Private Medical Insurance ProvidersHealth insurance companies
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 TOS and the provisions of any other arrangement between us and you, these TOS will take precedence where such conflict exists.
b ) "General Treatment" has the same meanings as in section 121-10 of the Private Health Insurance Act 2007 or any modification or substitution thereof. c) "Member" means a natural or legal entity who is a member of Nurses & Midwives Health Pty Limited with coverage for general treatment and who, in the case of being a member of a Nurses & Midwives Health Pty Limited household, comprises all members falling within that member's household.
2. a healthcare provider as specified or used in the private sickness insurance (accreditation) 2011 regulations, or any modification or substitution thereof. j) means'normal and appropriate fee': k ) "Date of Recognition" means the date on which you first provided a General Treatment to a Member for whom a right fulfils and for whom we have acknowledged you as a General Treatment Providers for the purposes of providing the Services, a General Treatment Event.
l ) "We", "Our", "We", "NMH" and "Nurses & Midwives, Medical Pty Limited" means the Nurse & Midwives, Medical Pty Limited ABN 70611479237 which is a private medical insurance company. m) "You", "Your" and "Recognised Provider" means a supplier authorised by Nurses & Midwives, Medical Pty Limited with the exception of: 1. providers of outpatient care facilities; 2. providers of authorised healthcare programmes; 5. providers of replacement healthcare facilities.
In NMH's opinion, you are a recognized supplier if: d) you fulfill all the criteria and fulfill all our expectation specified in these General Business Rules as they may be in force from then on. As a recognized supplier, you can rely on us to reimburse you for any general treatment benefits you offer 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).
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.
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 workingdays of a written inquiry or at the date of an on-site review. g) Electronic Member medical files shall be backed up periodically.
If we are not allowed to make payment for a benefit There are situations in which the benefit is not paid for an entitlement to a benefit. This includes, but is not restricted to: f) the goods or provision of goods or provision of provision of services have not been made to the Insured at the time of the loss; g) the provision of goods or provision of provision of provision of services shall not be required if the Insured is not able to produce a receipts in such format as NMH may reasonably request; h) the account/invoice/receipt is not genuine or the particulars have been changed; i) the fee applies to the provision of provision of services which are not included in the coverage of the insurance; e) the goods or provision of provision of provision of services shall not be subject to payment of the insurance premium if the Insured is not able to produce a receipts in such format as NMH may reasonably request; f) the account/invoice/receipt is not genuine or the particulars have been changed; g) the fee applies to the provision of provision of goods or provision of provision of provision of services which are not included in the coverage of the insurance.
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 Medical Insurance (Accreditation) Regulations or any change or substitution thereof; o) The enrolment fee is not a general medical fee for a particular state of healthcare; p) We consider the enrolment fee to be unreasonable upon receipt of unbiased medical or medical 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.
b ) The information provided to us will be treated in accordance with our data protection guidelines. au You consent to the establishment of appropriate guidelines and processes as well as associated conditional access systems and other technology in order to assure that the protection of the members' personally identifiable information is in accordance with the applicable data protection laws.
In addition, you consent to cooperate with our appropriate requests or instructions to store, secure, use and disclose our members' personally identifiable information. c) If you do not want us to store your information, we will not be able to evaluate our members' entitlements and you cannot therefore be a recognized vendor. d) 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 when you are a recognized vendor.
We may choose not to accept a recognized supplier if we determine that, in our reasoned judgment, the recognized supplier is entitled to do so: a) the Recognized Providers have been found guilty of a crime; 2) your medical care does not comply with the standard set forth in Regulations 7, 8, 9 and 10 of the Private Health Insurance (Accreditation) 2011 Regulations; 3) you have behaved in an improper or unprofessional manner, which means that your conduct in the course of discipline has resulted in a dislike of the Recognized Providers;
Recognised Provider has contravened any contract that it has with us; (5) Act in a way that would be contrary to the general group of Providers in that disciplinary area; (6) Violate any codes of ethics, accredition or other regulation of their group; (6) Violate any other legal or ethical requirement of their group; or (6) Violate any other legal or ethical obligation of their group; Significant differences between NMH and the recognised service provider may arise from the fact that the recognised service provider is (7) involved in dissatisfactory accounting practice, which means that the recognised service provider has routinely charged more than a normal and reasonable fee for its service; (8) NMH reasonably considers recordings of requested service to be abnormal, unreasonable or imprecise;
9 ) use the NMH trademark or IP without NMH's permission; 10) harm NMH's interest, goodwill or reputations; 11) NMH has opted 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.
d ) We may cancel these Conditions by written notification of 21 calendar Days if you or the Service (s) you have provided do 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.
Restoring acceptance is conditional upon the ability of the Supplier to reasonably meet our concern about 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 NMH. a) If a Supplier intends to challenge deregistration, it should do so immediately and in written form.
If we receive more than 7 workingdays after the date on which we announce our intent to cancel, we will not consider any appointments from providers. b) We will attempt to respond to the appointment within 7 workingdays of receiving it. When we need more free space, we will inform the vendor of the anticipated timescale.
Acceptance of the supplier will be deferred during the appeals procedure. c) We will inform the supplier of our definitive ruling in written form. Should you not be happy with the answer, you can refer the matter in written form 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.