Claims Process Guide

Step-by-step guide to making health insurance claims in New Zealand. From preparation to reimbursement, we'll walk you through the entire process.

Step-by-Step Claims Process

1

Before Treatment

  • • Check your policy coverage and waiting periods
  • • Verify the provider is approved by your insurer
  • • Get pre-authorization if required (especially for surgery)
  • • Confirm your excess amount and benefit limits
2

During Treatment

  • • Present your insurance card/details to the provider
  • • Pay any excess amount required
  • • Keep all receipts and documentation
  • • Ask for itemized invoices
3

Submit Your Claim

  • • Complete the claim form (online or paper)
  • • Attach all required documents
  • • Submit within the required timeframe (usually 12 months)
  • • Keep copies of everything for your records
4

Follow Up

  • • Track your claim status online or by phone
  • • Respond promptly to any requests for additional information
  • • Receive payment (usually within 10-20 working days)
  • • Review payment details and contact insurer if you have questions

Documents You'll Need

Essential Documents

  • Completed claim form
  • Original receipts and invoices
  • Medical reports or referrals
  • Specialist consultation notes
  • Discharge summaries (for hospital stays)

Additional Requirements

  • Pathology or radiology reports
  • Anaesthetist bills (for surgery)
  • Ambulance receipts
  • Prescription receipts
  • ACC decline letter (if applicable)

Types of Claims

Direct Settlement

Hospital/specialist bills your insurer directly. You only pay the excess.

Pros: Convenient, less paperwork
Cons: Must use approved providers

Reimbursement

You pay upfront and claim reimbursement from your insurer.

Pros: More provider choice, faster treatment
Cons: Need to pay upfront, more paperwork

Partial Payment

Insurer pays their portion directly, you pay the remainder.

Pros: Hybrid approach, reduced upfront cost
Cons: Requires coordination

Typical Processing Times

Standard Claims

  • Simple claims (GP visits, specialists):5-10 days
  • Hospital claims:10-15 days
  • Complex/surgical claims:15-30 days

Factors Affecting Speed

  • • Completeness of documentation
  • • Need for medical review
  • • Pre-authorization requirements
  • • Peak claim periods (end of year)
  • • Unusual or complex cases

Common Claim Issues & Solutions

Claim Rejected - Missing Information

Problem: Incomplete forms or missing documents result in claim rejection.

Solution: Double-check all requirements before submitting. Keep a checklist of required documents.

Claim Delayed - Waiting Period

Problem: Treatment occurs during a waiting period for your policy.

Solution: Check waiting periods before booking treatment. Consider deferring non-urgent procedures.

Claim Disputed - Coverage Question

Problem: Insurer questions whether treatment is covered under your policy.

Solution: Get pre-authorization for expensive procedures. Review your policy schedule carefully.

Tips for Successful Claims

Before Treatment

  • • Always call your insurer to check coverage first
  • • Get written pre-authorization for major procedures
  • • Verify provider details and approval status
  • • Understand your excess and benefit limits
  • • Check if referrals are required

When Claiming

  • • Submit claims promptly (within 12 months)
  • • Keep copies of all documents
  • • Provide complete, accurate information
  • • Follow up if you don't hear back within expected timeframes
  • • Keep detailed records of all communications

Ready to Get Protected?

Understanding the claims process is important, but having the right coverage is essential. Compare health insurance plans today.