Medical gap arrangements - practitioner application

Medical gap arrangements - practitioner application For services provided in a licensed private hospital or day hospital facility (Private Hospital) only. Please complete this form to apply for participation as an HBF Medical Gap provider. If you need assistance completing this form please contact the Provider Support Team on (08) 9265 6378 or email medicalgap@hbf.com.au. Please return the completed form by email to medicalgap@hbf.com.au, by mail to GPO Box C101 Perth WA 6809 or by fax to (08) 9265 6282. 1 Name of doctor (Medical Gap provider) Medicare registered specialty and specialty code Provider number(s) Corresponding practice name & practice address 2 To include additional provider numbers please attach a separate attachment to this form Contact details (Please note this information may be provided to members) Postal address for all correspondence Postcode Phone number Fax number Contact name Preferred email address Contact name 3 Direct credit payment details Bank details Name of financial institution and address Branch where account is held Branch number (BSB) Account number Account held in the name(s) of I authorise HBF to credit the nominated account with benefit entitlements arising from health insurance claims. Continued over

4 Level of cover You must choose the cover option under which you will participate in HBF s Medical Gap cover arrangement. The choice of cover you select is applicable for all of your Medicare Provider Numbers registered for practice at licensed private hospital or day hospital facilities. Please select your choice of cover by ticking the relevant box below: 1. Full Cover For all eligible In-Hospital Services (In-Hospital Services) I will charge all my HBF patients fees which do not exceed the fee specified in the HBF Full Cover Schedule and which I acknowledge will entitle eligible HBF members (HBF Members) to receive a Medical Gap benefit (Benefit) which fully covers the difference between my fee and the Medicare Benefit Schedule (MBS) fee, and does not require them to make a gap payment. OR 2. Opt In/Opt Out Known Gap Cover EITHER 2.1 Opt In For all In-Hospital Services I will on a case by case basis Opt In and elect to charge some of my HBF patients fees which do not exceed the fee specified in the HBF Full Cover Schedule which I acknowledge will entitle HBF Members to receive a Benefit from HBF to cover the difference between the MBS fee and the fee specified in the HBF Known Gap Benefit Schedule and will require them to make a known gap payment (if any) to cover the balance of my fee. OR 2.2 Opt Out For all In-Hospital Services I will on a case by case basis Opt Out and elect to charge some of my HBF patients fees more than the fee specified in the HBF Full Cover Schedule, which I acknowledge will not entitle HBF Members to receive any Benefit from HBF to cover the difference between my fee and the MBS fee and will require them to make the full gap payment to cover the balance of my fee. I will properly advise all HBF Members of the payment arrangements (including the total fee and any out of pocket expenses to the member) associated with the In-Hospital Services that I provide under Opt In/Opt Out Known Gap Cover before the commencement of service or, where this is not possible, as soon as practicable after the service is provided. Declaration I accept HBF s terms and conditions of participation attached to this application form in relation to the Medical Gap cover arrangements. I acknowledge that a failure to comply with any of the terms and conditions of participation may result in my status as an HBF Medical Gap provider being revoked. Name (please print) Signature Date

Terms and conditions of participation These terms and conditions of participation, together with the information contained in the Medical Gap - Provider Guide (together the Agreement), comprise the full terms and conditions of your participation in HBF s Medical Gap cover arrangement (Arrangement). Eligibility for participation You must be registered as a medical practitioner by the medical board in the state in which you practise, hold a Medicare provider number for each location in which you practise and be eligible for receipt of Medicare Benefit Schedule (MBS) benefits at the time of making this application. Acceptance of this application is at the discretion of HBF and in exercising that discretion HBF will take into account any matters HBF considers relevant in the decision making process. In the event you cease to be registered as a medical practitioner in the state in which you practise or to hold a Medicare provider number for each location in which you practise, this Agreement will automatically terminate. Who is eligible for HBF Medical Gap cover? Any HBF member with HBF Hospital cover (including Overseas Visitor cover) is eligible for Medical Gap cover provided: They are up to date with their premiums at the time of service/ treatment; They have served any necessary waiting periods; The service/treatment received is covered under their policy; and They are admitted to and the service/treatment is provided at a licensed private hospital or day hospital facility. When an HBF Medical Gap benefit can be paid HBF can only pay benefits if: The service is provided to an eligible HBF member (HBF Member) admitted to a licensed private hospital or day hospital facility (Private Hospital); An MBS item number is properly allocated to the service, the MBS item number does not appear on the HBF Limited Surgical Items List, and Medicare pays a benefit in respect of that MBS item number, or in the case of an HBF Member with Overseas Visitor cover a benefit would have been payable if that member had been an Australian resident; The HBF Member has not received (or established a right to receive) compensation or damages for treatment or services and is not otherwise entitled to benefits payable from any other source e.g. a Department of Veteran Affairs member; and The claim is lodged within two years of the date of service. Note that assuming an MBS item number has been properly allocated and otherwise complies with the terms above, HBF will always pay 25% of the MBS fee for eligible inpatient services. Under no circumstances are any of the conditions associated with the Arrangement to interfere with your clinical decision making or in any way affect the confidentiality between the patient and you. You must comply with all of the terms and conditions of this Agreement to participate in the Arrangement and failure to do so may result in termination of this Agreement. HBF Limited Surgical Items List Item numbers on the HBF Limited Surgical Items List (HBF Limited Surgical Items List) (which may be amended from time to time at HBF s absolute discretion) are excluded from the Arrangement, as these services/treatments include a high cosmetic component. Benefits for anaesthetic services associated with item numbers on the HBF Limited Surgical Items List are also excluded from the Medical Gap cover Arrangement. If your services include an MBS item number on the HBF Limited Surgical Items List, you must contact HBF prior to providing the service to ascertain if any MBS benefits are payable. To request the HBF Limited Surgical Items List please contact the Provider Support Team by phone on 9265 6378 or by email to medicalgap@hbf.com.au. Podiatric surgery HBF is unable to pay benefits for anaesthetic services associated with podiatric surgery carried out by a podiatric surgeon as those services are not specified on the MBS Schedule. Accordingly, any anaesthetic services provided in relation to podiatric surgery are not included in the Arrangement. Assessment of benefits HBF applies the Medicare assessment rules to calculate benefits payable. For the avoidance of doubt, if Medicare reduces the benefit payable on a service specified in the MBS Schedule for any reason, then HBF will reduce the benefit payable under the HBF schedule (which may be amended from time to time at HBF s absolute discretion), and consequently the cover under the Arrangement, by the corresponding amount. Account payment HBF will pay Medical Gap benefits for eligible In-Hospital Services (In-Hospital Services) provided to HBF Members by medical practitioners registered as direct billing providers under HBF s simplified billing system (Express Pay). Alternatively, you may submit claims electronically through ECLIPSE. Your account must be fully unpaid and include the following information: Your patient s full name and address; Your patient s HBF member number; Your patient s Medicare number and Medicare card reference number; Your patient s Medicare card expiry date; Details of the service(s), including the date the service(s) was provided, and the corresponding MBS item number(s); The total fees charged for each service provided; Confirmation that the patient has been advised of any financial interests the medical practitioner may have in the particular products or services recommended, or the facility where the service is provided; Confirmation that the patient has been advised of the payment arrangements (including the total fee and the member s actual out of pocket expense) for the services on the account; Confirmation the patient has not received (or established a right to receive) compensation or damages for treatment or services; Referral details, including the date of referral, provider number and full name of the referring medical practitioner; and Any other information relevant to assessment of the claim.

Express Pay claims assessing process: HBF will process the account and forward it to Medicare. HBF will arrange for the combined HBF and Medicare benefit to be paid directly to you by Electronic Funds Transfer within approximately 21 Business Days of receiving the claim. HBF will forward a detailed statement to you for your records. For claims submitted electronically via Eclipse, the Eclipse remittance advise (ERA) will match your Eclipse claim to the deposits made into your bank account allowing for automated reconciliation. Claims submitted more than two years after the date of service must be forwarded to the HBF Member for processing by Medicare Australia. The Medicare statement can then be forwarded to HBF by the member for consideration of payment of a benefit above the required 25% of MBS fee. HBF agrees to accept assignments under subsection 20A(2A) of the Health Insurance Act 1973 of the Medicare benefits payable in respect of the professional In-Hospital Services provided to HBF Members. Full Cover Option If you have elected to participate under the Full Cover Option, you agree, for all In-Hospital Services provided to HBF Members, to charge fees which do not exceed the fee specified in the HBF Full Cover Schedule (HBF Full Cover Schedule) and HBF agrees to pay benefits (combined HBF and Medicare benefit) equal to your fees. HBF will notify you if any fee charged is more than the HBF Full Cover Schedule and you will be required to adjust the fee charged to meet the conditions of being fully covered under the Arrangement. HBF may revoke your registration as an HBF Medical Gap provider and terminate this Agreement with 30 days written notice if HBF determines you have consistently charged fees outside the terms of the Agreement or above the HBF Full Cover Schedule and will require you to refund those excess fees. HBF may terminate the agreement immediately if having previously breached the conditions of this agreement and having been served with formal notice requiring compliance, you again breach the terms of the agreement. Opt In/Opt Out Known Gap Option If you have elected to participate under the Opt In/Opt Out Known Gap Option, you choose on a case by case basis whether you will charge HBF Members fees for In-Hospital Services which do not exceed the fee specified in the HBF Full Cover Schedule (Opt In) or which exceed the fee specified in the HBF Full Cover Schedule (Opt Out). When you charge a total fee for In-Hospital Services up to the HBF Full Cover Schedule, HBF agrees to pay benefits (combined HBF and Medicare benefit) equal to the HBF Known Gap Benefit Schedule for the service. The HBF Member will pay the gap between the total fee charged by you and the total combined Medicare and HBF benefits. When you charge a total fee for In-Hospital Services which exceeds the fee specified in the HBF Full Cover Schedule, HBF will pay a benefit of 25% of the MBS fee and the HBF Member will pay the difference between the MBS fee and your fees. You will make your payment arrangements (including your total fee and any out of pocket expenses) known to the HBF Member before the commencement of the In-hospital service or, where this is not possible, as soon as practicable after the service is provided. HBF may revoke your registration as a Medical Gap provider and terminate this Agreement with 30 days written notice if HBF determines you have consistently charged fees outside the terms of the Agreement and will require you to refund those excess fees. When providing services as an HBF Medical Gap provider, the total fee for the service(s) (which for the avoidance of doubt includes all fees associated with or otherwise relevant to the service(s) such as administration or booking fees) must be included on the account submitted to HBF. You must not raise any other account associated (either directly or indirectly) with the service(s) or require the HBF Member to pay an additional amount to the fee included on the account submitted to HBF. HBF may terminate the agreement immediately if having previously breached the conditions of this agreement and having been served with formal notice requiring compliance, you again breach the terms of the agreement. Information to members In response to enquiries from HBF Members eligible for Medical Gap cover, HBF will advise of the Medical Gap arrangement you operate under and confirm in writing any expected gap payments. HBF provides a list of medical practitioners participating in the Arrangement to HBF members. By signing this Agreement, you consent to your name being published in that list. Conditions of approval Acceptance of you as an HBF Medical Gap provider can be subject to any condition imposed by HBF, for example, compliance with billing procedures and account requirements. You should note that these conditions are in addition to those requirements contained in these terms and conditions or your registration with Medicare. Termination Either HBF or you may terminate this Agreement by providing 90 days written notice. You must continue to charge in accordance with your fee schedule during this 90 day period. If you otherwise breach the terms of this Agreement, are unable to pay your debts as and when they become due or are insolvent, HBF may give you 30 days notice of its intention to terminate this Agreement. In the event this Agreement is terminated, HBF will honour scheduled procedures for HBF Members prior to such termination at the agreed benefit levels, in accordance with this Agreement. You must at all times continue to comply with HBF s requirements for provider registration (as determined from time to time) and these requirements are deemed conditions of your registration as an HBF Medical Gap provider under this Agreement. If you fail to comply with HBF s requirements for provider registration or cease to be registered as a Medicare provider, this Agreement will automatically terminate. For the avoidance of doubt, your registration as a Medical Gap provider will automatically cease upon termination of this Agreement. Continued over

Changes in terms and conditions HBF may vary this Agreement, by giving not less than 90 days written notice. If you do not wish to comply with the Agreement as amended, you may terminate this Agreement in accordance with the termination provisions above. Account/receipt information and presentation of accounts All accounts and receipts presented to HBF for claiming benefits must meet the requirements described in this Agreement (see section entitled Account Payment on previous page). Audit procedures HBF conducts regular reviews on the claiming patterns of all providers as well as groups of providers, and on occasion it is necessary to seek further information from providers in regard to claims. You must comply with any requests made in connection with such reviews. Importantly, you must release information required for the review or processing of a claim in accordance with the authority signed by the HBF Member on the National Private Patient Hospital Claim Form. Failure to comply with audit requests will constitute a breach of the terms and conditions of this Agreement and may result in a decision to terminate this Agreement. Notice Any notice required under this Agreement may be given in writing to the other party by: (a) delivery by hand at the address specified in this Agreement, or such other address as is notified to the other party from time to time, and is taken to be received when signed for by, in the case of you by you or your practice manager, and in the case of HBF, the manager responsible for medical provider relations; (b) writing to the other party by post at the address specified in this Agreement, or such other address as is notified to the other party from time to time, in which case it is taken to be received two Business Days after posting (or seven Business Days after posting if posted to or from a place outside of Australia); (c) sending a fax to the other party at the designated number; for you being the number specified in this Agreement and for HBF being (08) 9265 6282, the number for Medical Gap Queries, which is taken to be received when the sender s facsimile system generates a message confirming successful transmission of the entire notice unless, within eight business hours after the transmission, the recipient informs the sender that it has not received the entire notice; or (d) sending an email to medicalgap@hbf.com.au, which is taken to be received when the sender has received a return email from the recipient acknowledging receipt, unless the content of the notice is contained within an attachment and the recipient s return email has advised that the recipient has been unable to open the attachment. Exclusivity This Agreement is not an exclusive arrangement for either party. Waiver A party does not waive a right, power or remedy if it fails to exercise or delays in exercising the right, power or remedy. A single or partial exercise of a right, power or remedy does not prevent another or further exercise of that or other right, power or remedy. A waiver of a right, power or remedy must be in writing and signed by the party giving the waiver. Entire agreement This Agreement constitutes the entire agreement between the parties regarding its subject matter and supersedes all previous agreements or undertakings between the parties regarding its subject matter. Governing law and jurisdiction This Agreement is governed by the law of Western Australia and each party irrevocably and unconditionally submits to the nonexclusive jurisdiction of the Western Australian courts. Relationship This Agreement does not create a relationship of employment, trust, agency or partnership between the parties. Severability A term or part of a term of this Agreement that is illegal or unenforceable may be severed from this Agreement and the remaining terms or parts of the terms of this Agreement continue in force. Privacy statement HBF Health Limited complies with the Privacy Act 1988 (Cth) (Privacy Act) to ensure that your personal information is protected. Personal information is information or an opinion about an identifiable individual, or an individual who is reasonably identifiable, whether the information or opinion is true or not, or is recorded in a material form or not. It includes your name, age, gender and contact details as well as your sensitive information (which includes health information). HBF s collection of personal information HBF collects and uses your personal information to assess your ability to be and to register as an HBF Medical Gap provider, manage our ongoing relationship with you, administer, process and audit private health insurance claims and pay private health insurance benefits to HBF Members, prevent, detect and follow up fraudulent or invalid claims or misrepresentations. We will generally collect your personal information during a face-to-face interview, over the telephone, through an online form or by way of a paper based form (including application forms). Some personal information is deemed to be sensitive information. We will treat sensitive information with particular care. The information we may collect Usually we will collect details of your name, address, age, telephone number, facsimile number, email address, professional qualifications, registration and practice details and any findings made against you.

How HBF will use and disclose your information HBF may use, and if necessary disclose, your personal information in order to carry out the purposes described in this statement. HBF may disclose your personal (including sensitive) information to persons or organisations such as: your relevant professional association and external consultant to review the claims history of HBF Members; regulatory bodies and government agencies (such as the Department of Health & Ageing, the Private Health Insurance Ombudsman and Medicare Australia and the Australian Health Practitioner Regulation Agency); and other parties to whom we are authorised or required by law to disclose information. HBF is unlikely to transfer your personal (including sensitive) information overseas. We may transfer your personal information overseas where the transmission is directly related to your registration as an HBF Medical Gap provider. In the event HBF transfers your personal (including sensitive) information outside Australia, we will comply with the requirements of the Privacy Act that relate to transborder data flows. We may use your personal information for the purpose of providing you with material, such as articles and information about provider arrangements that may be of interest to you. However, you may request not to receive such information by calling us on (08) 9265 6378, by emailing us at medicalgap@hbf.com.au and we will give effect to that request. Please allow five working days for your request to be actioned. If you do not wish to provide the personal information HBF requires for registration, we will not be able to register you as an HBF Medical Gap provider and HBF Members will not be able to claim benefits for services you provide under the Medical Gap arrangement. Access to your information and contacting us HBF will allow you to access and correct personal information we hold about you as required by law. If you have any queries about how HBF handles your personal information, or would like to request access to that information, please contact us: By mail HBF Privacy Officer, GPO Box C101, Perth WA 6839; or By telephone (08) 9265 6378. If you have any concerns or complaints about the manner in which your personal information has been collected or handled by HBF, please contact the Privacy Officer using the details above. The Privacy Policy contains further information about how HBF generally handles your personal information including: how you can access and correct personal information we hold about you; and how you can submit a privacy complaint to HBF and how HBF will deal with your complaint. HBF Health Limited ABN 11 126 884 786 Telephone 133 423 Postal address GPO Box S1440 Perth WA 6845 Online hbf.com.au HI-237 18/12/17