Claims may be short paid or rejected for a number of reasons.

The most common reasons for a short payment:

1. 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)
2. Voluntary use of a medicine that is not included in the medicine formulary
3. Services not regarded as Prescribed Minimum Benefits (PMB) level of care
4. Not obtaining authorisation for a chronic condition prior to seeing a GP
5. Not obtaining authorisation for certain tariff codes/diagnostic tests/scans
6. There may be mandatory co-payments for certain procedures

The most common reasons for a claim being rejected:

1. Not obtaining pre-authorisation for hospitalisation, procedure, scan, etc.
2. Not obtaining chronic authorisation for a medication prior to claiming from the chronic benefit
3. Depletion of benefit limits