Prior Approvals

Reassurance of cover and cashless service

What is it?

It can be stressful when you find out you need specialised medical treatment. We understand this and that’s why we want to make it easy for you to determine how your UniMed health insurance can apply before you are treated.

It’s called Prior Approval. It provides you with a clear understanding of how your treatment will be funded including eligible reimbursements under your UniMed health insurance plan and any payments you may be required to make. Knowing what your health insurance covers before you are treated provides valuable reassurance. That’s why most of our members ask for Prior Approval for Specialist Treatment or Surgery.

When do I need Prior Approval?

You can ask for Prior Approval for any healthcare service with fees over $500. This includes major diagnostic tests such as MRI, CT or PET scans as well as surgical procedures (day-stay or over night). Prior Approval is not mandatory but because it benefits our members we really encourage them to use it.

How to seek Prior Approval?

As soon as you know you need major diagnostic tests or surgery, speak with your Specialist (or their Practice Nurse) and gather together the information outlined below. Your Doctor should be familiar with the Prior Approval process as it is common throughout the health insurance industry.

You will need to provide us with:

  • Evidence of your medical condition (e.g. the referral letter from your GP, a specialist’s report or letter, copies of diagnostic results).
  • The name of the proposed procedure or treatment (your Specialist will give you this).
  • A cost estimate (your Specialist usually provides this).
  • A completed prior approval is required for the following:  cardiac condition, joint replacement, musculoskeletal condition, hernia, sinus/nasal, possible injury, or where you have been a Member of UniMed for less than 3 years or might have an endorsement on your policy related to the medical condition.
  • Copies of the letter from ACC declining coverage and any attachments if applicable.
  • Date of treatment and proposed hospital, if known.

You can scan, upload and email this documentation to us through this website or from your own email.

How long does Prior Approval take?

In most cases, we can provide confirmation of the extent of cover within 3 business days, but sometimes we may request further information including GP records or additional reports.

We always do our best to provide a decision as quickly as possible and it is only in the most exceptionally complex situations that decisions take longer than a week. Please make sure you leave enough time between contacting us and the date of treatment for us to process your request properly.

Please note that if you do not seek prior approval before undertaking treatment (surgery, imaging, diagnostics and tests), you may find that there is no cover or that the cover you have is not as you expect. You will be responsible for any shortfall incurred.

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Important information

The information in this website is intended as a guide and to cover the most common situations. Your specific situation will be determined by your own policy, which comprises the Benefit Schedule of the plan you have in place, the prevailing Conditions of Membership, your Membership Certificate, your employer’s scheme handbook (where applicable), and all other documents referred to.