Private Health Insurance Act 2007

CHAPTER 6 - ADMINISTRATION  

PART 6-4 - ADMINISTRATION OF PREMIUMS REDUCTION SCHEME  

Division 279 - Reimbursement of participating insurers and powers of Chief Executive Medicare  

Subdivision 279-A - Reimbursement of private health insurers for premiums reduced under scheme  

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.