Claims may be short paid or rejected for a number of reasons.
The most common reasons for a short payment:
- Voluntary use of a non-DSP – This is when you elect to make use of a service provider that is not included in your Fund’s list of contracted providers (doctor and/or hospital)
- Voluntary use of a medicine that is not included in the medicine formulary
- Services not regarded as Prescribed Minimum Benefits (PMB) level of care
- Not obtaining authorisation for a chronic condition prior to seeing a GP
- Not obtaining authorisation for certain tariff codes/diagnostic tests/scans
- There may be mandatory co-payments for certain procedures
The most common reasons for a claim being rejected:
- Not obtaining pre-authorisation for hospitalisation, procedure, scan, etc.
- Not obtaining chronic authorisation for a medication prior to claiming from the chronic benefit
- Depletion of benefit limits