Private Health Insurance Act 2007

[ CCH Note: S 279-10 will be substituted by No 54 of 2025, s 3 and Sch 2 item 11, effective 4 May 2026 or a single day to be fixed by Proclamation. However, if the provisions do not commence within the period of 6 months beginning on the day this Act receives the Royal Assent, they commence on the day after the end of that period. For application, transitional and validation provisions, see note under s 279-1 . S 279-10 will read:

SECTION 279-10 REQUIREMENTS RELATING TO REIMBURSEMENT CLAIMS  

279-10(1)
A private health insurer may only make one claim each month for reimbursement from the Chief Executive Medicare of amounts by which premiums under a * complying health insurance policy issued by the private health insurer are reduced.

279-10(2)
The claim must:

(a) be made within 7 days after the end of a month; and

(b) be given to the Chief Executive Medicare electronically in accordance with the electronic system approved by the Chief Executive Medicare under section 333-16 for the purposes of this paragraph; and

(c) include the information required by that system to be included in the claim; and

(d) be accompanied by any documents required by that system to accompany the claim.

279-10(3)
Before making a claim, a private health insurer must be satisfied that:

(a) the claim only includes amounts by which premiums under a * complying health insurance policy issued by the private health insurer have been reduced because of the operation of Division 23 ; and

(b) the private health insurer was a * participating insurer when the premiums were reduced; and

(c) the premiums were reduced in the 36 month period ending before the month in which the claim for reimbursement is made; and

(d) the amounts have not previously been reimbursed to the private health insurer under this Division.

[ CCH Note: S 279-11 will be inserted by No 54 of 2025, s 3 and Sch 2 item 11, effective 4 May 2026 or a single day to be fixed by Proclamation. However, if the provisions do not commence within the period of 6 months beginning on the day this Act receives the Royal Assent, they commence on the day after the end of that period. For application, transitional and validation provisions, see note under s 279-1 . S 279-11 will read:

SECTION 279-11 DETERMINATION OF CLAIM  

279-11(1)
If:

(a) the Chief Executive Medicare receives a claim in accordance with section 279-10 ; and

(b) the criteria specified in the Private Health Insurance (Incentives) Rules for the purposes of this paragraph have been met in relation to the claim;

the Chief Executive Medicare must pay the insurer, in accordance with section 279-15 , the amount payable under that section.

Note:

A decision under this subsection is able to be automated by a computer program: see section 333-17 .

279-11(2)
If the criteria specified for the purposes of paragraph (1)(b) are not met in relation to the claim, or part of the claim, the Chief Executive Medicare must:

(a) if the criteria are not met in relation to part of the claim - refuse the claim in part and only pay the insurer, in accordance with section 279-15 , the amount payable under that section in respect of such part of the claim that meets the specified criteria; or

(b) otherwise - refuse the claim.

279-11(3)
The Chief Executive Medicare must notify the private health insurer if the Chief Executive Medicare makes a decision mentioned in subsection (2) .

279-11(4)
A notice under subsection (3) must include reasons for the decision.

279-11(5)
The Chief Executive Medicare is taken, for the purposes of this Part, to have accepted a claim in whole if the Chief Executive Medicare does not notify the private health insurer of a decision mentioned in subsection (2) on or before the day under subsection 279-15(2) by which the claim would have been required to have been paid.