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.
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.
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. In exceptional circumstances, we may choose (in our absolute discretion) to waive the requirement to meet certain eligibility criteria.
General policy exclusions are listed in the policy document for each of our plans.
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. Policy variations are 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.
Cardiac services (heart disorder diagnosis & treatment)
Gastroenterology (digestive tract examination)
General surgery (breast, gall bladder, hernia)
Gynaecology (reproductive system)
Imaging (scans)
Internal medicine
Interventional radiology
Neurosurgery
Oncology (cancer diagnosis & treatment)
Ophthalmology (eyes)
Oral & maxillofacial
Orthopaedic
Other
Otolaryngology (ear, nose & throat)
Skin
Urology (kidney, bladder, and prostate)
Vascular surgery (artery & vein surgery)
Southern Cross Medical Care Society (trading as Southern Cross Health Society) is a licensed insurer and a licensed financial advice provider. For more information about the financial advice service we provide and a copy of our public disclosure statement please visit southerncross.co.nz/disclosure-statement.
Southern Cross Medical Care Society (trading as Southern Cross Health Society) has an A+ (Strong) financial strength rating given by Standard & Poor’s (Australia) Pty Limited. The rating scale is: AAA (Extremely Strong), AA (Very Strong), A (Strong), BBB (Good), BB (Marginal), B (Weak), CCC (Very Weak), CC (Extremely Weak), SD or D (Selective Default or Default). Ratings from ‘AA’ to ‘CCC’ may be modified by the addition of a plus (+) or minus (-) sign to show relative standing within the major rating categories. Full details of the rating scale are available at www.spglobal.com/ratings/en/about/intro-to-credit-ratings. Standard & Poor’s is an approved rating agency under the Insurance (Prudential Supervision) Act 2010.
