Eligibility criteria

As specified in Southern Cross policy documents, certain healthcare services have eligibility criteria which need to be met before a healthcare service will be covered under a member's policy.

What are eligibility criteria?
Eligibility criteria are additional terms and conditions we set from time to time for a particular healthcare service which must be met for the healthcare service to be covered under policy.

You must determine whether the healthcare service you are intending to provide to the member is eligible for cover under the member’s policy before applying for prior approval and claiming on behalf of the member. This includes consideration of eligibility criteria and policy exclusions. Checking these will ensure that prior approvals and claims are correct and ready for assessment.

We need to balance collective affordability with member access to private healthcare services from a range of qualified practitioners. One of the ways we do this is through eligibility criteria and policy exclusions. As an Affiliated Provider, to ensure members’ healthcare services you provide are funded under policy, you are required to provide these services in accordance with eligibility criteria and any policy exclusions.

Policy exclusions

General policy exclusions are listed in the policy document for each of our plans.

What are policy exclusions?
Policy exclusions(s) are conditions, treatments or situations that the relevant policy does not cover.

Southern Cross will not reimburse you for a service you provide that is for, or relates to, any of the below policy exclusions, any policy exclusions in your AP agreement, or any of the other general exclusions listed in the policy documents. A list of policy variations a list of variations to policy terms and conditions that may apply from time to time and may include the way we treat some exclusions and certain benefit terms.

Please also ensure you are familiar with all the general policy exclusions including:
Acute care means care provided in response to a sign, symptom, condition or disease that requires immediate treatment or monitoring.

Certain oral surgery or dental treatments, including:

implantation of teeth and/or titanium dental implants except as specifically provided by the Keeping Well and Vision and Dental modules (additions to Wellbeing plans)

surgery designed to assist or allow the implementation of orthodontic healthcare services except as specifically provided by the Keeping Well and Vision and Dental modules (additions to Wellbeing plans)

diagnosis, management and treatment of developmental or congenital abnormalities of the facial skeleton and associated structures

extraction of teeth except as specifically provided by extraction of unerupted or impacted teeth (under oral and maxillofacial in Affiliated Provider surgical procedures) benefit, or by the Keeping Well and Vision

and Dental modules (additions to Wellbeing plans).

Congenital condition(s) means congenital anomalies or defects which are present at birth and for which the policyholder or dependent had either:

signs or symptoms of the condition prior to the original date of joining, or

signs or symptoms of the condition within three months of birth, as reasonably determined by Southern Cross. Except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis and squint.

Health screening means diagnostic test(s), investigation(s), or consultation(s) in the absence of any sign or symptom suggesting the presence of the illness, disease, or medical condition the screening is designed to detect.

Unapproved healthcare services means healthcare services such as specific drugs, devices, techniques, tests, and/or other healthcare services that have not been approved by Southern Cross prior to treatment. Please see the list of unapproved healthcare services.

Detrimental to Health means a medical condition that is causing significant problems for the physical health of an individual.

Apply eligibility criteria and policy exclusions before applying for prior approval and claiming on behalf of Southern Cross members

As an Affiliated Provider, to ensure members’ healthcare services you provide are funded under policy, you are required to provide these services in accordance with eligibility criteria and any policy exclusions.

Cardiac services (heart disorder diagnosis & treatment)