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Medical Gap Arrangements

GapCover for providers

We are committed to the purpose of striving for better health outcomes for our private health insurance members. As part of this commitment, GapCover aims to reduce or eliminate the out-of-pocket medical expenses paid by our members when they have a hospital stay.

This page explains what you need to know about becoming a GapCover provider and participating in the GapCover scheme. If you'd like more detailed information, please download our GapCover Provider Guide.

How GapCover works

The ‘gap' is the difference between the fees charged by you and the Medicare Benefits Schedule (MBS) fees for the services you provide to our members. This difference can leave our members with out-of-pocket expenses. With GapCover, you can help close this gap.

Please be aware that some levels of cover have excluded services. GapCover will not apply for an excluded service.

GapCover Schedule of Benefits as at 1 May 2017

The GapCover Schedule of Benefits is indexed in line with the Medicare Benefits Schedule (MBS). The GapCover Schedule has been updated to reflect the indexation of the MBS from 1 July 2014.

The changes that took effect as at 1 May 2017 are listed below. Please refer to the Department of Human Services website for further information - www.mbsonline.gov.au

New MBS items

30642 35730 41618 42705 73069

Deleted MBS items

12025 12026 12027

Amended descriptions for the following MBS items

6024 6058 12000 12003 12021 12022 12024 30631 30634 30635 31340 32213 32214 32215 32216 32217 32218 36663 36664 36666 36667 36668 42725 42734 42758 42788 42789 42791 42792 69471 73336 73922 73923

Fee amended for the following MBS items

73053 73055 73057

Known gap

As long as your fees do not exceed the relevant amount in the GapCover Schedule of Benefits, the account will be paid in full and there will be ‘no gap' for our members.

However, you may wish to charge a Known Gap (an out-of-pocket expense that the member pays). This is any amount you charge that exceeds the amount shown in the GapCover Schedule of Benefits, up to a maximum of $500 per claiming provider (ie. per doctor's account).

If you submit an account where the Known Gap exceeds $500 per claiming provider, the benefit payable for that claim will be reduced to the MBS fee. In other words, the claim cannot be paid as a GapCover claim.

If the gap amount is to be charged to our member you must have obtained Informed Financial Consent (IFC).


As you can see from the following example, the out-of-pocket cost can be significantly reduced for our member when you choose to participate in GapCover.

Doctor's total charge $800


GapCover Schedule fee
The higher fee that will be paid up to for treatment covered by GapCover.


MBS fee for all items


Medicare pays


75% of the MBS fee

We pay


25% of the MBS fee


The difference between the MBS Schedule fee and the GapCover Schedule fee

Member pays


The difference between the GapCover Schedule fee and the Doctor's charge

In this case, Medicare will pay 75% of the $400 MBS fee. We will pay the remaining 25% of the MBS fee plus an extra $200 up to the GapCover Schedule fee of $600. The out-of-pocket cost for the member is $200.

This treatment can be covered under GapCover because the doctor has charged the agreed GapCover fee and the out-of-pocket for the member is less than $500 per claiming provider.

How to register to participate in GapCover

To join GapCover, simply fill out the GapCover Application Form and Change of Details Form and return by fax to (03) 8456 6250.

Terms and conditions

To participate in GapCover you must agree to and abide by the followingTerms and Conditions found in the Resources and Forms section.

How to claim

Claiming is easy and quick through Eclipse, the in-patient claiming system developed by Medicare Australia that enables providers, health insurers and Medicare to exchange and pay claims electronically. To claim through Eclipse simply send your claims for our members to ahm Health Insurance using Fund ID ‘ahm' and Claim Type ‘SC'.

If you don't have eclipse you can also claim manually by using a batch header.

The benefit we pay you will be based on the MBS item numbers provided by you on your account.

We use our best endeavours to process accounts within 21 days, provided they satisfy our requirements (see the GapCover Provider Guide for more information). The benefit will be paid in accordance with the GapCover Schedule of Benefits and the Medicare Australia assessing rules, which are subject to change.

How to register

To register for Eclipse or if you want more information about how it works, contact the Medicare Australia eBusiness Service Centre on 1800 700 199 or email co.eclipse@medicareaustralia.gov.au.

Already an Eclipse user?

If you're already an Eclipse user and want to start transacting with us, simply register to participate in GapCover and start sending your bills via Eclipse by using Fund ID ‘ahm' for our members and Claim Type ‘SC'.

Have a question about claiming? Why not give us a call on 1300 309 438.