Access Gap Cover

What is Access Gap Cover?

• AGC is a medical gap cover scheme administered by AHSA and provided by AHSA participating funds.
• It consists of eight state- and territory-based fee schedules. Your provider number (location) determines which fee schedule to use.
• It can be used for admitted patients or patients receiving Hospital-Substitute Treatment.
• You can opt in and out on an episode by episode basis.
• It is a ‘no gap’ and a ‘known gap’ scheme (no additional registration required for ‘known gap’).
• It has defined terms and conditions and a billing guide which must be adhered to if you wish to participate.
• AGC benefits and the allowable patient co-payment (where the doctor charges a co-payment) are maximum fees only under the terms of AGC and are not prescribed or recommended fees.

 What are the benefits for doctors?

• Allows for a ‘known gap’ of $500 per doctor per episode where written Informed Financial Consent (IFC) has occurred
• Doctors can ‘opt in and out’ of AGC on an episode by episode basis
• Improved cash flow for doctors – 21-day turnaround (provided account has been received from the hospital and there are no issues with the Medicare claim)
• Reduces bad debts for doctors
• Benefits are paid directly into your nominated bank account
• You do not have to deal with Medicare – the fund will send you the total payment which includes the Medicare and the participating health fund benefit.
• Doctors provide registration and other contact details (e.g. bank details) once for all participating AHSA funds
        o One fee schedule per state or territory for all participating AHSA funds
        o One set of terms and conditions and one billing guide for all participating AHSA funds

  • Co-Payment Rule Change - 1 July 2020

  • AGC Fee Schedules

    This section contains the Schedules of Benefits in PDF and Excel format.
  • Billing Guide and Terms and Conditions

    The Billing Guide provides an overview of AGC including how to participate, how to claim as well as FAQs. The Terms and Conditions outline the rules of AGC.
  • FAQs

    A list of frequently asked questions received from doctors about Access Gap Cover, medical claiming, billing etc.
  • Participating Fund Contact List

    This contact list contains Health Fund information including: the current postal address (for claims), contact numbers and email addresses, Fund Identification Codes and Eclipse Participant ID's. Important Notices or exclusions for all AHSA Funds who participate in Access Gap Cover are listed. General information in relation to Health Fund name changes, mergers and Funds who are no longer a part of AHSA can be found on the last page. Funds who are not on this list DO NOT participate in Access Gap Cover. REMINDER: HBF participates in AGC for all states except WA.