Health fund checks | RebateRight

A health fund is a patient’s private health insurer. The health fund checks confirm the patient’s membership with their fund, and estimate what the fund pays for an admission. The answers come from the fund itself, through Services Australia.

Test environment only. Services Australia is certifying this service, and it reaches production once certified.

Get Participants

Get the fund list

Each fund’s code, and the claims and checks it accepts.

PVF or OPV

Verify the patient

The fund confirms the membership. Medicare can confirm the patient in the same request.

ECF or ECO

Estimate the cost

The fund estimates what it pays, and what the patient pays.

Your software

Give the patient the report

The estimate, with the statements Services Australia requires.

Every check needs a fund code from step 1. No check needs another check first.

Which check do I send?

To confirm the membership

Health fund verification

Confirms that the fund holds the patient’s membership. Send typeCode PVF.

Medicare and health fund verification

Confirms the patient with Medicare, then the membership with the fund, in one request. Send typeCode OPV.

To estimate the cost

Health fund eligibility check

Estimates what the fund and the patient pay for an admission to a hospital or day surgery. Send typeCode ECF.

Overseas visitor eligibility check

Estimates what the fund pays for an overseas visitor’s treatment, in or out of hospital. Send typeCode ECO.

What it takes	`PVF`	`OPV`	`ECF`	`ECO`
Patient’s details and fund membership	Required	Required	Required	Required
Medicare card number and IRN	Not sent	Required	Not sent	Not sent
Admission or treatment	Not sent	Not sent	Required	Required
What it returns	The fund’s status	Medicare’s status and the fund’s	The patient’s cover, excess, exclusions and co-payments	The same, with the fund’s benefit for each medical service

Each check has its own endpoint. Its typeCode must match that endpoint, or Medicare rejects the request with 2030.

For Medicare alone, Patient Verification checks the patient’s Medicare details, and Eligibility Check estimates Medicare’s benefit for each service.

Fund codes

Every check and every in-patient claim names the patient’s fund by its 3-letter fund code.

Fund code
Where you get it	`id`, on each fund Get Participants returns
Where you send it	`healthFund.organisation`, in every verification, eligibility check and claim for a member of that fund
When to refresh	Services Australia asks you to send Get Participants before your first in-patient claim, then every 2 weeks to a month, and whenever you need to.
When it is out of date	A response returns `9672`. Send Get Participants again, then resend the request.
Other names	Services Australia calls it an Organisation Identifier. Its older name is Fund Brand ID.

What each fund supports. A fund supports a function when its service list includes the text in this table.

Function	Text in `service`
Agreement claim, `AG`	`In Patient Medical Claim - Agreements`
Scheme claim, `SC`	`In Patient Medical Claim - Schemes`
Billing Agent claim, `MB`	`In Patient Medical Claim - Billing Agents`
Patient Claim, `PC`	`In Patient Medical Claim - Patient Claims`
Health fund eligibility check	`Online Eligibility Check - Fund`
Overseas visitor eligibility check	`Online Eligibility Check - Overseas`

The service list leaves out patient verification. A fund that does not accept verifications through this channel returns 9671.

Patient verification

A health fund verification confirms that the fund knows the patient, from the details you hold. A Medicare and health fund verification checks Medicare first, then the fund.

Hospital cover. The fund confirms a membership with code 0 only when it includes hospital cover. A membership with extras cover only returns another code. Extras cover is also called ancillary cover.
Details you hold. Use the check to confirm details you already hold. Services Australia does not allow it to be used to search for a patient whose details you do not know.

Collect the patient's details

Send the patient’s name, date of birth and sex as Medicare holds them, with the fund code and the membership number from the patient’s card. Where the fund holds a different name for the patient, send that name as well. Health fund verification gives each field’s format.

Add Medicare details for a combined check

For a Medicare and health fund verification, also send the Medicare card number and Individual Reference Number (IRN) in patient.medicare. Leave patient.medicare out of a health fund verification.

Set the date of service

Send the date of the admission or service in dateOfService.

Read the result

Each status gives a code and a text. Show each text to the user exactly as returned.

Status	Field	Code `0` means
The fund’s	`healthFundStatus.status`	The fund knows the patient.
Medicare’s, in a combined check	`medicareStatus.status`	Medicare matched the patient.

Health fund verification lists the codes a fund returns, and Medicare and health fund verification lists Medicare’s. Look up any other code in the Services Australia return-code lookup.

Where Medicare returns different details in medicareStatus.currentMembership or medicareStatus.currentMember, offer the user an update to the patient’s record.

Show the date of the check

Show the date of the patient’s last verification with their record.

Eligibility checks

Before an admission, an eligibility check estimates what the health fund pays and what the patient pays. The estimate lets the patient give informed financial consent. The check sends no Medicare details.

The 2 checks differ in these fields.

Field	Health fund, `ECF`	Overseas visitor, `ECO`
`hospitalInd`	Not sent	Required: `Y` in hospital, `N` out of hospital
`facilityId`, `sameDayInd` and each event’s `admissionDate`	Required	Required in hospital
`claimTypeCode`, `serviceTypeCode`, `principalProvider` and each event’s `serviceProvider`	Not sent	Required
`service`	Optional, for prosthetic or miscellaneous items	Required, for MBS items and prosthetic or miscellaneous items

Overseas visitor eligibility check sets out the admission fields to send out of hospital. Each endpoint’s page gives every field’s format and the limits on events and services.

Read the result

When status is COMPLETE, healthFundClaimEstimation holds the fund’s estimate. Show each explanation’s text to the user exactly as returned. Health fund eligibility check and Overseas visitor eligibility check describe each field of the estimate.

Give the patient the report

Services Australia advises that legislation requires any eligibility check result shown or printed for the patient to carry the current disclaimer, privacy notice and authorisation statement. The eligibility check report is an estimate, and it is not used for claiming.

Part	What the report shows
Header	”Quote only not for claiming”
Identifiers	The Location ID and `accountReferenceId`
Patient	The patient’s details
Cover	The fund’s cover details
Outcome	The fund’s explanation
Estimate	The estimate for each service
Statements	The current disclaimer, privacy notice and authorisation statement

The disclaimer tells the patient that the estimate is not an undertaking by Services Australia or the fund to pay a claim. Services Australia publishes the current wording and layout in the Online Eligibility Check specification, on its Health Systems Developer Portal. Use that wording exactly.

Eligibility Report (PDF) prints the eligibility check report for a Medicare Eligibility Check. For a health fund or overseas visitor check, your software prints its own eligibility check report, with the fund’s cover details.

In the test environment

Use the test fund and facility in Hospital, fund, and billing IDs. For a Medicare and health fund verification, also use a Medicare test patient from the same page.

What Services Australia requires

Each rule Services Australia sets for these checks appears at the step it applies to. What Services Australia requires of your software lists the rules that apply across every step.