GENERAL HEALTH INSURANCE

Make a claim


NRMA Health Insurance is here to help you protect your most valuable asset – your health. One of the ways the Fund does this is by making it simple and convenient for you to claim your health benefits. You can choose the most convenient way to submit your claims: by mail or with a swipe of your NRMA Health Insurance card at any provider with a HICAPS or IBA facility.

How to make a claim

The claims process is simple and straightforward. It varies slightly depending on which of the following services you are claiming for:

Hospital Cover claims

  1. Before you go into hospital, or a day facility, ask your doctor for the anticipated Medicare item number/s for your treatment
  2. Call 133 234 to confirm that your treatment is covered and that the hospital or day facility that you have chosen has an agreement with the Fund, so that you don’t run up unnecessary expenses
  3. Check the Fund’s list of current Agreement Hospitals to see if your chosen hospital is listed

How to pay?

  1. The Fund pays the hospital directly
    If your hospital has an agreement with the Fund, the hospital will send the bill to the Fund at the end of your stay. Your account will then be paid and you will be advised of the details. If there are any charges payable by you, such as long distance phone calls and newspapers, the hospital will bill you separately
  2. You pay the hospital any excess or co-payment
    If you have chosen a Hospital Cover with an excess or co-payment, the hospital may ask you to pay either of these upfront or they may bill you after they have received the balance of the payment from the Fund

What you need to know

  • There will be no benefit paid for excluded services so you are responsible for paying for those
  • Generally, health funds do not cover out-patient treatment – which is medical treatment given where you aren’t formally admitted into hospital. This includes things like emergency room treatment and consultations with a specialist before a labour admission
  • You must hold Hospital Cover for a certain length of time (the ‘waiting period’) before you can make a claim. You can however, claim immediately for accidents where the treatment or service is covered by your level of cover
  • You should also check the policy booklet for what’s not covered

Gap Cover Claims

What is Gap Cover? The Federal Government sets a fee that they will pay for doctor’s services under the Medical Benefits Schedule. Medicare pays for 75% of that set fee on your behalf, and the Fund pays the remaining 25%. If a doctor charges above that set fee, the extra amount (known as the ‘medical gap’) is not covered by Medicare but it is covered in full or in part by the Fund if the doctor participates in the Fund’s Gap Cover Scheme.

Gap Cover Scheme, you will either:

  1. Have no gap
  2. Or you will know up front what you have to pay
Gap Cover claims process
You don’t pay the gap cover directly yourself. There are two claims methods available:
  1. Your doctor can send the claim directly to the Fund
  2. If the account is sent to you, write ‘Gap cover’ on it, together with your Medicare number and forward it to:

    NRMA Health Insurance Claims
    GPO Box 5295
    Brisbane QLD 4001

What you need to know

  • Doctors operate independently from hospitals, so ask your doctor prior to your admission about their fees for your hospital treatment and whether they will participate in the Fund’s Gap Cover Scheme
  • Don’t forget to ask about the fees of other practitioners that may be involved in your hospital treatment, eg anaesthetist, pathologist and so on
  • If there are any gaps for you to pay, ask for a written cost estimate. This is known as ‘informed financial consent’
  • Check the Fund’s list to see if your hospital is included in the Fund’s Gap Cover Scheme

Extras Cover Claims

For day-to-day extra health services, such as dental, optical and others, there are three ways to claim:
  1. The Fund pays the service provider
    A cheque is made out to your service provider. You need to pay any outstanding balance
  2. Easy Claim
    When you have paid a bill in full, your Extras benefit can be paid directly into your nominated bank account, in which case you will receive a letter confirming the payment details. You have immediate access to the funds
  3. HICAPS or IBA ‘on the spot’ payment
    These electronic claim payment systems are very convenient, quick and easy and are available at participating dentists, opticians, physios, chiropractors and podiatrists. Just look for the HICAPS or IBA logos. You swipe your NRMA Health Insurance card and your benefit will be deducted from your bill. You just pay the balance

What you need to know

  • Easy Claim
    If you want the convenience of Easy Claim but haven’t filled in the Easy Claim authority section on the application form, call 133 234 and request a Change of Details form. Fill in Part F on the form and post it to:


    NRMA Health Insurance Claims
    GPO Box 5295
    Brisbane QLD 4001

  • Waiting periods
    You must hold Extras Cover for a certain length of time before you can make a claim. The time is called the ‘waiting period’ and different services have different waiting periods
  • Limits
    The limit is the maximum amount you can claim in a service category per person and per calendar year. Limits also apply to the number of times benefits are payable for the same service and per calendar year unless otherwise stated