HICAPS — On-the-Spot Health Fund Claiming

HICAPS is the electronic claims system most Australian dental practices use to process private health insurance rebates at the point of payment. If you have ever swiped your health-fund card at the dentist and walked out only paying the gap, that was HICAPS in action.

Sandgate Family Dental is a HICAPS provider, so we can process eligible claims for most major Australian funds — including HCF, nib, CBHS, HIF, Smile, RT Health, Frank, and many others — at the practice on the day of your appointment. You bring your card, we process the claim, the fund pays its rebate, and you settle any remaining gap with us in person.

To make a booking, use our online booking page or call the practice. Bring your fund card with you on the day — that is everything we need to claim.

What HICAPS actually is

HICAPS — Health Industry Claims and Payments Service — is a terminal-based system run by NAB Health that links a healthcare provider’s payment terminal directly to the major private health funds. The terminal looks similar to a normal EFTPOS machine. When your card is swiped, the system:

• Connects to your fund using your membership details
• Sends through the item numbers for that day’s treatment
• Receives the approved rebate amount back from the fund
• Applies that rebate against your invoice in real time
• Leaves only the gap (if any) for you to pay

The whole process usually takes under a minute and removes the need for paper claims, receipts to keep, or waiting for cheques in the post.

Which funds are supported

HICAPS is connected to almost every Australian private health fund that offers dental extras. That includes — but is not limited to — HCF, nib, CBHS, HIF, Smile, RT Health, Frank, Medibank, Bupa, AHM, Australian Unity, Defence Health, Police Health, Teachers Health, Westfund, and many smaller funds and union-backed schemes.

If your fund is supported by HICAPS and your policy covers the item being billed, we can claim on the spot. In the very rare cases where HICAPS is unavailable — for example a temporary network outage — we will give you a fully itemised receipt with all the item codes and you can submit a manual claim to your fund directly. They will then reimburse you in the usual way.

What HICAPS is and is not

HICAPS is the claiming mechanism. It is not a guarantee of cover. What HICAPS does:

• Submits the day’s claim to your fund electronically
• Returns the fund’s decision on what is rebatable at that moment
• Applies that rebate against your invoice on the spot

What HICAPS does not do:

• Set your rebate level — that is set by your individual policy
• Override waiting periods or exclusions on your policy
• Pay anything beyond what your fund has agreed to cover for that item

If your fund pays 60% of a fee for a particular item, HICAPS will process 60%. If you have reached your annual limit, HICAPS will process zero. Your exact rebate depends on your policy, level of cover, annual limits, and any waiting periods — your fund can confirm in advance.

HICAPS at our practice — what to expect

At a typical appointment:

• You arrive with your health-fund membership card (physical or digital).
• We complete your treatment and the receptionist generates an itemised invoice.
• The card is swiped or tapped on the HICAPS terminal, with the relevant item numbers attached.
• The fund returns the rebate amount in a few seconds.
• You pay the remaining gap by EFTPOS, credit card, or cash.

That is the end of the transaction — nothing further to lodge, no claim form to fill in, and no waiting for reimbursement.

HICAPS and preferred providers

HICAPS works at any practice that has a HICAPS terminal. It does not depend on the dentist being a “preferred provider” for your fund. You can still claim eligible benefits at Sandgate Family Dental using HICAPS, whether or not we are a preferred provider for your fund. The rebate is paid at the rate set by your individual policy.

Some funds offer enhanced rebates (“100% back on selected items”) only at their contracted preferred providers. Where that is the case, the rebate at our chair will be paid at the standard policy rate, and the small gap that results is something we are upfront about before the appointment.

Limits, exclusions, and HICAPS responses

It is occasionally surprising when HICAPS comes back with a smaller rebate than expected. The most common reasons are:

• Annual limit reached — once your dental limit for the benefit year is used, further claims will return nil until the year resets.
• Item not on your policy — for example, root canal therapy on a policy that only covers general dental.
• Waiting period still running — particularly for newly purchased major-dental cover.
• Item rebated at a per-tooth or per-year frequency limit — for example, a fund that only covers two examinations per year will decline a third.

In all these cases the HICAPS decision reflects your policy, not the practice. Your fund can tell you why a particular item was declined or rebated at a particular amount.

HICAPS for children — CDBS

The Child Dental Benefits Schedule is processed through Medicare, not HICAPS. When you bring your child in for an eligible CDBS visit, we bulk-bill the relevant items directly to Medicare — see our CDBS bulk-billing page for more.

HICAPS FAQs

Related information

• Health funds and your dentist
• Preventive cover
• Major dental cover
• CDBS for children
• Payment options
• Your first visit

Book your appointment

Have your fund card ready and book an appointment online or phone the practice. We will swipe through HICAPS at the end of your visit and you only need to pay any remaining gap.