There are a number of reasons why a claim may be rejected. Please see below for the most common rejection reasons:
- If your policy is unfinancial at the date of service you will not be able to submit your claim until your standard contribution has been paid and your membership is paid up to date.
- If the procedure is not covered under your level of cover.
- If the procedure is classified as an outpatient service and you hold a domestic level of cover. This is a Medicare benefit only, for further information on this, please see "What is an outpatient service?"
- If you are still serving waiting periods for a particular service that you are trying to claim for. For example, if you tried to claim a major dental item number within the 12 months of cover, your claim would be rejected as you're required to serve a 12 month waiting period for major dental.
- In the case of pharmacy claims, if the total amount per script/item is below the Pharmaceutical Benefit Scheme (PBS) amount of $38.80, this is not an eligible claim and therefore it will be rejected.
- If your date of service is before you HIF join date you cannot claim for this service.
- If you have used our Smartclaim app to submit your claim and the photograph of the account is unclear or if information is missing, we cannot process the claim.
- If you have exceeded your annual limit under the service category you're claiming for.