Private Health Insurance - PruHealth with Vitality

Fee Eligibility

Fee Eligibility for Healthcare Providers

What do fees include?

  • All pre and post-operative care
  • Daily ward care, including intensive care for procedures for which it is expected
  • Pre-operative anaesthetic assessment
  • Management of post-operative analgesia
  • Management of commonly occurring minor complications in the peri-operative period

PruHealth will pay

  • Fees that do not exceed our reasonable and customary rates for procedures that have been authorised by us in advance
  • For continuous regional anaesthesia e.g. brachial plexus block, epidural block where performed by the operator, in the absence of general anaesthesia. The multiple procedure billing rules should be followed
  • For topical or infiltration anaesthesia, or moderate conscious sedation, where performed by the operator, in the absence of general anaesthesia. In such cases the code AC100 should be used
  • For continuous epidural blockade, or major nerve blockade after localisation, performed by an anaesthetist in addition to general anaesthesia. The multiple procedure rules should be followed
  • Fees of a standby consultant where there is written motivation for the clinical need received in advance of the procedure and this is agreed by us

PruHealth may pay

  • Fees that exceed our reasonable and customary rates for procedures that have been unusually complex and have been agreed by us in advance of invoicing
  • Fees of a second consultant where the procedure is unusually complex and this has been agreed by us in advance of the procedure
  • For procedures that are experimental, provided there is evidence of their safety and efficacy, they are performed as part of a properly conducted clinical trial and they are discussed with and agreed by us in advance

PruHealth will not pay

  • Surgeons' fees for local anaesthesia where an anaesthetist has provided anaesthesia
  • For additional procedures that are integral to the procedure(s) being performed (unbundling). For examples, please see the section on unbundling
  • Fees of surgical assistants
  • For routine postoperative care, including daily visiting
  • Fees for consultations by radiologists or anaesthetists
  • Consultant fees for histopathology or diagnostic imaging in a private hospital
  • Fees for consultations on the same day as an inpatient procedure

Consultant fees

Health insurance from PruHealth with Vitality

For more information, click the links below.

Multiple procedure billing guidelines

Unbundling rules