Fee Eligibility

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

rightpromo

For more information, click the links below.

Multiple procedure billing guidelines

Unbundling rules