How we work with ACC

ACC has two categories of cover which are treated differently by both ACC and Southern Cross.

1. Personal injury caused by accident (PICBA)
2. Treatment injury.

Southern Cross health insurance policies do not provide cover for accident treatment or treatment injury expenses that ACC is legally responsible for. However, in some cases ACC will not pay the full amount charged for treatment. In these cases a member may be able to make a claim under their policy.

Personal injury caused by accident (PICBA)

If a member is declined by ACC and the treatment they require is eligible under their Southern Cross policy, they must send us a copy of their decline letter from ACC. Once we receive of a copy of ACC’s decline letter and a copy of the ARTP (Assessment Report and Treatment Plan), prior approval is issued. The claim is released for payment when received.

No cover will be approved before we receive the ACC decline letter. If treatment is required before an ACC decision then it is classified as acute and will not be covered by Southern Cross.

We also need members to undertake a review in those cases where it appears the surgery is causally linked to a personal injury caused by an accident (as opposed to degeneration or other factors). Southern Cross will help members through all stages of the review process.

Personal injury caused by accident includes work-related gradual process injury.

Treatment injury

Occasionally a patient receives an unexpected injury during treatment or surgery. The ACC Act defines an injury caused as a result of treatment from a registered health professional, that is not an ordinary consequence, as a treatment injury.

ACC is the "first insurer" for such injuries. For more information visit ACC's Treatment Injury page. ACC is legally responsible for the costs of treatment injury, but to make things easier for members Southern Cross offers to pay for the treatment and recover the costs from ACC, provided all the following criteria are met:

  • The member is entitled to cover under their Southern Cross policy.
  • The provider has filed a treatment injury claim (ACC 45 and ACC 2152 forms).
  • The member has returned a member consent form which allows Southern Cross to process the ACC claim on the member's behalf.
  • ACC has confirmed to Southern Cross that the potential treatment injury claim has been received.

If ACC declines the treatment injury claim

Please make sure your patient sends Southern Cross a copy of the ACC decline letter or treatment injury decision, because we might want to review the decision with ACC. All reviews are conducted in consultation with the member.
 

If you have any questions about this process, please contact provider@southerncross.co.nz or phone the Provider line on 0800 770 843.