Private Healthcare Insurance ProvidersHealth insurance companies
Provider I Teacher Health
and a) According to the health rules for teachers, we only charge for treatments provided by a recognised health care professional. The present General Business Rules ("the present Rules") are the rules under which we accept general care providers for the purposes of providing care. You are deemed to agree to these Rules when a Member makes a legitimate request for your Service from us unless you notify us otherwise. b) This Privacy Statement outlines, but is not limited to, the circumstance in which we are able to identify or not identify a Supplier. c) If there is a conflict between these Rules and the rules of any other arrangement between us and you, these Rules will take precedence to the full extent of such conflict.
b ) "General treatment" has the same significance as in 121-10 of the Private Health Insurance Act 2007 or any modification or substitution thereof. c) "Member" is a natural or legal entity who is a member of the Teacher Health Fund with coverage for General Treatment and, in the case of familial affiliation, comprises all members affected by such affiliation.
2. a healthcare institution as specified or used in the Private Sickness Insurance (Accreditation) Regulations 2011, or any modification or substitution thereof. j)'Normal and reasonable fee' means: the trade organisation or institution. k ) "Date of Recognition" means the date on which you first provided a General Treatment to a Member for whom a benefit has been claimed and for whom we have recognized you as a General Treatment Providing Party for the purposes of providing the benefit.
c) "You", "Your" and "Recognized Provider" means a recognized supplier by Teachers Gesundheit, with the exception of: 1. providers of outpatient care facilities; 2. providers of authorised healthcare programmes; 5. providers of replacement healthcare facilities. The THF believes that you are a recognized supplier if: d) you fulfill all the criteria and fulfil our expectation specified in these General Business Conditions as they may be in force from then on.
a) Requests to educators, trade associations, registrars, governmental agencies, legal, parastatal or other bodies regarding your vocational training and skills and/or your vocational and ethic behavior, include but not limit to requests for memberships, accreditations, registrations, licenses, certifications or other forms of recognitions, whether or not this request was completed and whether or not this request was revoked.
As a recognized supplier, you can rely on us to reimburse you for any general care benefits you give to our members: A) Vouchers and billsa) Vouchers and bills that you have made out to members should be on your formal stationery or on a voucher bearing an formal supplier's seal, should be an exact account of the period of care, and should contain the following:
1. Your full name, practice address and phone number (must be provided as part of the provider's heading or seal and not handwritten). a) You or your associates may not act as an attorney and assert any claim on a Member's account except when using online claim (HICAPS or CSC HealthPoint). a) You must keep a detailed medical record of each Member you treat:
Guidance (ii) Date of each operation. iii ) type of therapy. iv) type of disease (symptom/reason for initiation of treatment). If there is no such legal provision - for a duration of at least 7 years and if the member is under 21 years for a duration of 7 years after becoming 21 years old. c) You must keep an accounting system that keeps a record of the full name and duration of each member case.
d ) Members' medical files must be kept in English or must be English translation at your cost. e) If you are supplying goods made or adapted specifically for the exclusive use of an Individual THF member purchaser, you must keep a copy of all order documents and vendor invoice relating to such goods and make them available upon request.
These include, but are not limited to, restorations, crown teeth, bridgework, custom orthotics and optic lens systems. f) Member medical files in connection with complaints shall be made available to us upon our demand within 10 working days of receipt of a letter of inquiry or at the date of an on-site review. g) Electronic Member medical files shall be backed up periodically.
h ) You acknowledge and consent that we may review the medical files of our Members at any times and with due diligence during our regular office working times in order to verify benefit entitlements to protect our legitimate commercial interests. If we are not allowed to provide a benefit There are situations in which the benefit is not paid for an entitlement to a benefit.
f ) The goods or provision of the service have not been made to the Insured at the time of the loss; g) Payment is not due if the Insured is not able to produce a voucher in the manner reasonably required by the TFH; h) The account/invoice/voucher is not genuine or the particulars have been changed; i) The fee relates to non coverage e.
g. the provision of reporting; j) payments are also required from another resource for all or part of the Activities, Medicare Australia included; k) the Member has obtained more than one Activity (other than dentistry and optics ) on the same date from the same supplier, in which case the highest benefit medical care is provided; l) the Activity is unlawful (e.g. drugs imported); m) the Activity has not been performed by you.
As an example, the provision of our enrolment fees has been made by patients working under your immediate control and/or guidance (with the exclusion of those enrolled by oral hygiene practitioners for whom we have not provided vendor numbers and where the Act allows such practice); n) The enrolment fee does not comply with the 2011 Private Insurance (Accreditation) Regulations or any change or substitution thereof; o) The enrolment fee is not a general rate of care for a particular state of healthcare; p) We consider the enrolment fee to be unreasonable upon receipt of unbiased healthcare or clinic consultation;
q ) Services are not to be paid if a Services has not been provided personally and personally with the Member (except for Skype meetings for psychology); r) Services are not to be paid for Services which an Insured is eligible to obtain free of cost, e.g. return or welfare insurance services; s) Services are not to be paid if the Services have been provided free of cost or on production of a free present;
t ) The goods or service have not been provided to the Member in Australia; u) Service and handling for yourself as an individually (or member) or for the husband, wife, de facto associate or relatives of a practicing professional; or associate; or associate; or spouse, de facto associate or relatives of the partitioner associate.
10 ) Data protection page a) It is important to us that the personally identifiable information of our members is securely gathered, held and transferred in accordance with applicable data protection laws. a) The information provided to us will be treated in accordance with our data protection policy. It is your agreement to set appropriate guidelines and practices and associated conditional upon-entry and other technology safeguards to protect the personally identifiable information of our Members in accordance with applicable data protection laws.
In addition, you consent to cooperate with our appropriate requests or instructions for the collection, safety, use and disclosure of our members' personally identifiable information. b) If you do not want us to store your information, we cannot evaluate our members' entitlements and you cannot therefore be a recognized vendor. c) You consent to our sharing of your name, office address, telephone number(s), office data and billing information with members, to include, but not be restricted to, publication on our website while you are a recognized vendor.
11 ) Why Teachers Health cannot recognize a provider) We may choose not to recognize a recognized supplier if we determine that the recognized supplier did so in our opinion: a) the Recognized Providers have been found guilty of a crime; c) a crime has been established but no record of the crime has been made; d) your medical care does not comply with the standard set forth in Regulations 7, 8, 9 and 10 of the Private Health Insurance (Accreditation) Regulations 2011;
Recognized Vendor has (3) been acting in an improper or unprofessional way, which means that you have been subject to disrespect of the Recognized Vendor by reason of conduct of a profession or profession; (4) have violated any contract that the Recognized Vendor has made with us; and (5) have been acting in a way that would be unreasonable to the general organ of the Vendors in that profession or profession;
Failure to comply with (6) a codes of practice, accrual or other applicable regulation of their organisation; (7) Involvement in dissatisfactory accounting practice, which means that the recognised provider has routinely charged more than a customary and reasonable fee for its service; (8) Record keeping of requested service is reasonably considered by THF to be abnormal, unreasonable or imprecise;
9 ) Use THF's trademark or IP without THF's permission; 10) Harm Teachers Health's interest, goodwill or reputations; 11) THF has decided to discontinue acceptance of the provider's services; 13) We believe in our reasoned belief that the security of a member or its members may be compromised.
b ) You can cancel these conditions without giving reasons with a period of 21 business to us in written form. Neither you nor we may have any claims against the others resulting from these Conditions at the time of cancellation, such notification by notification shall not apply to you or we. c) We may cancel these Conditions by giving you 21 days' written notice if you or the service you have provided does not or no longer comply with the standard of care set out in Regulations 7, 8, 9 or 10 of the 2011 Private Health Insurance (Accreditation) Regulations.
Said cancellation by notification shall have no effect on any claims you or we may have against the others at the time of cancellation under these Conditions. For how long will a provider not be recognized? a) A non-recognized provider can be given a date after which he can apply for a new provider license.
The restoration of acceptance is due to the fact that the supplier is able to adequately meet our doubts as to its eligibility as an accepted supplier. b) A supplier who is deregistered due to unlawful activity or serious wrongdoing is not eligible to re-register with THF. intent to reject it. c) Appeals procedure. c) We will inform the supplier in written form of our ultimate determination.
Should you not be happy with the answer, you can refer the matter in writing to an outside body such as the Private Health Insurance Ombudsman. Amendments to these Conditions a) From a) From a) to a) from a) from time immemorial, we may revise or modify these Conditions. b) We will post on our website a statement of any changes that are detrimental to our recognized suppliers.
Applicable law to these ConditionsThese Conditions shall be construed in accordance with the law of the State of New South Wales and the Contracting Party shall submit each other to the exclusive jurisdiction and venue of the New South Wales Court.