NIB Medigap versus GapSure

NIB Medigap versus GapSure

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

MediGap

If you’re a medical specialist, you can register to become a MediGap provider.

Prior to 1st October 2024

For dates of service prior to 1st October 2024 MediGap is No Gap scheme which means you agree not to charge NIB members any out of pocket costs for their inpatient service. Provided there's no gap amount you can submit these claims through ECLIPSE and get paid electronically into your nominated account.

If you charge an out of pocket amount, the rebate is reduced to 100% of MBS and the claim can only be sent as a Patient Claim, with rebates going to/via the patient.  For this reason we recommend to only use this for fully paid NIB patient accounts prior to 1st October 2024

From 1st October 2024

For dates of service from 1st October 2024, 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. 

Should you exceed a gap of $500 the rebate is reduced to 100% of MBS.

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

GapSure Anaesthetics schedule


NIB GapSure Anaesthetics billing is an opt-in arrangement for a higher value per unit on all MBS Item numbers ($43/unit from 1/8/2023). 
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 (CESOFT Version 8 and above).

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


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