Benefits for patients who are Southern Cross members
'Affiliated Provider-only' refers to healthcare services that are only reimbursed by Southern Cross if the provider has an Affiliated Provider agreement for them.
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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There are five ways for Southern Cross policyholders to claim:
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:
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 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.