Medical Practitioners | Bupa Medical Gap Scheme (2024)

Bupa Medical Gap Scheme

What is the Bupa Medical Gap Scheme?

The Bupa Medical Gap Scheme ("Scheme") is designed to provide greater transparency and certainty for customers with regards to any out of pocket costs they may experience when seeking in-patient medical treatment. Importantly, when the Scheme is used:

1. Bupa will pay a higher benefit directly to the specialist than would normally be payable under the Medicare Benefits Schedule ("MBS"); and
2. It will streamline the claims submission and payment process for specialists, patients and Bupa.

Can I register for both 'No gap' and 'Known Gap'?

No. Specialists must register to be EITHER "No Gap" specialist or a "Known Gap" specialist for each unique practice location. You can differentiate which Scheme you use at different practice locations, but you cannot register for both Schemes at the same practice location. Should you wish to switch between these Schemes, you must submit a Change of Details Form. Please allow up to 30 days for your Scheme status to be updated. Please also ensure you include your Bupa Practice Identification (ID) number on the Change of Details form, as this will assist us to identify your practice.

If a specialist registers for "No Gap":

• They will be promoted as a "No Gap" specialist
• A higher 'No Gap' benefit is payable
• They agree to accept the "No Gap" benefit as full payment for the episode of care, meaning that the customer will pay $0 to the specialist for that treatment
• They can opt out of the Scheme on a case-by-case basis

If a specialist registers for "Known Gap":

• They will be promoted as a "Known Gap" specialist
• They will receive the "Known Gap" benefit
• They can charge the patient a gap of up to $500 per episode of care
• They can opt out of the Scheme on a case-by-case basis

Why is the maximum Known Gap I can charge limited to $500?

Specialists that participate in the Bupa Known Gap Scheme, can charge a Known Gap of up to $500 per doctor for each episode of treatment. The customer will never pay more than $500 under the Known Gap Scheme to a specialist.

Our customers tell us out-of-pocket costs are confusing so we've capped this amount to help provide certainty to Bupa customers that they will not be out-of-pocket more than $500 per specialist if they use a Bupa Known Gap Scheme specialist.

Of course, where appropriate, we apply indexation to the rates paid to providers but believe providing continued certainty for customers is important and as such, have maintained the Known Gap amount to a maximum of $500.

Where can the Scheme be used?

If a specialist does choose to participate in the Scheme, they must register each of their unique practice location with Bupa as either a "No Gap" specialist or, a "Known Gap" specialist. The specialist can choose to use the Scheme for inpatient admissions, as a private patient in a public hospital or, in a private hospital, which has an agreement with Bupa.

Private Hospitals

Bupa will apply Scheme benefits to registered Scheme specialists, where the Bupa customer has been admitted to a licensed Hospital or Day Hospital with which Bupa has a Members First, Network or Fixed Fee agreement.

For services provided in facilities that do not have an agreement with Bupa, benefits up to 100% of the MBS Schedule Fee (MBS) will be payable by Bupa and Medicare.

Public Hospitals

The Public Hospital Medical Gap Scheme will apply. Rates and Terms for the Scheme will be equivalent to the current Scheme for Private Hospitals. Participating specialists may apply the Scheme in the following manner:

• Provide a No Gap option for emergency or unplanned admissions (Known Gap will not be available for these types of admissions); and
• Provide either a No Gap or Known Gap option for planned or pre-booked admission.

For the purpose of the Public Hospital Gap Scheme, we consider a pre-booked admission to be where the Hospital performs an electronic eligibility check to Bupa at least 2 days prior to the admission.

For claims submitted under the Known Gap, where an online Eligibility check is not received, benefits will be limited to 100% of the MBS Schedule Fee.

How does the Scheme work?

Specialists have the option to register with Bupa as either a No Gap or Known Gap specialist:

• No Gap specialists accept the higher Scheme benefit as full payment for the entire episode of care, with no additional out of pocket costs (gap) to be charged to the patient.
• Known Gap specialists accept the Scheme benefit in full but can elect to charge the patient a maximum out of pocket cost of no more than $500 for each episode of treatment.

Using the Scheme

Only claims submitted directly to Bupa under the Terms by the specialist are eligible for the Scheme rates. View the latest Terms and Conditions.

Why should I join the Bupa Medical Gap Scheme?

You will receive payments quicker and as one payment. This will reduce the paperwork for you, your practice and your patients.

Benefits of the Bupa Medical Gap Scheme

How will my status as a participating Scheme specialist be promoted?

To assist Bupa customers and referring specialists to be able to identify specialists who are registered under the Scheme, Bupa may promote details of your practice including contact details, information about your participation in the Scheme, and the location(s) at which you practice.

This information may appear in any Bupa approved media or materials, including on any Bupa website or Mobile App, via call centres and retail centres or affiliated partner websites.

Bupa may also advise customers to ask you about the Scheme and any Known Gaps when they contact you.

How to join the Medical Gap Scheme

1. Complete in full the Medical Gap Scheme Registration Form.
2. Return the fully completed and signed Registration form, including all supporting documentation to provopsmedical@bupa.com.au. Failure to provide all requested information on the Registration form, including supporting documentation will result in the Registration Form being returned to the Practice.
3. Once the Registration form has been completed by Bupa, a confirmation email will be sent to the practice advising of your new Bupa Practice Identification (ID) number. This is to ensure Bupa benefits are paid into the correct bank account and, helps us to identify your practice correctly.

It is important that you include your Bupa Practice ID number in all correspondence submitted to Bupa, as this will assist us to identify your practice.

How to claim

Bupa encourages the use of ECLIPSE, as it provides a secure method for the submission of claims for in-patient medical services. Claims submitted via ECLIPSE are automatically processed through both Medicare and Bupa contributing to a speedier payment cycle.

If you are submitting claims under the Terms of the Scheme via ECLIPSE, please submit the claims using claim type AG for Agreement Claims. Bupa does not currently accept claim type SC for Scheme Claims.

If you elect to not bill a claim under the Terms of the Scheme and still wish to submit the claim via ECLIPSE, the claim can be submitted to Bupa using claim type PC for Patient Claims. In this case, benefits will be paid up to 100% of the MBS Schedule Fee.

Other key important elements of ECLIPSE claiming include:

• Fund BRAND ID: please ensure all claims are submitted using the correct Bupa FUND BRAND ID BUP.
• Fund Payee ID: this is your Bupa Practice ID number. It is important you include your Bupa Practice ID number in the Fund Payee ID, as this will ensure all payments are directed to the correct nominated bank account;

If you would like to register for ECLIPSE or want to know more about electronic claiming or software vendors, please contact the Australia Medicare eBusiness Service Centre on 1800 700 199 alternatively, you can email ebusiness@humanservices.gov.au or eclipse@bupa.com.au.

Submitting claims manually?

Whilst we recommend the use of ECLIPSE, we realise on occasion there will be instances where Scheme specialists may need to submit a claim manually.

On these occasions, you MUST attach a current Batch Header Form and include:

• Your Bupa Practice ID number and Practice name
• Full details relating to the patient, including Medicare card number and patient suffix
• Bupa membership number
• Full details of the service provided including the total fees charged (inclusive of any gaps)
• Facility ID/Hospital Provider Number, including name and number (ID) and the referring Provider's details.
• The Bupa Batch Header must be signed and legible
• Please accompany with a Doctor Account Form if you do not have your own invoice.
• All manual claims can be submitted to Bupa either by post or e-mail:
  Bupa
  Medical Claims
  GPO Box 9809
  BRISBANE QLD 4001
  Email: gapscheme@bupa.com.au

If you are submitting claims for Pathology services which are subject to the Rule 3 exemption, you must include the time of service in order for Bupa to submit your claims to Medicare.

Your accompanying invoices must be legible and preferably not handwritten.

Failure to provide the required information or should the Batch Header and/or invoices not be legible, will mean your claim is rejected, requiring it to be re-submitted.

Claims enquiries

There can be many reasons why a payment has not been made. When a claim is rejected it can relate to either a Medicare and/or Bupa assessment. Any rejected claims will be listed in your Medical Gap Scheme reports with a rejection code.
If you wish to enquire about a claim, please call the Bupa Medical Claims Provider Support on 134 135, and choose the provider option 3.

When are benefits not payable?

All claims submitted to Bupa are subject to the normal Medicare Australia rulings. If there are restrictions for the medical items, some benefits are not payable.

Please also refer to the Scheme Terms and Conditions for further information including patient eligibility and payment of benefits.

Bupa and Medicare rejection codes are subject to change. If you are still unsure why a claim has been rejected please call the Bupa Medical Claims Provider Support team on 134 135. and choose the provider option 3.

Checking a patient's eligibility?

Specialists can check a patient's eligibility electronically via ECLIPSE or by calling 134 135 and choosing the provider option 3.

Benefit Statements Online

Use Bupa's secure provider website for quick and easy access to your weekly medical benefit Statements. If you haven't already registered, simply complete the online Bupa Partner Portal Access Form.

For further information, please contact the Healthcare Management (HCM) Operations team on 1800 060 239.

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