Part Part 11 - Financial Sector (Collection of Data) (reporting standard) determination No. 1 of 2024 - Total Hospital Treatment Medical Services Statistics | Zoe
Financial Sector (Collection of Data) (reporting standard) determination No. 1 of 2024
Part 11Total Hospital Treatment Medical Services Statistics
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Part 11 Total Hospital Treatment Medical Services Statistics
Agreement
Means an agreement entered into between a medical practitioner, within the meaning of that term in subsection 3 (1) of the Health Insurance Act 1973, and an insurer under which the practitioner agrees to accept payment by the insurer in satisfaction of the amount that would, apart from the agreement, be owed to the practitioner in relation to the treatment provided to the insured person.
No Gap Agreement
Means an agreement where the medical practitioner agrees to accept a payment by the insurer in full satisfaction of the amount owed so that there no gap, or no out of pocket expenses to be paid by the insured person.
Known Gap Agreement
Means an agreement where the medical practitioner agrees to accept a payment by the insurer in part satisfaction of the amount owed and the patient has provided informed financial consent so that the gap or out of pocket expenses to be paid by the insured person are known in advance.
No Agreement
Is where there is no agreement in place.
Amount charged
Is the amount accepted in full payment (if known), or the invoice amount. For analytical purposes the amount charged and related data are collected in ranges with reference to the MBS where the amount charged is:> MBS to 125% MBS Fee.>125% to 150% MBS Fee.>150% to 200% MBS Fee.>200% MBS Fee.
Medicare benefit
Is the amount calculated by reference to the fees for medical services set out in the table of schedule fees.Schedule fee, in relation to a professional medical service, means the fee specified in the table in respect of the service.A Medicare benefit in respect of a professional service is:(a) in the case of a service provided:(i) as part of an episode of hospital treatment; or(ii) as part of an episode of hospital-substitute treatment in respect of which the person to whom the treatment is provided chooses to receive a benefit from a private health insurer; an amount equal to 75% of the Schedule fee.
Fund Benefit
Is the amount the fund pays in full or part satisfaction of the amount owed to the provider in excess of the Medicare benefit.
Gap
Is the amount paid by the insured person, or their out of pocket expense, and is calculated as:
No of services
Is the number of medical services for the category.
% of services
Is the number of medical services for the category as a percent of the total number of medical services over all categories.
Amount charged % of MBS
Is the total amount charged in the category divided by the Medicare benefit schedule (MBS) fee. This is calculated as:Note: that the Medicare benefit is 75% of the schedule fee.
Days - Hospital-substitute Treatment.............27
dependent child........................20
Diabetes Educators......................35
Dietitians...........................35
Discontinued.........................25
—E—
Eligible Benefits........................31
End of quarter.........................25
Episode/s...........................26
Excess & Co-payments....................22
Excess/Co-Payments.....................31
Exclusionary Policies.....................23
Exercise Physiologists.....................35
—F—
family.............................22
Fees Charged.........................31
Fees excluding Medicare benefit...............30
Full Cover...........................31
Fund Benefit..........................41
—G—
Gap..............................41
General Treatment.....................26, 36
Accidental Death/Funeral Expenses.37
Acupuncture/Acupressure.........37
Ambulance.....................37
Chiropractic....................37
Community, Home, District Nursing.37
Dental.........................37
Dietetics.......................37
Domestic Assistance.............37
Ex gratia Payments..............37
Hearing Aids and Audiology.......37
Hypnotherapy...................37
Maternity Services...............37
Natural Therapies................38
Occupational Therapy............38
Optical........................38
Orthoptics (Eye Therapy).........38
Osteopathic Services.............38
Overseas.......................38
Pharmacy......................38
Physiotherapy...................38
Podiatry (Chiropody).............38
Preventative health products/Health management programs 37
Medical devices or human tissue products, Aids and Appliances 38
Psych/Group Therapy............38
School........................38
Sickness and Accident............39
Speech Therapy.................39
Theatre Fees....................39
Travel and Accommodation........39
General Treatment Ambulance Only Policies.........26
General Treatment claims processing.............32
General Treatment Only Policies...............26
Gross Benefit.........................29
—H—
HCCP.............................29
HCCP Claimants.......................30
HCCP Net Benefits......................30
HCCP Threshold.......................30
High Cost Claims Pool....................29
holder.............................21
Hospital and General Treatment Combined..........26
Hospital Treatment......................25
Hospital Treatment Only Policies...............26
Hospital-substitute Treatment.................25
Hospital-Substitute Treatment.................28
—I—
Incomplete episode......................27
Ineligible Benefits.....................28, 31
Insured Persons........................21
—K—
Known Gap agreement....................41
—L—
leave days...........................27
leave periods..........................27
Lifetime Health Cover.....................39
base rate.......................40
Certified age of entry.............40
cover age......................40
Loading.......................40
Loading removed................40
—M—
Medical benefits........................28
Medicare benefit........................41
Mental Health Workers....................35
—N—
New Policies/persons.....................24
No Agreement.........................41
No Excess & Co-payments..................23
No Gap Agreement......................40
No of Services.........................41
Non-Exclusionary Policies..................23
Nursing Home Type Patients.................28
—O—
Occupational Therapists....................35
Osteopaths...........................36
Overnight...........................28
—P—
Physiotherapists........................36
Planning............................33
Podiatrists/Chiropodists....................36
Policies............................21
Policy Holder.........................21
private health insurance policy................21
Private Hospitals.......................27
Medical devices or human tissue products Benefits.....28
Psychologists.........................36
Psychologists, occupational therapists and Aboriginal health workers 35
Public Hospitals........................27
—R—
Reduced cover.........................32
Retention index - Hospital Treatment policy holders.....32
Risk Equalisation Levy....................30
Risk Factors for chronic disease................34
—S—
SEU/s.............................21
single.............................22
single equivalent unit/s....................21
single parent..........................22
Some Lifetime Exclusions..................32
Speech Pathologists......................36
Start of quarter.........................23
—T—
Transferring from another Fund................24
Transferring from another policy...............24
Transferring from another state................24
Transferring to another policy.................24
Transferring to another state.................24
Treatment greater than one day................28
[1] The information required by this reporting standard in relation to Norfolk Island residents must be reported in the reporting form for NSW.
[2] For the avoidance of doubt, APRA’s expectation is that if the due date for a particular reporting period falls on a day other than a usual business day, a private health insurer will submit the information required no later than the due date.
[3] The information required by this reporting standard in relation to Norfolk Island residents must be reported in the reporting form for NSW.
[4] A benefit is regarded as being paid during a quarter in which both the benefit is recorded and liability for it is accepted.