> For clean Markdown of any page, append .md to the page URL. > For a complete documentation index, see https://docs.rebateright.com.au/llms.txt. > For AI client integration (Claude Code, Cursor, etc.), connect to the MCP server at https://docs.rebateright.com.au/_mcp/server. # Health fund checks 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. > **Note** > > Test environment only. Services Australia is certifying this service, and it reaches production once certified. 1 Get Participants Get the fund list Each fund's code, and the claims and checks it accepts. 2 PVF or OPV Verify the patient The fund confirms the membership. Medicare can confirm the patient in the same request. 3 ECF or ECO Estimate the cost The fund estimates what it pays, and what the patient pays. 4 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](/api-reference/health-funds/health-fund-verification) Confirms that the fund holds the patient's membership. Send `typeCode` `PVF`. #### [Medicare and health fund verification](/api-reference/health-funds/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](/api-reference/health-funds/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](/api-reference/health-funds/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](/api-reference/medicare-eligibility/patient-verification) checks the patient's Medicare details, and [Eligibility Check](/api-reference/medicare-eligibility/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](/api-reference/health-funds/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](/api-reference/health-funds/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](/api-reference/health-funds/health-fund-verification) lists the codes a fund returns, and [Medicare and health fund verification](/api-reference/health-funds/medicare-and-health-fund-verification) lists Medicare's. Look up any other code in the [Services Australia return-code lookup](https://www.servicesaustralia.gov.au/look-up-medicare-online-and-eclipse-return-codes). 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](/api-reference/health-funds/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](/api-reference/health-funds/health-fund-eligibility-check) and [Overseas visitor eligibility check](/api-reference/health-funds/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)](/api-reference/medicare-eligibility/eligibility-report-pdf) prints the eligibility check report for a Medicare [Eligibility Check](/api-reference/medicare-eligibility/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](/test-data#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](/services-australia-requirements#health-fund-checks) lists the rules that apply across every step.