Access Gap Cover

What is Access Gap Cover?

Access Gap Cover (AGC) is a billing scheme that aims to reduce or eliminate out-of-pocket expenses to members for doctor and specialist services received in hospital. Doctors may choose to participate in AGC on a patient-by-patient basis, so you should discuss this with your doctor.
Why won't my doctor or specialist participate in Access Gap Cover?

It is up to your doctor or specialist to decide whether to charge you under the Access Gap Cover (AGC) scheme. Even if the doctor has participated in this scheme before it does not automatically guarantee that the doctor has participated in AGC for your treatment. Doctors and specialists are free to choose whether they will participate on a patient-by-patient basis. This decision remains solely with the doctor or specialist.

Benefits / Claiming

Benefit limits are per calendar year. What does this mean?

A calendar year is from 1 January to 31 December. Overall benefit limits are available between this yearly period. Once a benefit limit is reached over the course of a calendar year it will not be refreshed until 1 January of the following calendar year.
How many Extras services can I receive benefits for in one day?

Benefits are limited to one service per patient, per provider, per day.

If a provider performs more than one consultation, the treatment that attracts the higher benefit will be paid.

Where multiple visits/services are performed on the same day at different times by the same provider, then the visit/service that attracts the higher benefit will be paid.
Am I covered for medical procedures in my doctors’ room rather than a hospital?

If you receive services in your doctors' room rather than a day surgery or hospital you are only entitled to benefits from Medicare. We will not pay a benefit for services outside of a hospital for non admitted patients.

Medicare will pay 85% of the Medicare Benefits Schedule (MBS) fee, and you will be required to pay the remainder of the account.
Can I claim benefits back for doctor/specialist appointments?

Your private Hospital cover takes effect when you are admitted to hospital. Any out-of-hospital medical expenses incurred (scans, blood tests, appointments) will not be covered by your private health insurance. They may be covered to some extent by Medicare.
How can I claim for Healthy Lifestyle benefits such as gym membership?

To be eligible to claim for Healthy Lifestyle benefits the program or service must be approved by UniHealth and received as part of a health management program intended to prevent or help a specific health condition. To comply with legislation, we require your health professional (e.g. GP, medical specialist or allied health provider) to sign the Healthy Lifestyle supporting documentation form.

Benefits are not payable for meal replacement products or prepared food.
The benefit limit says 75%, how does this work?

This means that you will receive a benefit of 75% of the cost up to the maximum limit available on your level of Extras cover.
For example, if you have Top Extras, the benefit for blood glucose monitors is 75% of the cost up to $160.

If you buy a blood glucose monitor for $200 your benefit would be $150 (75% of the cost).
If your monitor costs $300, 75% of the cost is $225 and your benefit would be $160 (since the maximum benefit for this item is $160).
What pharmaceuticals am I covered for?

Benefits are payable for drugs prescribed by a doctor that are not covered by the Pharmaceutical Benefits Scheme (PBS) but are approved by the Therapeutic Goods Administration (TGA). You can claim a benefit for the difference between the actual cost of the item and the PBS co-payment amount up to a maximum amount of $60.
What out-of-pocket expenses can I expect for Extras services?

The out-of-pocket expense will be the difference between what the provider charges and the benefit we pay. For example if you see a physiotherapist (second visit) and are charged $70 for a standard consultation you will receive a $40 benefit from UniHealth. This will leave you with a $30 out-of-pocket charge.
What is an increasing limit and how does it work?

Increasing limits are calculated based on years of continuous membership of Teachers Health Top Extras cover. This means that the longer you hold Top Extras cover with us the higher the overall benefit will be for major dental and hearing aids. Loyalty limits accrued at other health funds are not transferable.
My child has been admitted to a public hospital and I am required to stay with him/her in the hospital overnight. Is a benefit payable?

If you have Top Extras cover, a benefit of $30 a day up to a maximum of $200 per person per calendar year is payable.
I need to travel more than 200km (return trip) to receive treatment for a serious medical condition. Is a benefit payable?

If you have Top Extras cover, a benefit of 15 cents per kilometre up to a maximum of $400 per person per calendar year is payable for a serious medical condition requiring treatment that is not available closer to your home and confirmed by a doctor or specialist. A benefit is not payable for ambulance transportation or where the distance is less than 200km return from your home.
Where fund benefits are not payable.

There are certain circumstances that will prevent the payment of a claim including:

  • lodgement of claim two years or more after the date of service

  • when you or someone on your membership has the right to recover costs for a third party or authority, either by law or by statute, or from any insurance or employment benefits scheme

  • when no charge has been raised (services received is free of charge)

  • for any period during which your membership is unfinancial or suspended

  • waiting periods have not been served

  • provider is not recognised by UniHealth at the time the service is received

  • the official receipt is not provided

  • a member has treated themselves

  • a member has been treated by someone on the same Policy as themselves or their Partner or their Dependants

  • a member has been treated by their business partner / associate or the business partner / associate of someone on the same policy as themselves or their Partner or their Dependants

  • for services not provided face-to-face (with the exception of telepsychology services provided by a registered psychologist)

  • for hospital and general treatment received, or goods purchased overseas.
What constitutes an official receipt?

A receipt must be on official letterhead or stamped with a provider stamp containing the:

  • name of the practitioner providing the service

  • address where the service was provided

  • contact number for the provider

  • provider number (where available or practical) and/or registration number of provider with professional associations

If an account or receipt is produced electronically it should be signed at the time of issue either by the provider or their representative.

The receipt should be itemised with the following details:

  • the name of the patient receiving the service

  • the date of each individual service provided

  • the type of each individual service provided

  • the cost of each individual service provided

  • a body part identifier, prescription/script number or tooth identification where required
    whether the account has been paid or not

Handwritten provider details and alterations to accounts will not be accepted.


    What is an excess?

    An excess is an amount you pay each calendar year when admitted to hospital. Choosing a product with an excess reduces your premium and is only payable if you are admitted to hospital.

    The excess you pay will depend on the level of your cover and excess you choose.
    When do I pay the excess?

    If you have an excess on your level of Hospital cover, you’ll be pay directly to the hospital on your admission. See the table below for the levels of Hospital cover that include an excess. You’ll only pay the total excess once per person, per year (to a maximum of twice per membership, for couple, family and single parent memberships). The excess is waived for child dependants under 25 on most of our covers, except for Basic Hospital (Basic Plus).
    Top Hospital 300 (Gold) & Top Hospital 500 (Gold) Total excess of $300 or $500 (depending on the excess you’ve chosen) when admitted to a private hospital. This excess is paid once per person, per calendar year. No excess for a public hospital admission. The excess does not apply to child dependants under the age of 25.
    Mid Classic 300 (Silver Plus) & Mid Classic 500 (Silver Plus) Total excess of $300 or $500 (depending on the excess you’ve chosen) when admitted to a private or public hospital. This excess is paid once per person, per calendar year. The excess does not apply to child dependants under the age of 25.
    Mid Hospital 300 (Basic Plus) & Mid Hospital 500 (Basic Plus) Total excess of $300 or $500 (depending on the excess you’ve chosen) when admitted to a private or public hospital. This excess is paid once per person, per calendar year. The excess does not apply to child dependants under the age of 25.
    Basic Hospital (Basic Plus) Total excess of $300 when admitted to a private or a public hospital. This excess is paid once per person, per calendar year. The excess applies to every person on the membership, including child dependants under the age of 25.

    Fraud prevention

    As a not-for-profit organisation, UniHealth exists for our members and we work hard to improve efficiencies, reduce operating costs and keep premiums as low as financially sustainable.

    An area that is increasingly impacting on our operating expense is false claims, or more accurately – fraud. Each year we find that the volume of fraudulent claims increase despite our monitoring and audit processes.

    Private Healthcare Australia estimates that millions of dollars are lost every year in private healthcare through fraud and inappropriate claiming. Every dollar of this ultimately affects the premiums of those holding private health insurance, with fraud causing resources to be diverted away from the payment of necessary services and legitimate claims.
    What is fraud?

    Fraud can occur through a healthcare provider or health fund member providing misleading or false information or withholding information. Examples include:

    - charging for treatment(s) that have not been provided
    - creating false documents
    - altering accounts to increase financial benefits.
    What is UniHealth doing to detect and prevent fraud?

    At UniHealth we have a dedicated investigations team that engages in a variety of activities designed to either prevent such losses, or detect and recover these losses on behalf of our members.
    What can you do?

    To help ensure that your membership is protected from fraud or misuse and help us keep premiums as low as possible, don’t forget to:

    - report any stolen or lost membership cards within 24 hours
    - never leave your membership card with service providers
    - check your limits online
    - keep your online member services password safe and change it regularly
    - always check your receipts including signing for services claimed electronically

    UniHealth and the investigations team will always treat any concerns raised with the utmost confidentiality and protect your identity or respect your right to remain anonymous.

    Members can assist us reduce fraud by reporting any suspicious activity to:

    Going to hospital

    I need to go to hospital for surgery or treatment. What should I do?

    Have a read of the Hospital Guide so you can get a better understanding about what you should know before going to hospital. We strongly encourage you to contact UniHealth before scheduling your surgery or treatment to ensure that you are covered and to check if the hospital of choice is an 'Agreement Private Hospital'. We can also help you understand what your out-of-pocket expenses may be.
    What may I have to pay for during my hospital stay?

    There are some services that you may receive in hospital that are not covered by us. These include:

    - Telephone charges
    - TV hire, internet access or other items of a non-medical nature
    - Pharmaceuticals that are not covered in the agreement with the hospital or that are listed under the Pharmaceuticals Benefits - Scheme (PBS)
    - X-rays, scans and other tests
    - Consumables and disposables of robotic surgery
    Am I classified as an in-patient (admitted in a hospital) when having chemotherapy or dialysis on a daily basis?

    You will be covered for chemotherapy or dialysis received on a daily basis as long as the hospital you are receiving the treatment from has an agreement with UniHealth and admits you as a day patient.
    What happens if I get taken to hospital in an emergency?

    In an emergency situation, you will be taken by an ambulance to the nearest accident and emergency department of a public hospital. In this situation you have the right to choose to be treated as a public patient at NO charge, by a doctor appointed by the hospital. You are fully covered for the emergency ambulance transportation provided by a state government service (including state government air ambulance) under UniHealth Hospital and Extras cover.

    If you are taken to an accident and emergency department at a private hospital you will be charged for treatment as an out-patient and there will be no benefits available from UniHealth for medical charges raised by doctors or facility fees raised by the hospital’s accident and emergency department.

    Joining UniHealth

    How can I join?

    Joining UniHealth is fast, easy and hassle free. You can join:

    - online;
    - over the phone, by calling 1300 367 906;
    - or, by completing a printed application form.
    Am I eligible to join?

    UniHealth is open to people in the higher education community, and their families. Eligible members include:

    Teachers and academics:
    If you are a full-time, part-time or student member of any of the following education unions, you are eligible to join:

    - New South Wales Teachers Federation
    - Australian Education Union (AEU) and affiliated unions
    - Independent Education Union (IEU) and affiliated unions
    - National Tertiary Education Union
    - State School Teachers Union of Western Australia
    - Institute of Senior Education Administrators

    Administration and support staff:
    If any of the following criteria describe you, then you are also eligible to join:

    - A member of the Institute of Senior Education Administrators NSW (SEANSW)
    - A current or former staff member employed by the NSW Department of Education and Training, The Office of the NSW Board of - Studies, the Institute of Teachers or in the TAFE Commission, who is (or was) a member of an appropriate union, where one exists.
    - A current or former employee of the NSW Teachers Federation or Teachers Mutual Bank (formerly known as Teachers Credit Union) who is (or was) a member of an appropriate union, where one exists.

    Family members:
    The family of existing UniHealth members are also eligible to join. Eligible family members include:

    - A partner or former partner, including same-sex and de facto partners
    - Dependant and adult children, including their partner and children
    - Siblings, including their partners and children
    - Grandchildren
    - Parents
    Do you have a 'cooling off' period?

    Our cooling off period means that if you change your mind within 30 days from the date your health insurance policy started, we will cancel your membership and provide a full refund, providing no claims have been paid during this period.
    Transferring to UniHealth.

    If you are already with another fund and would like to switch to UniHealth you just need to join online or complete an application form ensuring you fill out the clearance certificate section. This gives us permission to organise the transfer for you and also understand your level of cover and waiting periods already served.
    What is a Private Health Information Statement (PHIS)?

    A Private Health Information Statement (PHIS) is an industry-wide standard format summary for your policy, replacing the Standard Information Statement (SIS) that was used previously. PHIS help you review or compare your policy against any other policy, from any health insurer in Australia. If you would like a PHIS for any of our products, they are available at For further information about our services or policies - including all policy details - please contact UniHealth on 1300 367 906 or investigate the products on our website.

    Lifetime Health Cover

    What is Lifetime Health Cover and how can I avoid the loading?

    Lifetime health cover (LHC) is a government initiative designed to encourage individuals to purchase private hospital cover earlier in life and maintain it.

    If you don’t take out and maintain private hospital cover from the time you turn 31, you’ll have to pay a 2% LHC loading on your premium for each year if you decide to take out private hospital cover later.

    Read more about LHC here.

    Medicare Levy Surcharge

    What is the Medicare levy surcharge?

    The Medicare levy surcharge is an additional 1 – 1.5% surcharge of taxable income imposed on higher income earners who are eligible for Medicare but do not have private Hospital cover. If the surcharge applies to you, your Medicare levy increases from 2.0%, that is paid by most Australian tax payers, to 3.0 – 3.5% of your taxable income.

    The Medicare levy surcharge is means tested based on income.
    How to avoid the Medicare levy surcharge?

    If you are single and earn more than $90,000 a year or a couple/family earning more than $180,000 per year, you can avoid paying the Medicare levy surcharge by taking out any of our Hospital or Combined cover products.
    Medicare levy surcharge Percentage
    Singles less than $90,000 0.0%
    Couples/families less than $180,000 0.0%
    Singles $90,001 - 105,000 1.0%
    Couples/families $180,001 - 210,000 1.0%
    Singles $105,001 – 140,000 1.25%
    Couples/families $210,001 – 280,000 1.25%
    Singles more than $140,001 1.5%
    Couples/families more than $280,001 1.5%

    Medicare Safety Net

    What is the Medicare Safety Net?

    The Medicare Safety Net is there to help you. It provides families and individuals with financial assistance towards high out-of-pocket expenses associated with medical services provided as an out-patient. Once you meet a Medicare Safety Net threshold, you may be eligible for additional Medicare benefits for out-of-hospital Medicare Benefits Schedule (MBS) services for the rest of the calendar year.

    Register for the Medicare Safety Net for free at This allows Medicare to track your out-of-hospital, out-of-pocket expenses and advise you when you are nearing the threshold.

    Members Area

    What should I do if I have forgotten my password?

    Go to Online Member Services and then click on 'Forgotten password' from the right hand side. Enter the details required and your password will be emailed to you.
    What is Online Member Services?

    Online Member Services provides you with access to your health insurance policy details 24 hours a day, 7 days a week. It is a convenient way of tracking your health cover, obtaining information and making changes to your policy and those covered at a time when it suits you.
    How do I register for Online Member Services?

    Enter the Online Member Services area, select 'Register' on the right hand side, enter your details and submit.
    I want to receive my mail electronically - how do I change my mail preference?

    To change your mail preference to receive correspondence electronically, follow these simple steps:

    - log in to Online Member Services
    - select Contact details from the My Membership main menu
    - select Edit
    - scroll down to Contact preferences

    From the drop down menu select either of the following:

    - via Member Services area (with email notification)
    - via Member Services area (with SMS notification)
    - select Next to confirm the change
    - tick the declaration and select Submit to finish transaction.

    Mental Health Waiver

    What is the Mental Health Waiver?

    Following a government reform introduced on 1 April 2018, members who have served their 2 month waiting period on a Hospital product with a restricted level of cover for Psychiatric services can upgrade to a Hospital product which covers Psychiatric services and choose to have the two month waiting period for these higher benefits waived.
    When can I use the Mental Health Waiver?

    Members can choose to use their waiver at the time of upgrading or at any time prior to serving the two month waiting period.
    How can I access the Mental Health Waiver?

    To access the waiver, members must have:

    - private hospital cover;
    - served the two month waiting period on a Hospital product with a restricted level of cover for in-hospital Psychiatric services; and
    - upgraded to a Hospital product which covers in-hospital Psychiatric services.

    If you upgrade your Hospital cover within five (5) days of your admission to hospital, you’ll be entitled to higher benefits from the time you’re admitted (retrospective cover). If you upgrade your Hospital cover after five days of your admission to hospital, you’ll only be eligible for higher benefits from the date of upgrade (no retrospective cover).

    The Mental Health Waiver can be used by each individual on a policy but can be used once per person in a lifetime.
    I need more information

    Click here for more information or contact us.

    My membership

    Can my partner manage my membership also?

    Yes. If you would like your partner (who is on your membership) to have authority to operate your membership, ensure that you tick the box for partner authority on the membership application form when you are joining. Otherwise, you can let us know via email or post.
    I am going overseas for a holiday, what should I do?

    We strongly advise you to take out adequate travel insurance as UniHealth benefits do not cover the costs of Hospital treatment or Extras services outside of Australia. If you are travelling overseas for a period of more than two calendar months but less than 36 calendar months you may suspend your health cover while you are away.
    When can I suspend my policy?

    You can suspend your policy if you have been a financial member for a minimum of 12 months and are:

    - travelling overseas for more than 2 months but less than 36 months
    - experiencing financial hardship
    - taking leave without pay

    It is important to note that during a suspension period you will not be able to make any claims and if you develop a condition or illness during the suspension period, you may not be immediately covered. Please contact us to discuss. Downgrading your level of cover might be a better option for you.
    How can I upgrade or downgrade my cover?

    You can upgrade or downgrade your level of cover at any time. Upgrading your cover can done via our Online Member Services area or by calling or emailing us. When upgrading your cover, waiting periods will apply for services that were not previously covered. If you wish to downgrade your cover you will need to do this in writing. When downgrading your cover, it is important to understand what you may no longer be covered for.
    What does Emergency Ambulance transport cover?

    This covers you for emergency ambulance with state government services (including air ambulance) and non-emergency ambulance with state government ambulance services, or a private ambulance service that we approve. Keep in mind that this doesn't include transport to a hospital for management of an ongoing health condition, transport between hospitals, transport for patients requiring day treatment, and transport to and from nursing homes or
    specialist/diagnostic centres.

    Queensland and Tasmanian residents are covered by State funded ambulance services.
    What is a Private Health Information Statement (PHIS)?

    A Private Health Information Statement (PHIS) is an industry-wide standard format summary for your policy, replacing the Standard Information Statement (SIS) that was used previously. PHIS help you review or compare your policy against any other policy, from any health insurer in Australia. If you would like a PHIS for any of our products, they are available at For further information about our services or policies - including all policy details - please contact UniHealth on 1300 367 906 or investigate the products on our website.
    How can I make a payment?

    Here are three easy ways to make a payment if you need to:

    1. BPAY - contact your financial institution and quote our BPAY reference number (228361) and your BPAY member reference number. If you are unsure of your BPAY member reference number please contact us.
    2. Phone - payments can be made using our secure pay-by-phone service by calling 1300 665 709. Accepted credit cards are MasterCard and Visa.
    3. Credit card - via our Online Member Services. You may pay your premium through our secure online member services centre. Accepted credit cards are MasterCard and Visa.

    Planning a family

    What happens if I am considering getting pregnant but my Hospital cover excludes pregnancy?

    It is important you have Hospital cover that includes pregnancy benefits, as a nine month waiting period applies for all services relating to pregnancy and childbirth. This means, you will need to have held appropriate Hospital cover well in advance of your pregnancy.

    Learn more about pregnancy and birth cover.
    When do I need to add my baby to my policy?

    When you are settled in and have a few moments to spare, give us a call on or log on to the Online Member Services to add your baby to your cover. You will need to advise us of the name, date of birth and sex of your baby. All waiting periods will be waived for your baby if you add him/her to your membership from the date he/she was born, within two months of the birth.

    Please note: If you are on a single membership, you will need to upgrade to a Family or Single Parent membership to add your baby to your cover.
    When is my baby an admitted patient?

    Babies born without complications are generally not admitted to hospital, but treated as an out patient. A newborn baby is classified as an inpatient when one of more of the following criteria are met:

    - the baby is admitted to an approved neo-natal intensive care facility
    - the baby is the second or subsequent born in a multiple birth situation (i.e. twins or triplets)
    - the baby is more than 10 days old and still in hospital.

    Private Health Insurance Rebate

    What is the Private Health Insurance Rebate?

    The Private Health Insurance Rebate reduces your premium amount, making health insurance more affordable and accessible for you. The rebate is income tested against the income tier thresholds in the table below. Your rebate percentage entitlement will be reduced as your income tier rises.

    View the Private Health Insurance Rebate levels here.
    Who is eligible to claim the Private Health Insurance Rebate?

    The Private Health Insurance Rebate is available to everyone who is eligible for Medicare and has private health insurance and whose taxable income falls within tiers 2 and below.
    How can I claim the Private Health Insurance Rebate?

    You can claim the Private Health Insurance Rebate as:

    - as a reduction on your premium amount
    - through your annual tax return

    More information about the Private Health Insurance Rebate.
    Do I need to tell UniHealth my income?

    Members will be encouraged but not required to nominate a tier with UniHealth.
    What happens if I select the wrong tier?

    There is no limit to the number of times you can change the tier nomination and no penalties are applied for not making a nomination or making an incorrect nomination.
    What happens if I over claim or under claim the rebate?

    Adjustments will be made through the tax system. UniHealth will not be informed or involved.
    Can UniHealth provide advice to me regarding which tier I should nominate?

    UniHealth is unable to provide financial advice to its members. We encourage you to discuss with your tax agent, financial planner or with the Australian Taxation Office.
    Where can I find more information?

    More information can be found on the Australian Taxation Office website.

    Online claiming

    Member app

    For easy and convenient claiming, UniHealth now offers a mobile claiming app for both Apple and Android devices. Simply take a photo of your receipt to submit your claim! Please note, that you will need to keep your original receipts for two years.

    For more information and to download the app, please click here.
    What can I claim online?

    You can claim the following range of services online (subject to your level of cover):

    - Complementary Therapy consultations (eg acupuncture and remedial massage)
    - Chiropractic consultations
    - General Dental (item numbers)
    - Optical (item numbers)
    - Podiatry consultations
    - Physiotherapy consultations
    - Physiotherapy Group Therapy
    - Exercise Physiology consultations
    - Exercise Physiology Group Therapy
    - Speech Therapy consultations
    - Occupational Therapy consultations
    - Psychology consultations
    - Audiology consultations
    - Dietician consultations
    - Limited Major Dental – Endodontics (item numbers)
    Why can't I find my provider from the list of providers or the search function?

    Providers must be recognised by UniHealth for benefits to be payable.

    You may have previously received a benefit from the Fund when a provider was recognised. Some providers, particularly those providing complementary therapies, are required to maintain professional indemnity insurance and membership of a recognised professional association to stay recognised with UniHealth. Where this does not occur the provider will no longer be recognised by UniHealth.
    How much can I claim online?

    Up to $500 per day worth of benefits can be paid online. This is the limit for the entire membership. This limit is not per person.

    If claims lodged in a day exceed $500 in benefit you will be required to submit the receipts for the entire claim in order for the total benefit to be released.
    Am I required to send in my receipts?

    If the benefit payable is under $500 you will not be required to submit your receipts. However you are required to keep your receipts for two years from the date of lodging your claim as we may conduct a random audit. If you are not confident that you won’t misplace the receipts you can always submit the receipts at the time of claiming.

    If the total benefit for your claim exceeds $500 your benefit will not be paid until all the receipts for the claim are submitted to the Fund.
    How long do I have to keep my receipts for?

    You are required to keep your receipts for two years from the date you lodge the claim online.
    What happens if I don't send in my receipts or keep them and I am audited?

    You may be required to repay the benefits and may also be blocked from further online claiming.
    How can I send in my receipts?

    There are two ways to submit your receipts if you want to continue to send them to UniHealth to have on file.
    1. After finalising your claim, the details will be shown on screen. If you select the button 'Email Receipts' that appears on this page, an email message will be generated which includes your member number and claim number in the subject line. Attach scanned copies of your receipts to this email and press send.
    2. You can email your receipts to Please ensure that your member number and claim number are included in the subject line. You can find your claim number in the Claims History section of the online member services area.
    What types of audit will be conducted on online claims?

    UniHealth will conduct random audits of online claims. This could involve a written request to you to forward in the receipts for your claim or we may contact the provider to check the service details.
    The service listed on my receipt does not match the service description in the dropdown. Should I just select something else?

    No. You should only claim for services online that match the description on your receipt. For example if your Podiatrist itemises a receipt for a Biomechanical Assessment and the only option is Podiatry Consultation, you should not select Podiatry Consultation. The Fund does not pay a benefit for Biomechanical Assessments and submitting your claim as a consultation may result in a request for refund of the payment.

    If the service listed on your receipt is not in the dropdown please contact the Fund to see if benefit is payable. You may need to send in a claim form for this benefit to be paid.
    Will I be required to repay benefits if I have entered the incorrect details?

    If incorrect details are included, resulting in the payment of benefit that you would not otherwise be entitled to, you will be required to repay those benefits. You may be temporarily suspended from access to online claiming or blocked for all future claiming.

    Examples of where incorrect details may occur include: date of service, incorrect patient, incorrect provider or incorrect item number is selected.
    Is there a time limit on how long I have to lodge a claim?

    UniHealth accepts claims up to two years after the date of service.
    The service that I claimed for has not been approved for payment. A message "Service cannot be processed. Refer Health Fund." was returned. Why?

    There are a variety of reasons that a benefit might not be payable. Some of the most common are listed below. These might explain the reason your claim was not approved. If not please contact the Fund and we will explain the reason.

    - You have already reached the calendar year limit for the service you are claiming
    - You are claiming for two services on the same day from the same provider. This could be due to you selecting the wrong date. Or you may be entering a consultation and a group therapy service for the same day. Benefits are limited to one service, per patient, per provider, per day. If your provider has performed more than one consultation or service on the same day, the treatment that attracts the higher benefit should be entered. This will most likely be the consultation.
    - The service has previously been paid for. You may have received a benefit on the date of service through an electronic claim when your provider swiped your membership card.
    - A Dental Reasonability Rule may have been triggered. Reasonability Rules have been put in place at UniHealth to enable benefits to be paid in accordance with the Fund Rules and to make sure that providers are using the correct item numbers for the services they provide to our members.

    Example 1 Dental item 012 Periodic Oral Examination
    Reasonability Rule states a maximum of two services per calendar year. This is based on the traditional 6 monthly check-ups.

    Example 2 Dental item 161 Fissure sealing – per tooth
    Reasonability Rule states item 161 is not payable with dental items 531 to 572. This is because when you are filling a tooth using item 531 to 572 on the same tooth, the fissure sealing is included.
    Can I add the delivery charge into the cost of service?

    No. There is no benefit payable for the delivery charge or postage and handling. You may be charged this when purchasing contact lenses online. This charge should not be added to the cost of the contact lenses.


    Some extra reasons to smile

    Orthodontic treatment in Australia isn’t cheap. You could end up spending anywhere from $4,000 to $8,000 (or even more) – and while a lot of these costs are covered by Medicare, you’ll still be out-of-pocket. Things like the initial consultations, photographs and teeth removal aren’t normally included.

    If you have Top Extras

    Once you’ve served your 12-month waiting period, you can claim up to $2,500 per person (lifetime limit).

    If you have Essential Extras

    Orthodontia is combined with your Major Dental benefit. Once you’ve had your cover for 12 months, you can claim up to $300 for orthodontia per year – up to a lifetime limit of $2,500 per person.

    A few tips for an easier treatment

    - Chat through any treatment options and fees with your orthodontist before you start treatment.
    - Send us a copy of your treatment plan – so we can give you an accurate estimate of how much you might be out-of-pocket.
    - Send us your receipts and a completed claim form after your treatment, because you can’t claim for orthodontia through HICAPS or online.

    Some other things you should know

    - Orthodontic benefits are only available to members with Top Extras or Essential Extras cover who have finished their 12-month waiting period.
    - You can’t claim for services you received during the 12-month waiting period – or before your treatment starts.
    - If you pay upfront you can still claim each year while your braces are still on. We’ll keep paying benefits up to your policy’s annual or lifetime limit.
    - If you’ve already received orthodontic benefits from a health fund before switching to UniHealth, they’ll be deducted from the amount we can give you back for the rest of your treatment.

    Restricted and excluded services

    What is a restricted service?

    We pay Minimum Benefits for restricted services. This means that we will pay the minimum default benefit rate for a shared room as set out by the Commonwealth Minister for Health from time to time, and minimum benefits for Government approved Prosthesis List items.

    If you choose to be treated:

    - in a private hospital - the benefits we pay will not cover all hospital costs resulting in significant out-of-pocket expenses
    - In a public hospital as a private patient - you may have an out-of-pocket expense to pay, in the event that the minimum benefit is less than what your chosen public hospital charges

    Regardless of where you’re treated, the hospital should advise you before you are admitted or have treatment, and seek your consent about any out-of-pocket expenses you’ll need to pay. This is known as informed financial consent.

    Mid Hospital (Basic Plus), Basic Hospital (Basic Plus) and StarterPak (Basic Plus) have restricted services.

    What is an excluded service?

    An excluded service is a service where no benefits are payable - regardless if it is performed in a public or private hospital. If a service is not covered by Medicare (e.g. elective cosmetic surgery) there will be no benefit payable from your Hospital cover.

    Mid Classic (Silver Plus), Basic Hospital (Basic Plus) and StarterPak (Basic Plus) have excluded services. If you go to a private or public hospital as a private patient for any excluded services you will not be covered; see our Hospital cover for details.

    Switching funds

    How do I switch to UniHealth?

    Switching to UniHealth is easy. You can notify your current fund yourself or we can do it for you. Simply complete the Transfer Certificate details when you join and we will take care of the transfer. This gives us permission to contact your previous fund to obtain your cover details.

    What is a Transfer Certificate?

    A Transfer Certificate (also known as a Clearance Certificate) is a certificate issued by a health fund when a member terminates a policy or wishes to transfer to another fund.

    It is a record of your private health insurance cover including details about:

    - type of cover
    - level of cover
    - join and cancellation dates
    - waiting periods served
    - certified age of entry (CAE)
    - a history of recent claims.

    Will I have to re-serve any waiting periods?

    If you are transferring to an equivalent level of cover with equivalent benefits, you will not have to re-serve your waiting periods with UniHealth. If your previous level of cover was lower than your UniHealth cover, waiting periods will apply to any services that were not covered by your previous fund. Waiting periods will also apply to services that are covered at a higher level.

    For example: You switch to UniHealth to Top Extras cover. Your previous level of cover did not include benefits for remedial massage. Top Extras provides benefits for remedial massage under complementary therapy and has a two month waiting period. In this instance you will be required to serve the two month waiting period before you can make any claims for complementary therapies.

    Tax statements

    When will I get my tax statement?

    Members can download a copy of their previous year's tax statement at any time through Online Member Services.

    New tax statements are available from mid-July each year and include details of all payments processed up to and including 30 June. Statements cannot be prepared before this date.

    Keep an eye on our website around tax time for more info.

    Waiting periods

    What is a waiting period?

    A waiting period is a period of time you need to wait after taking out your cover before you can receive benefits for services or items covered. Benefits are not payable for services received over the course of a waiting period.
    Who does a waiting period apply to?

    Waiting periods apply to:

    - new members to private health insurance.
    - existing UniHealth members who upgrade to a higher level of cover or reduce their level of excess – in this case you will need to serve the relevant waiting period for the higher benefit entitlement.
    - members who transfer from another health fund who have not already completed the required waiting periods, or who are transferring to a higher level of cover.

    All health funds have waiting periods.
    How long is the waiting period?

    The length of a waiting period will depend on the type of service. Please see the Hospital waiting periods and Extras waiting periods FAQs below for what these waiting periods are.

    Hospital waiting periods

    Pre-existing conditions 12 months
    Pregnancy & birth-related services 9 months
    Psychiatric, rehabilitation & palliative care 2 months
    All other hospital services 2 months
    Emergency Ambulance transport 1 day

    Extras waiting periods

    Orthodontia 12 months
    Wheelchair purchase 24 months
    Major dental 12 months
    Medical appliances 12 months
    Optical and Healthy Lifestyle 6 months
    All other services 2 months
    Emergency Ambulance transport 1 day

    Pre-existing conditions

    What is a pre-existing condition?

    A pre-existing condition is an illness, ailment or condition where the signs or symptoms existed at any time during the six months before taking out private health insurance or transferring to a higher level of cover.

    UniHealth will appoint a medical practitioner to determine whether you have a pre-existing ailment, based on information provided by your treating doctor or specialist.
    Who does the pre-existing condition rule apply to?

    This rule applies to:

    - new members
    - existing members who are upgrading their level of cover.

    A 12 month waiting period applies to all pre-existing conditions except psychiatric, palliative care and rehabilitation, which are covered by the two month waiting period.
    What if I have a pre-existing ailment?

    If you are a new member to private health insurance you will have to wait 12 months before you can receive benefits for items or services related to a pre-existing condition. This means that if you receive treatment for a pre-existing condition within the 12 month waiting period, you will not be eligible for benefits.

    If you change to a higher level of cover, you may have to wait 12 months to receive benefits, including benefits for services not previously covered.

    Wisdom teeth

    I need to have my wisdom teeth removed. Am I covered?

    If you are planning to have your wisdom teeth removed by your dentist in a private practice, Top Extras, Essential Extras and StarterPak will provide benefits.

    If you are admitted to a hospital for the removal of your wisdom teeth, your Hospital cover will cover the hospital costs such as accommodation, theatre and anaesthetist fees but Extras cover that offers major dental benefits will still provide benefits for the dentist to do the extraction.

    Claiming for Travel

    So that we can ensure your travel claim is assessed quickly and correctly, some supporting documentation is required.

    If the service you are travelling for is outside of 200km round trip distance and not available closer to home, we require;

    • A letter from the treating Doctor confirming attendance has occurred that meets the following criteria;

    - On a Letterhead
    - Patient Name Included
    - Practice Address Included
    - Doctor’s Name Included
    - Doctor’s Provider Number Included
    - Date of Service Included

    If the service you are travelling for is available closer than the provider you visited (but still outside of 200 km round trip distance), we require the above letter to include the referring Doctor’s details including;

    - Referring Doctor’s Name
    - Referring Doctor’s Provider Number
    - Referring Doctor’s Address

    We can also accept a Medicare ‘Statement of Claim and Benefit’ in place of the Doctor’s letter for either scenario outlined above.