wishes to appeal a review decision, the member advocacy team can offer general advice and refer members to appropriate lawyers but will not be directly involved. Contact the member advocacy team at [email protected].

To ensure users of our web-based systems have a safe and secure experience, we’re unable to support older website browsers or operating systems - in particular those which are no longer supported by their manufacturer.

For a list of supported browsers, and instructions on how to update your browser please view our Provider Web browser support.

A telehealth consultation is the use of video or phone to deliver healthcare consultations when Southern Cross patients and Affiliated Providers are in different physical locations and when no physical examination is required.

Short initial and follow-up communications with patients that are normally conducted in between appointments (eg emails/phone calls to discuss test results) have always been considered a component of professional healthcare and therefore will be included in the telehealth consultation.

If you have any questions about telehealth consultation contracting, please see Telehealth information for providers or contact your partnership manager. If you have any questions about applying for prior approval or claiming regarding telehealth, please contact your relationship manager.

There are three simple ways:

• Go to Healthcare finder
• Within your electronic medical record system, click on the HealthLink icon
• Go to Healthpages.

For more information, see Referrals to an Affiliated Provider.

We encourage members to seek referral to an AP to help moderate claims costs in the long term. In all Southern Cross plans (apart from UltraCare), some services are AP-only.