Hospital or medical claims can be confusing, particularly when Medicare is involved, but we’re here to help you every step of the way.
Teachers Health will pay benefits for any treatments received as an in-patient during your hospital stay, depending on your level of Hospital cover. Teachers Health will not pay for visits to your specialist before or after your hospital admission.
You will need to pay any excess payments for hospital admissions direct to the hospital. You may need to make this payment when you are admitted or the hospital may bill you at a later date - just ask the hospital if you’re unsure.
Hospitals will usually bill the remainder of your account directly to Teachers Health.
Doctor and specialist bills
If your doctor or specialist is participating in the Access Gap Cover (AGC) scheme
They will generally send any AGC bills direct to Teachers Health for payment. If the bill is sent to you instead, please forward it to us (do not take it to Medicare) and we will forward your claim to Medicare on your behalf and pay your doctor or specialist directly.
If your doctor or specialist is NOT participating in the Access Gap Cover (ACG) scheme, please take your bill directly to Medicare who will process the claim before we can pay any benefits.
For visits to your specialist before and after you go to hospital:
Medicare pays 85% of the Medicare Benefits Schedule for treatments incurred before and/or after you go to hospital - you will need to pay the remainder of the account.
For treatment in hospital:
Medicare pays 75% and Teachers Health pays 25% of the Medicare Benefits Schedule for any in-hospital treatments.
Doctors and specialists may, at their discretion, charge above the Medicare Benefits Schedule (MBS) fee for a service. The difference between these fees and the MBS fee for the service is referred to as 'the gap', which you will need to pay as your out-of-pocket expense.
Overview of the Access Gap Cover scheme
*Important info about receipts
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
If an account or receipt is produced electronically, it should be signed at the time of issue either by the provider or their representative. Handwritten provider details and alterations to accounts will not be accepted.