Practitioner Obligations. (a) The Practitioner must: (i) inform a HBF Member of any financial interests in a hospital or, if provided, any financial or other incentive to general practitioners or other specialists for the HBF Member’s referral; and (ii) ensure that no gap prosthesis are offered as an option to HBF Members, where the Practitioner proposes the use of a prosthesis during a Service. (b) The Practitioner must comply with Medicare rules and guidelines, including: (i) ensuring each Service provided by the Practitioner during or directly related to an Episode has an MBS item number and that this is properly assigned; and (ii) the Medicare Multiple Operation Rule. (c) The Practitioner must ensure that: (i) unless permitted by Medicare, the provider number of the Practitioner is not used by any other person to perform professional services or to submit an account to HBF; (ii) all clinical records and documentation are completed by the Practitioner, including discharge summaries and any General Practitioner correspondence, within 48 hours of a HBF Member’s discharge from Hospital; and (iii) where a Type C Procedure is undertaken, the Practitioner complies with the requirements of the Private Health Insurance (Benefit Requirements) Rules in filling out a Type C certificate. The Practitioner acknowledges the documentation referenced in this clause 8(c)(ii) and (iii) is used by Hospitals for coding and billing purposes and needs to be completed promptly, correctly and prior to submission of a claim to HBF. (d) The Practitioner cannot: (i) charge fees for any in hospital services, such as nursing, consumables or a prosthesis; (ii) raise any other account associated with the Service or require the Eligible Member to pay any gap payment, additional amount, or charge any administration, management, travel or booking fees; (iii) charge for any Service that has not been provided by the Practitioner themselves; or (iv) charge for a Service where there is no MBS item number.
Appears in 4 contracts
Samples: Medical Gap Agreement, Medical Gap Agreement, Medical Gap Agreement
Practitioner Obligations. Each Practitioner must comply with the following for Direct Billing:
(a) The be registered as a Practitioner must:
(i) inform a HBF Member on AHPRA’s register of any financial interests in a hospital or, if provided, any financial or other incentive to general practitioners or other specialists for the HBF Member’s referral; and
(ii) ensure that no gap prosthesis are offered as an option to HBF Members, where the Practitioner proposes the use of a prosthesis during a Service.practitioners;
(b) The Practitioner must hold a Medicare provider number for each location in which they practice;
(c) be eligible for receipt of MBS benefits;
(d) comply with Medicare rules and guidelines, including:
(i) ensuring each Service provided by the Practitioner during or directly related to an Episode has an MBS item number and that this is properly assigned; and
(i) (ii) the Medicare Multiple Operation Rule.
(ce) The Practitioner must ensure that:
(i) unless permitted by Medicare, the provider number of the Practitioner is not used by any other person to perform professional services or to submit an account to HBF;Direct Bill HBF;
(ii) all clinical records and documentation are completed by the Practitioner, including discharge summaries and any General Practitioner correspondencesummaries, within 48 hours of a HBF an Eligible Member’s discharge from Hospital; and
(iii) where a Type C Procedure is undertaken, the Practitioner complies with the requirements of the Private Health Insurance (Benefit Requirements) Rules in filling out a Type C certificate. The Practitioner acknowledges the documentation referenced in this clause 8(c)(ii2(e)(ii) and (iii2(e)(iii) is used by Hospitals for coding and billing purposes and needs to be completed promptly, correctly and prior to submission of a claim to Direct Billing HBF.
(df) The Practitioner canmust:
(i) where a Gap is payable by the Eligible Member obtain Informed Financial Consent from the Eligible Member;
(ii) maintain appropriate copies of medical records, account and other records that relate to the provision of Services by the Practitioner to Eligible Members;
(iii) subject to clause 4(d)(i)and 4(d)(ii), comply with any reasonable request by HBF for an audit of a Practitioners records in relation to Eligible Members, including assisting HBF by:
(A) providing further information in regard to claims;
(B) providing evidence of Informed Financial Consent; and
(C) releasing information required for the review or processing of a claim in accordance with the authority signed by the Eligible Member on the National Private Patient Hospital Claim Form.
(g) The Practitioner must not and must ensure that its practice manager, staff and other associated personnel do not:
(i) charge fees for enter into any in hospital servicesconduct or activities that might reasonably be regarded as harming HBF, such as nursing, consumables its name or a prosthesisreputation with patients;
(ii) raise become involved in any other account associated with the Service situation which will bring HBF into disrepute, contempt, scandal or require the Eligible Member to pay any gap payment, additional amount, or charge any administration, management, travel or booking fees;ridicule; or
(iii) charge for any Service that has not been provided by the Practitioner themselves; orincite, recommend or encourage patients to change health insurance funds.
(ivh) charge The Practitioner must promptly notify HBF of any change in the billing address and any update to their bank account details relevant for a Service where there is no MBS item numberthe payment of Direct Billing claims.
(i) The terms and conditions of this Agreement must not interfere with the Practitioner’s clinical decision making.
Appears in 1 contract
Samples: Direct Billing Agreement
Practitioner Obligations. (a) The Practitioner must:
(i) inform a HBF Member of any financial interests in a hospital or, if provided, any financial or other incentive to general practitioners or other specialists for the HBF Member’s referral; and
(ii) ensure that no gap prosthesis are offered as an option to HBF Members, where the Practitioner proposes the use of a prosthesis during a Service.
(b) The Practitioner must comply with Medicare rules and guidelines, including:
(i) ensuring each Service provided by the Practitioner during or directly related to an Episode has an MBS item number and that this is properly assigned; and
(ii) the Medicare Multiple Operation Rule.
(c) The Practitioner must ensure that:
(i) unless permitted by Medicare, the provider number of the Practitioner is not used by any other person to perform professional services or to submit an account to HBF;
(ii) all clinical records and documentation are completed by the Practitioner, including discharge summaries and any General Practitioner correspondence, within 48 hours of a HBF Member’s discharge from Hospital; and
(iii) where a Type C Procedure is undertaken, the Practitioner complies with the requirements of the Private Health Insurance (Benefit Requirements) Rules in filling out a Type C certificate. The Practitioner acknowledges the documentation referenced in this clause 8(c)(ii) and (iii) is used by Hospitals for coding and billing purposes and needs to be completed promptly, correctly and prior to submission of a claim to HBF.
(d) The Practitioner cannot:
(i) charge fees for any in hospital services, such as nursing, consumables or a prosthesis;
(ii) raise any other account associated with the Service or require the Eligible Member to pay any gap payment, additional amount, or charge any administration, management, travel or booking fees;
(iii) charge for any Service that has not been provided by the Practitioner themselves; or
(iv) charge for a Service where there is no MBS item number.
(e) Where the Practitioner is subject to a Gap Choice Election to participate as:
(i) A Full Cover provider the fees charged to HBF Members for Services during an Episode must not exceed those set out in the Full Cover Schedule;
(ii) A Known Gap provider on an Opt-in basis for an Episode, the fees charged to HBF Members for Services during that Episode must not exceed those set out in the Full Cover Schedule. HBF will notify the Practitioner in the event that any fee charged is more than that set out in this clause 8(e). The Practitioner must then promptly adjust the fee charged to ensure compliance with this clause 8(e).
(f) The Practitioner must ensure that prior to the delivery of any Service the HBF Member is provided with:
(i) details of the fees to be charged under this Agreement;
(ii) an estimate of the costs for any Services payable by the HBF member due to the operation of clause 6.2 or clause 7; and
(iii) any other information about costs the HBF Member is likely to incur which is available to the Practitioner and necessary to enable the HBF Member to make a fully informed decision about whether or not to proceed with the Services.
(g) The Practitioner must not and must ensure that its practice manager, staff and other associated personnel do not:
(i) enter into any conduct or activities that might reasonably be regarded as harming HBF, its name or reputation with patients;
(ii) become involved in any situation which will bring HBF into disrepute, contempt, scandal or ridicule; or
(iii) incite, recommend or encourage patients to change health insurance funds.
(h) The Practitioner must promptly notify HBF in the event that disciplinary action is commenced against the Practitioner by XXXXX, Medicare or any other industry body.
(i) The Practitioner must promptly notify HBF of any change in the correspondence or billing address, locations at which the Practitioner practices and any update to their bank account details relevant for the payment of benefits.
(j) The terms and conditions of this Agreement must not interfere with the Practitioner’s clinical decision making.
(k) A Practitioner may vary their Gap Choice Election by giving HBF at least 90 days notice of the change to their Gap Choice Election (Election Change Notice Period).
(l) During any Election Change Notice Period, the Practitioner must comply with all terms relating to the Gap Choice Election in force at the start of the Election Change Notice Period.
Appears in 1 contract
Samples: Medical Gap Agreement
Practitioner Obligations. Each Practitioner must comply with the following for Direct Billing:
(a) The be registered as a Practitioner must:
(i) inform a HBF Member on AHPRA’s register of any financial interests in a hospital or, if provided, any financial or other incentive to general practitioners or other specialists for the HBF Member’s referral; and
(ii) ensure that no gap prosthesis are offered as an option to HBF Members, where the Practitioner proposes the use of a prosthesis during a Service.practitioners;
(b) The Practitioner must hold a Medicare provider number for each location in which they practice;
(c) be eligible for receipt of MBS benefits;
(d) comply with Medicare rules and guidelines, including:
(i) ensuring each Service provided by the Practitioner during or directly related to an Episode has an MBS item number and that this is properly assigned; and
(i) (ii) the Medicare Multiple Operation Rule.
(ce) The Practitioner must ensure that:
(i) unless permitted by Medicare, the provider number of the Practitioner is not used by any other person to perform professional services or to submit an account to Direct Bill HBF;
(ii) all clinical records and documentation are completed by the Practitioner, including discharge summaries and any General Practitioner correspondencesummaries, within 48 hours of a HBF an Eligible Member’s discharge from Hospital; and
(iii) where a Type C Procedure is undertaken, the Practitioner complies with the requirements of the Private Health Insurance (Benefit Requirements) Rules in filling out a Type C certificate. The Practitioner acknowledges the documentation referenced in this clause 8(c)(ii2(e)(ii) and (iii2(e)(iii) is used by Hospitals for coding and billing purposes and needs to be completed promptly, correctly and prior to submission of a claim to Direct Billing HBF.
(df) The Practitioner canmust:
(i) where a Gap is payable by the Eligible Member obtain Informed Financial Consent from the Eligible Member;
(ii) maintain appropriate copies of medical records, account and other records that relate to the provision of Services by the Practitioner to Eligible Members;
(iii) subject to clause 4(d)(i)and 4(d)(ii), comply with any reasonable request by HBF for an audit of a Practitioners records in relation to Eligible Members, including assisting HBF by:
(A) providing further information in regard to claims;
(B) providing evidence of Informed Financial Consent; and
(C) releasing information required for the review or processing of a claim in accordance with the authority signed by the Eligible Member on the National Private Patient Hospital Claim Form.
(g) The Practitioner must not and must ensure that its practice manager, staff and other associated personnel do not:
(i) charge fees for enter into any in hospital servicesconduct or activities that might reasonably be regarded as harming HBF, such as nursing, consumables its name or a prosthesisreputation with patients;
(ii) raise become involved in any other account associated with the Service situation which will bring HBF into disrepute, contempt, scandal or require the Eligible Member to pay any gap payment, additional amount, or charge any administration, management, travel or booking fees;ridicule; or
(iii) charge for any Service that has not been provided by the Practitioner themselves; orincite, recommend or encourage patients to change health insurance funds.
(ivh) charge The Practitioner must promptly notify HBF of any change in the billing address and any update to their bank account details relevant for a Service where there is no MBS item numberthe payment of Direct Billing claims.
(i) The terms and conditions of this Agreement must not interfere with the Practitioner’s clinical decision making.
Appears in 1 contract
Samples: Direct Billing Agreement
Practitioner Obligations. Each Practitioner must comply with the following for Direct Billing:
(a) The be registered as a Practitioner must:
(i) inform a HBF Member on AHPRA’s register of any financial interests in a hospital or, if provided, any financial or other incentive to general practitioners or other specialists for the HBF Member’s referral; and
(ii) ensure that no gap prosthesis are offered as an option to HBF Members, where the Practitioner proposes the use of a prosthesis during a Service.practitioners;
(b) The Practitioner must hold a Medicare provider number for each location in which they practice;
(c) be eligible for receipt of MBS benefits;
(d) comply with Medicare rules and guidelines, including:
(i) ensuring each Service provided by the Practitioner during or directly related to an Episode has an MBS item number and that this is properly assigned; and
(ii) the Medicare Multiple Operation Rule.
(ce) The Practitioner must ensure that:
(i) unless permitted by Medicare, the provider number of the Practitioner is not used by any other person to perform professional services or to submit an account to Direct Bill HBF;
(ii) all clinical records and documentation are completed by the Practitioner, including discharge summaries and any General Practitioner correspondencesummaries, within 48 hours of a HBF an Eligible Member’s discharge from Hospital; and
(iii) where a Type C Procedure is undertaken, the Practitioner complies with the requirements of the Private Health Insurance (Benefit Requirements) Rules in filling out a Type C certificate. The Practitioner acknowledges the documentation referenced in this clause 8(c)(ii2(e)(ii) and (iii2(e)(iii) is used by Hospitals for coding and billing purposes and needs to be completed promptly, correctly and prior to submission of a claim to Direct Billing HBF.
(df) The Practitioner canmust:
(i) where a gap is payable by the Eligible Member obtain Informed Financial Consent from the Eligible Member;
(ii) maintain appropriate copies of medical records, account and other records that relate to the provision of Services by the Practitioner to Eligible Members;
(iii) subject to clause 4(d)(i) and 4(d)(ii), comply with any reasonable request by HBF for an audit of a Practitioners records in relation to Eligible Members, including assisting HBF by:
(A) providing further information in regard to claims;
(B) providing evidence of Informed Financial Consent; and
(C) releasing information required for the review or processing of a claim in accordance with the authority signed by the Eligible Member on the National Private Patient Hospital Claim Form.
(g) The Practitioner must not and must ensure that its practice manager, staff and other associated personnel do not:
(i) charge fees for enter into any in hospital servicesconduct or activities that might reasonably be regarded as harming HBF, such as nursing, consumables its name or a prosthesisreputation with patients;
(ii) raise become involved in any other account associated with the Service situation which will bring HBF into disrepute, contempt, scandal or require the Eligible Member to pay any gap payment, additional amount, or charge any administration, management, travel or booking fees;ridicule; or
(iii) charge for any Service that has not been provided by the Practitioner themselves; orincite, recommend or encourage patients to change health insurance funds.
(ivh) charge The Practitioner must promptly notify HBF of any change in the billing address and any update to their bank account details relevant for a Service where there is no MBS item numberthe payment of Direct Billing claims.
(i) The terms and conditions of this Agreement must not interfere with the Practitioner’s clinical decision making.
Appears in 1 contract
Samples: Direct Billing Agreement
Practitioner Obligations. (a) The Practitioner must:
(i) inform a HBF Member of any financial interests in a hospital or, if provided, any financial or other incentive to general practitioners or other specialists for the HBF Member’s referral; and
(ii) ensure that no gap prosthesis are offered as an option to HBF Members, where the Practitioner proposes the use of a prosthesis during a Service.
(b) The Practitioner must comply with Medicare rules and guidelines, including:
(i) ensuring each Service provided by the Practitioner during or directly related to an Episode has an MBS item number and that this is properly assigned; and
(ii) the Medicare Multiple Operation Rule.
(c) The Practitioner must ensure that:
(i) unless permitted by Medicare, the provider number of the Practitioner is not used by any other person to perform professional services or to submit an account to HBF;
(ii) all clinical records and documentation are completed by the Practitioner, including discharge summaries and any General Practitioner correspondencesummaries, within 48 hours of a HBF Member’s discharge from Hospital; and
(iii) where a Type C Procedure is undertaken, the Practitioner complies with the requirements of the Private Health Insurance (Benefit Requirements) Rules in filling out a Type C certificate. The Practitioner acknowledges the documentation referenced in this clause 8(c)(ii) and (iii) is used by Hospitals for coding and billing purposes and needs to be completed promptly, correctly and prior to submission of a claim to HBF.
(d) The Practitioner cannot:
(i) charge fees for any in hospital services, such as nursing, consumables or a prosthesis;
(ii) raise any other account associated with the Service or require the Eligible Member to pay any gap payment, additional amount, or charge any administration, management, travel or booking fees;
(iii) charge for any Service that has not been provided by the Practitioner themselves; or
(iv) charge for a Service where there is no MBS item number.
(e) The Practitioner must ensure that
(i) the fees charged to HBF Member’s for Services during an Episode do not exceed those set out in the Full Cover Schedule; or
(ii) in the case of a Specialist Anaesthetist, the fees charged to HBF Member’s do not exceed the fees specified in the Specialist Anaesthetist Schedule. HBF will notify the Practitioner in the event that any fee charged is more than that set out in this clause 8(e). The Practitioner must then promptly adjust the fee charged to ensure compliance with this clause 8(e).
(f) The Practitioner must ensure that HBF Members are treated as favourably as patients of other health funds.
(g) The Practitioner must not and must ensure that its practice manager, staff and other associated personnel do not:
(i) enter into any conduct or activities that might reasonably be regarded as harming HBF, its name or reputation with patients;
(ii) become involved in any situation which will bring HBF into disrepute, contempt, scandal or ridicule; or
(iii) incite, recommend or encourage patients to change health insurance funds.
(h) The Practitioner must promptly notify HBF in the event that disciplinary action is commenced against the Practitioner by AHPRA, Medicare or any other industry body.
(i) The Practitioner must promptly notify HBF of any change in the correspondence or billing address, locations at which the Practitioner practices and any update to their bank account details relevant for the payment of benefits.
(j) The terms and conditions of this Agreement must not interfere with the Practitioner’s clinical decision making.
Appears in 1 contract
Samples: Medical Gap Agreement
