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Having health insurance with Accuro provides you with peace of mind that when you need to use your cover, we are here to support you through those stressful times.

Here is everything you need to know about pre-approvals and claims so you know what to do when the time comes to use your cover.

What is a pre-approval?

A pre-approval is confirmation that you are covered for an upcoming surgical procedure or medical treatment.  We recommend that you seek pre-approval for any procedure that costs over $1,000 before it takes place, so that you have peace of mind that you are covered and are fully aware of any excess you may need to pay.  However, you can submit a pre-approval for procedures that cost less than $1,000. To submit a pre-approval you will be required to complete a pre-approval form and provide supporting documentation.  Please see our information on How to apply for pre-approval for further details.

The best way to submit a pre-approval is through the Accuro Member Portal, which provides us with faster visibility of your request.

Why is a referral or specialist letter required for every pre-approval or claim?

A referral letter is the letter that your GP (or referring practitioner) sends to a specialist to explain the medical reason why you are being referred to them.  A specialist letter is a letter from your specialist that provides the details of your specialist consultation and why this was required. This will usually include any relevant medical history or concerns and enables us to assess your request for pre-approval or claim against your cover.

When is a medical report required?

A medical report is required for all pre-approvals or claims for the first 5 years of your policy. This medical report is completed by the GP who holds your medical history and allows us to assess your claim and ensure that any symptoms you are experiencing were not present prior to the start date of the policy and therefore deemed as a pre-existing condition.

Can I submit a pre-approval online?

Yes, you can submit a pre-approval online through the Accuro Member Portal.  If you have not yet registered for the portal, please go to our How to Register for the Portal page and follow the simple instructions.  

This is the best way to submit a pre-approval as it provides us with faster visibility of your request.

How do I make a claim?

To submit a claim you will be required to complete a claim form and provide supporting documentation. 

Please see our information on How to make a claim for further details.

The best way to make a claim is through the Accuro Member Portal, which provides us with faster visibility of your request.

If you have not yet registered for the portal, please go to our How to Register for the Portal page and follow the simple instructions.  

Can I submit a claim online?

Yes, you can submit a claim online through the Accuro Member Portal.  If you have not yet registered for the portal, please go to our How to Register for the Portal page and follow the simple instructions.  

This is the best way to submit a claim as it provides us with faster visibility of your request.

Do I have to pay for my surgery first and then claim it back?

No, if you have pre-approval for a surgery you can ask the provider to send the invoices directly to us and include your pre-approval reference number so the invoice can be processed easily.  You can also forward these onto us if you receive them from the provider.

If you don’t have pre-approval you can still send your invoices to us along with all supporting documentation required.  We will assess your claim against your cover, but reimbursement is not guaranteed.  The provider may also require payment up front if they do not have pre-approval confirmation from us.

If you are claiming for items under a reimbursement only plan such as GP visits, dental or optical appointments, these need to be paid upfront and then claimed for as a reimbursement.

How does the excess work?

The excess is the amount of money you need to pay towards the total cost of any claims you submit. We offer you different excess options that can help to make your premiums cheaper. The higher the excess, the larger the discount on your premium.

We only apply an excess once per individual that is insured, per policy year. For example, if the excess on your plan is $250 and we accept a claim for a CT scan costing $2,000, we’ll pay $1,750 and you would pay the excess balance of $250. If you then require an MRI within the same policy year costing $1,200, we'll pay the full amount because you’ve already paid the excess.

Different excess amounts may apply to your main surgical plan and other add on plans such as the Specialist plan.

If you have our Major Medical or Real Value plan you would pay 20% of accepted claims until you have paid your excess level for the year. This means you would not pay more than 20% of accepted claims, and you would not pay more than your excess level per person per year.  Processing fees for claims over a certain amount may also be applicable on these plans.

How do I pay my excess?

If you have pre-approval for a surgery, you will need to send all the invoices directly to us for payment.  We will deduct any excess amounts due and the provider will re-invoice you for the excess amount, which needs to be paid direct to them.

If you don’t have pre-approval you can still send your invoices to us along with all supporting documentation required.  We will assess your claim against your cover, but reimbursement is not guaranteed.  Any excess will be removed from the amount we can cover.

Can I choose any private hospital or Specialist, or do you have affiliated providers that I must use?

Yes, you can choose whichever private hospital or specialist that you would like, however they do need to be a registered Medical Specialist with the Medical Council of NZ.

If you would like some help in finding a specialist that is an expert on your condition, then you can use the Find an Expert service provided by Best Doctors – call 0800 425 005.

You can also search for a registered specialist on the Medical Council of NZ website https://www.mcnz.org.nz/registration/register-of-doctors/

Do I need to provide eftpos chits/receipts for my claims?

You do not need to provide an eftpos receipt with your claim. We would always reimburse you if the balance on the invoice is $0. If the balance is still showing as owing, we will pay directly to the provider (hospital, clinic, etc) unless we can see that you have paid and in that case you may need to include the eftpos receipt but please ensure that it does not cover any information on the invoice.

What happens if my claim is declined?

There are many reasons a claim may be declined, the most common are:

  • the claim is for something that is deemed to be pre-existing to the policy start date and was not disclosed at the time of application
  • the claim is too old (your claim must be submitted within 12 months of the event date in order to be eligible for claiming)
  • the treatment or illness in question simply is just not covered by your particular policy

If we do decline a claim, we always offer you the option to review the decision, in which we invite you to submit a formal request for review along with medical information that supports your request. Declining a claim is not something we like to do, so as long as the claim falls within the Terms and Conditions of your policy we will always aim to pay your claim.