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Fee guidelines

Helping you to understand your fee codes and how we set our fees

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How we set our fees

We set our fees through market research and regular benchmarking. We also take into consideration:

  • A provider’s technical expertise
  • The complexity and operating time of procedures
  • Efficiency and utilisation levels
  • Potential business risks associated with private practice

  • Sometimes our fees may not reflect exceptional circumstances. If you give us details, before you invoice us, we’ll review the amount we pay.

    We may also challenge invoices. But in these cases, we’ll always work with you to find a rate that’s fair to you, and us.

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    Our billing standards

    To protect our members, we only work with providers who show a total commitment to our values.

    Part of this commitment is an agreement to our Billing Standards.

    Fee eligibility

    When you submit an invoice to use, your Invoices should include all relevant information. This includes:

  • All pre and post operative care
  • The use of topical or infiltration anaesthesia or moderate conscious sedation
  • Daily ward care for in-patient stays
  • Pre-operative anaesthetic assessment
  • Management of post-operative analgesia
  • Management of common minor complications in the peri-operative period
  • All follow-up consultations within 28 days of the surgery
  • Fees that don’t go over our usual rates, for procedures we have authorised in advance
  • Continuous regional anaesthesia performed by the operator instead of general anaesthesia [1]
  • Continuous epidural blockade performed by an anaesthetist as well as general anaesthesia [1]
  • Fees of a standby, recognised consultant. Where there is exceptional motivation for the clinical need [2]
  • Fees that exceed our guidelines for procedures that have been complex [2]
  • Fees of a second consultant where the procedure has been complex [2]
  • Fees of one, or more, recognised consultants for urgent care. Only where we have agreed in advance and the treatment is complex
  • Pathology services by a privately owned clinic. We must have an existing agreement in place with the clinic
  • Other exceptional agreements on a one-off basis
  • Unbundled additional procedures that are integral to the original procedure
  • Fees for surgical assistants
  • Fees for post-operative care in the first 28 days after surgery
  • Fees for consultations by radiologists, anaesthetists or pathologists
  • Recognised consultant fees for histopathology or diagnostic imaging in a private hospital
  • Fees for pathology when the billing provider did not provide the service
  • Fees for consultations on the same day as a procedure
  • Fees for any tests or procedures that do not need the use of specialist or surgical equipment
  • Fees for remote monitoring
  • Phlebotomy
  • Fees for correspondence and reports provided required for assessing the eligibility of a claim
  • Any other ineligible treatment
  • [1] Follow the multiple procedure rules in these scenarios

    [2] We need to agree these scenarios in writing at least 72 hours in advance

    Multiple procedure billing

    This allows you to carry out more than one procedure during an operating session

  • If the same operator carries out two procedures during an operating session. We'll pay up to 25% over the highest fee.
  • If the same operator carries out three or more procedures during an operating session. We'll pay up to 40% over the highest fee.
  • We will only consider payment for more than three procedures in exceptional circumstances
  • We will only pay the fee of the primary consultant in cases where one consultant assists another
  • Where an operator carries out two procedures on the same day but not in the same session, we’ll pay up to 100%
  • We won’t consider paying for unbundled procedures in any circumstances
  • There are specific CCSD codes for procedures performed bilaterally.

    If a code exists for a bilateral (e.g. Bilateral mastectomy) we’ll pay the highest fee for that code only.

    Where there’s no bilateral procedure code, the multiple rules apply.

    If you give us details of complications or unusual circumstances before invoicing, we’ll review the amount we pay.

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    Unbundling rules

    Unbundling is the breaking down of a procedure and charging for each component individually.

    Therefore, we won’t pay for procedures that are:

  • Considered integral to the original procedure, such as cardio catheterisation prior to a coronary angioplasty
  • Integral to a wide range of procedures, such as phlebotomy
  • Gaining access to the operating site
  • Endoscopic procedures that are done as part of an open procedure
  • For postoperative analgesia [1]
  • [1] We will not accept codes W9030, W9040, W9012, W9013, W9014, W9015, S5210, A7350 and AC100


    Need some help?

    If you need further guidance on fees, please submit a query form to get in touch with us.