HICAPS Provider Agreement Terms and Conditions
As a Health Service Provider claiming benefits for service rendered to a Union Health Fund Member, you are bound by the rules set out in the HICAPS Provider Agreement Terms and Conditions. Below is an extract of the HICAPS Provider Agreement Terms and Conditions as they apply to Health Service Providers utilising this service:
3 HICAPS System
3.4 You must do the following:
(a) not disadvantage a Cardholder, such as by charging a fee, solely because a health insurance claim is to be processed through the Network in respect of Goods or a Health Service (however, this clause does not prevent charging for Merchant Service Transactions in accordance with your merchant agreement);
(b) provide the Goods or Health Service to a Cardholder to which a Transaction Request relates prior to initiating the Transaction Request;
(e) immediately stop using the Network to process health insurance claims using a Transaction request and request quotations using a Quotation request in respect of a Fund when the Fund requests You to do so in circumstances where (but not limited to) the Fund reasonably suspects that there has been inappropriate activity and/or You are in breach of this agreement;
(h) where a Cardholder requires a Quotation and the Fund has agreed to process Quotation Responses, ensure that a Quotation Request is forwarded to the Cardholder’s Fund and a Quotation Response is received by return before the Goods and/or Health Service the subject of Quotation is provided to that Cardholder. Quoting must only be done at the request of the cardholder once the Goods or Health Service has been determined and agreed to by the Cardholder. The details in the Quotation must be accurate, true, and supported by relevant evidence which must be provided to the relevant Fund upon request;
(j) only process Transactions and submit Quotation Requests for the provision of Goods or Health Service(s) performed(or, in the case of Quotation Requests, to be performed) at the Registered Provider Location, except where a Fund authorised the provision of Goods or Health Service(s) and processing of Transactions at a location other than the Registered Provider Location;
4 Handling Transactions
4.2 In relation to a health insurance claim to be made on a Fund You must do the following:
(a) where the claim is to be processed through the Network, process the claim through the Network in a Cardholder’s presence as soon as reasonably practicable after the related Health Service has been provided to the Cardholder;
(c) use reasonable care to detect forged or unauthorised signatures or the unauthorised use or forgery of a Card and, in particular, use reasonable endeavours to verify the identity of a Cardholder independently from the Card;
(d) require the Cardholder to review and sign the receipt, certifying the Important Declaration, generated by a Terminal or HICAPS Go where a Transaction Request, or Cancel Request is made;
(e) require the Cardholder to review and sign the receipt, certifying the important declaration, generated by the Terminal where a transaction Request, Reversal Request or Void Request is made;
(f) give the Cardholder a copy of the signed receipt referred to in paragraph (e) and retain the original signed receipt referred to in paragraph (e);
(g) retain each receipt referred to in paragraph (e) for at least 24 months or any longer period required by law after the Transaction Request has been processed through the Network;
(h) provide a Fund with evidence, including treatment plans, appointment schedules, signed receipts and other supporting documentation as requested, of a Transaction processed for the purposes of that Fund within 10 Business Days of the Fund requesting that evidence; and
4.3 Where You initiate a health insurance claim on behalf of a Cardholder, You must take all reasonable steps to satisfy Yourself that:
(a) all particulars are true and correct including, without limitation, all item numbers and codes that are included in a Transaction Request represent an accurate description of the Goods and/or Health Service delivered;
(b) the Transaction Request will be valid and acceptable;
(c) the relevant Cardholder is not disputing liability for the Goods and/or Health Service the subject of the Transaction Request; and
(d) the Goods and/or Health Service(s) in the Transaction were performed or supplied at the Registered Provider Location unless authorised by the Fund.
5 Settlement of Transactions
5.3 A Transaction Request is not valid if:
(a) the Transaction Request is illegal or any particulars of a health insurance claim are not true;
(b) the Transaction Request is not authorised by a Cardholder to which a Transaction Request relates;
(c) You did not provide a Health Service to a Cardholder to which a Transaction Request relates before processing the Transaction Request;
(d) another person provided the Health Service the subject of the Transaction Request;
(e) the Cardholder does not confirm that the Transaction is certified by the Cardholder in accordance with clause 4.2(e) of this agreement;
(f) you have breached either clause 3.3 or 4.2 of this agreement
5.4 A Transaction Request is not acceptable if the Cardholder disputes liability for the Goods and/or Health Service the subject of the Transaction Request at any time for any reason and this clause applies even if a Fund has authorised the Transaction Request.
5.8 Where a Fund has settled a Transaction Request pursuant to clause 5.6, the Fund may require You to pay back the amount relating
to the Transaction Request if the Transaction Request is not valid or acceptable and the Fund may direct HICAPS to debit the account nominated by You for settlement adjustments.
