Claiming made easy

Whether you can claim depends on what’s included under your policy.

Before you claim, it’s a good idea to:

• Log in to your member account to check your inclusions, remaining limits and waiting periods.
• Make sure your provider is recognised by ahm by searching with our Find a provider tool.
• Confirm the service is included for the person listed on your membership.
• Some treatments and services are excluded on certain covers. Check your member guide or product guide for full details on what’s excluded on your cover. If a service is excluded, ahm won’t pay towards it and you’ll need to pay the full cost.
• For hospital claims, check your excess and inclusions before admission.

A provider is a health professional or business that delivers a health service, like a dentist, physio, optometrist or pharmacist.

To receive a benefit, the provider must be recognised by ahm and the service must be included under your policy. You can check recognised providers using ahm’s Find a provider tool or by contacting ahm before your appointment.

Benefits paid will depend on your level of cover, annual limits and waiting periods.

If you have both Medicare and Private Health Insurance, how you claim depends on the type of service.

• Extras services (like dental, physio or optical) are usually claimed directly with ahm. Medicare generally doesn’t pay a benefit for Extras.
• Hospital services work differently. Medicare may pay a benefit for eligible hospital treatment, and ahm may also pay a benefit depending on your Hospital cover, inclusions, excess and waiting periods.

Extras and Hospital claims are processed separately, and not all services are included on every policy. Always check your Member Guide or Product Guide before treatment or admission.

• Extras claims (online or app): Paid into your bank in 2–5 business days once processed. Read more about extras claiming
• Hospital claims: These can take a little longer - usually up to 6- 8 weeks for everything to be processed and reimbursed. Find out more here: How do I make a hospital claim?

Things to check to avoid delays:

• Your receipt has all the mandatory details (clear, itemised, provider name/number, date, service) See our receipts guide for examples
• The service is included in your cover.
• Any waiting period for the service has been served.
• Medicare or your provider has submitted their paperwork (for hospital or medical claims).
• The service date is within the last 2 years.

• Assessing: We’re checking over your claim to make sure everything’s good to go. Sometimes this means we’re waiting for your transfer certificate from your previous insurer (if you're new to ahm, we might still be waiting for your transfer certificate from your previous fund- this usually takes 14-20 days), or that your claim needs a manual assessment- For example, confirming waiting periods, checking a Health Improvement form, or making sure we’ve got all the right info. Once it’s sorted, your claim will automatically move to ‘Paid’ in your claim history.
• Approved: Your claim’s been accepted and is now awaiting payment into your nominated bank account.
• Paid: Your payment’s been processed! It can take a couple of days to land in your account depending on your bank. You’ll see it marked as ‘Paid’ in your claim history once it’s on its way.
• Rejected: If it’s a HICAPS claim, your provider will let you know if it’s not accepted. For online claims, you’ll see an on screen message explaining why.