NIB Medigap and GapSure (Anaesthetists Only) Claims

NIB Medigap and GapSure (Anaesthetists Only) Claims

NIB has MediGap for Medical Specialists and GapSure for Anaesthetists billing arrangements, for more information see https://www.nib.com.au/providers/medical

MediGap - for Medical Specialists


MediGap can be used as a No Gap or Known Gap scheme. Once registered for MediGap you do not need to register individually as either a No Gap or a Known Gap Provider. You may charge at the MediGap schedule (No Gap) or with a gap of up to $500 per episode, on a case by case basis. The rebate to the patient will be the same in either case. You must show the gap on the claim. 

IMPORTANT NOTE: Should you exceed a gap of $500 the rebate is reduced to 100% of MBS. Where you have decided to charge above the MediGap rate, NIB requires the claim to be sent as a Patient Claim (IMC-PC). For this reason we recommend that you take payment in full prior to submitting the claim so that the rebates can go directly to the patient. See Section 5: Claiming requirements in the nib MediGap network Terms and Conditions.

NIB MediGap network Terms and Conditions also apply to members of these partner brands:
  1. AAMI Health Insurance
  2. Apia Health Insurance
  3. Suncorp Health Insurance
  4. Qantas Health Insurance
  5. ING Health Insurance
  6. Priceline Health Insurance
  7. Real Health Insurance
  8. Seniors Health Insurance
  9. United Healthcare Global for Medicare eligible residents in Australia.

Note for Assistant Surgeons

Where the surgeon submits a single Claim to the Fund including both the assistant surgeon’s fees together with the surgeon’s fees the maximum total Known Gap for that Claim cannot exceed $500. For this reason we advise that Assistant Surgeons submit their own claim separately.

See these links for further information
https://www.nib.com.au/providers/medigap
https://www.nib.com.au/docs/medigap-terms-and-conditions/ 

GapSure - Anaesthetist opt-in


NIB GapSure Anaesthetics billing is an opt-in arrangement for a higher value per unit on all MBS Item numbers (currently $45/unit). 
A discretionary $500 known gap is permitted on GapSure claims but only where the base procedure is 5 or more RVG units.
The NIB GapSure Anaesthetics schedule is not discretionary. Once registered, it's applicable to all your NIB billing until you opt out.

You'll need to indicate which NIB schedule to use in your Provider Settings > Online page > Default Fee Basis 

See https://www.honeysucklehealth.com.au/for-providers/anaesthetics-network/ for more information