Benefit Entitlement Policy

1.       PREFACE

To ensure prudent administration, risk management and governance Emergency Services Health maintains a register of Board of Director approved policies.

The Board of Directors, where appropriate, has approved policies to delegate their authority or provide guidance to appropriate employees.

These policies are reviewed regularly, but not later than the review date specified in this policy.

2.       DEFINITIONS

Board of Directors (Board or BOD) means those persons appointed as Directors of Emergency Services Health Pty Ltd when meeting formally in relation to its Corporate Governance responsibilities.

Chief Executive Officer (CEO) means the person appointed by the Board of Directors to give effect to the Board’s decisions. Where there is a Managing Director, reference to the CEO is also reference to the person who is the Managing Director.

Leadership Team (LT) means the CEO plus the Senior Managers.

Senior Manager (SM) means any person reporting directly to the CEO, with the designation of manager, whether permanently or temporarily employed, but not including contract or consultant service providers.

3.       INTRODUCTION

This policy is a guideline for employees when handling a request from an insured person on:

  • (a) details of entitlement to benefits; and
  • (b) specific information on benefits payable prior to treatment being undertaken.

Emergency Services Health will make available other mechanisms for an insured person to ascertain a benefit entitlement, such as a provider using an electronic claiming system (eg HICAPS, ECLPISE) or a recognised hospital directly contacting Emergency Services Health.

4.       POLICY

4.1     Commitment

Emergency Services Health understands and recognises an insured person’s right to seek clarification on benefit entitlements and specific information on benefits payable prior to treatment being undertaken.

Emergency Services Health is committed to improving the quality of products, services and processes so that requests for information is readily available to assist the insured person in understanding their benefit entitlement.  An insured person may obtain an understanding of their benefit entitlement:

  • By contacting Emergency Services Health by telephone or in writing (mail, email, facsimile);
  • By utilising Emergency Services Health’s printed or electronic (website) material.
  • Through their health service provider, who may utilise electronic claiming systems to obtain benefit quotes or establish eligibility, as appropriate, or in the case of hospital providers, also contacting Emergency Services Health.

4.2     Assistance

Emergency Services Health serves a diverse community and endeavours to resolve an enquiry by appropriately considering an individual’s particular needs.  Specialist services appropriate to the individual to achieve a satisfactory response for all parties will be organised if required e.g. language or interpreting services.

4.3     Responsiveness

Emergency Services Health employees will in most instances have the training and authority to address and finalise an enquiry.  A responsive peer and supervisor support system is established to enable expedient resolution of enquiries.

4.4     Data Collection

Emergency Services Health uses a comprehensive and integrated communication system for the collection of data.  The communication system captures information about each interaction with contributors, dependents, providers and other third parties.  All communications through the general enquiries line will be recorded.  An employee will record, in the Communications Register, all benefit entitlement enquiries in accordance with Communications Register procedures.  The data collected is collected and stored for subsequent reference when queries may arise. 

4.5     Systemic and Recurring Problems

Emergency Services Health is committed to continually monitoring its performance in handling benefit entitlement requests to ensure that policy holders’ and organisational expectations are met.  Emergency Services Health will review and analyse the Communications Register to identify any systemic and recurring requests.  Where Emergency Services Health identifies systemic or recurring issues or requests, appropriate action will be undertaken.

4.6     Benefit Entitlement Procedure

The steps in processing a telephone request for information includes the employee:

  • (a) clearly identifying themselves, using their first name, listening and understanding the caller in a courteous manner and determining the needs of the caller;
  • (b) being mindful of privacy obligations, verifying that the person has a benefit entitlement within an insurance policy and ensuring that the insurance policy is financial;
  • (c) providing the requested information using the benefit quote within the operating system;
  • (d) taking into consideration benefit restrictions, maximums, waiting periods, the state of residence (or cover) etc. before providing advice to the person;
  • (e) recording all the details of the request in Emergency Services Health’s Communications Register.

Where a complaint about a benefit entitlement arises the employee will handle the complaint in accordance with the Complaints Policy.  When appropriate, employees receiving a benefit entitlement request or a request for specific information on benefits payable prior to treatment will recognise and acknowledge the right of the requester to comment and or complain.

5.       POLICY ADMINISTRATION

Date Policy Approved             21 September 2016

Policy Review Date                 30 September 2019

Policy oversight:                     CEO

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