How to read a private health fund fee schedule
A fund schedule is useful only when the correct version is matched to the service, provider and scheme.
1. Check the effective date
Use the schedule that applies to the patient’s date of service. Funds can replace schedules during the year, so an older spreadsheet or PDF may no longer apply.
2. Confirm the scheme
Identify whether the claim is being considered under GapCover, MediGap, Medicover, Access Gap Cover, a medical gap scheme or another arrangement. The scheme rate can differ from the standard MBS fee.
3. Confirm state or provider-number location
Some arrangements, especially Access Gap Cover schedules, are state based. Check the location associated with the provider number rather than assuming the patient’s home address determines the schedule.
4. Search the MBS item number
Locate the exact MBS item and read any notes, restrictions or modifiers that accompany it. Do not rely on a similar item number.
5. Check participation and patient eligibility
A published amount does not itself guarantee payment. Provider participation, patient cover, hospital episode details and claim rules can affect the benefit.