Just received a benefit statement from us and want to know more? Take a look at these frequently asked questions. 

Q. Is this a bill?

No. This statement is for your records only and outlines benefits paid on behalf of your membership with Emergency Services Health. If there are any additional out of pocket expenses your provider should have already advised you and may bill you separately.

Q. Why am I receiving this statement?

Statements are a good way for you to receive regular information about your cover and give you visibility of the claims paid on your behalf during the period. If a Hospital or Medical provider has made a claim on your behalf, you will receive a statement by email or post each month (depending on how you’ve asked us to communicate this type of message with you and in line with our Privacy Policy).

Q. Can I opt out of receiving a statement?

Since your statement is important for transparency of claims paid on your behalf, members are unable to opt out. Where no Hospital or Medical claims have been paid during the month, you will not receive a statement.

Q. I received medical or hospital treatment on the date stated, but I don’t recognise this provider. Who are they?

Some services may be performed by an assistant surgeon or an anaesthetist. Your treatment may have also included x-ray or pathology services. The name displayed would likely be for the provider who performed those services. If you are still concerned the provider is incorrect, please contact us and we can investigate the claim further.

Q. I do not remember engaging a provider to perform a service on the date stated. What is this claim for?

Please contact us with the date of service, provider and amount shown so we can investigate this for you.

Q. Can I have a statement for my Ancillary claims?

Yes, if you would like an Ancillary claim benefit statement at any time, please contact us. You will continue to receive a remittance advice when your Ancillary claims are paid.

Q. Why does my statement show a negative number?

Negative numbers normally reflect a claim adjustment for a previous period. If you would like further information about the adjustment, please contact us and we can investigate the claim further.

Q. Why does the Date of Service fall outside the statement date range?

There can be a delay between the date a service is provided and the date the claim is paid. The statement lists all claims paid during the period. Since you would already be aware of the date you received the service, the date of service is shown as a point of reference.

Q. Why is there a delay between the Date of Service and the date my claim was paid?

Hospital and Medical providers raise their accounts at various time frames from the Date of Service. This means we can receive these bills a considerable time after discharge. Once we receive a bill, we endeavour to pay the claims received as quickly as possible.

Q. What are “Medical claims”?

Medical claims are for inpatient (admitted to hospital) services only and reflect your private health insurance component of the benefit paid (does not include Medicare benefits where applicable). They do not cover services performed by a GP or Specialist not relating to an in-patient episode of hospital treatment.

Q. My statement includes all people within my membership. Can I have a statement showing only my own?

Yes. To request an ad hoc statement for only your claims, please contact us. Our monthly statements will continue to show all claims during the period.

Q. I am a dependant (child or partner) on the policy. Can I stop my claims displaying on their statement?

As per our Privacy Policy, a person over the age of 14 years may request to have their sensitive information kept private from other persons insured on the policy. Emergency Services Health will endeavour to keep the information private, but will be obliged to disclose information on request by the Contributor of the insurance policy, or a parent or guardian of the person. If any insured person aged 18 years or older wants to guarantee that their personal information (in particular sensitive information) is not disclosed to other persons on the health insurance policy, they will need to purchase their own health insurance policy.

To request your sensitive information be kept private from other persons insured on the policy, please contact us. Please refer to our Privacy Policy for further information.

Q. Why are other insured persons not showing on my statement?

There are a few reasons why a claim is not displaying on your statement. The claim may not have been paid during the statement period, or we may not have received the bill from your provider yet. Alternatively, as per our privacy policy, Emergency Services Health people have the ability for their information to be kept private. Please refer to our Privacy Policy for further information.

Q. A person is showing on my statement who was removed from my membership a few weeks ago. Why can I see their claims?

There can be a delay between the date a service is provided and the date the claim is paid. It is likely the claim was paid after the person left your membership. Since all claims paid during the period are displayed, this claim was included.

If you believe this may not be the case, please contact us and we can investigate the claim for you.

Q. My membership is currently suspended or closed – why am I receiving this statement?

There can be a delay between the date a service is provided and the date the claim is paid. It is likely the claim was paid after you suspended or closed your membership. Since all claims paid during the period are included in a statement, a statement has been generated for you.

If you believe this claim was not for you, please contact us and we can investigate the claim for you.

Q. I thought my Medical and Hospital claims were covered 100%. Why is the Total Benefit Amount different from the Provider Fee?

If you transferred to Emergency Services Health from another health fund, an excess may have still applied to your cover until the end of your waiting period. Gaps may also apply for theatre fees or some prosthetics. Any such discrepancies should have been brought to your attention prior to your service.

If the benefits paid do not match what you were expecting, please contact us so we can investigate the claim for you.

Q. Can I receive my statement by post instead of email (or vice versa)?

Please contact us to arrange this. Once you have answered some security questions we can change your preferences for general correspondence.

Q. How do I change my contact details, level of cover or the people included in my membership?

In line with our Privacy Policy, there are restrictions on who can update particular details within a membership. Please contact us to discuss which details you would like to change, any documentation required and who has authority on your membership to make the required change.

 

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