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Resolve Dental Consultancy
Health Fund & HICAPS Claiming Guide 2026
Health Fund & HICAPS Claiming Guide 2026
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$29.00 AUD
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he Complete Staff Reference Guide for Processing Health Fund, Medicare, CDBS, and DVA Claims in Australian Dental Practices
Every FOC team member who works at a dental reception desk needs to understand how health fund claiming works — not just how to swipe the card, but what each funding stream covers, what to do when HICAPS is declined, how to check CDBS eligibility, and what DVA patients need. Most practices train their FOC verbally on this. This guide puts it all in writing.
The Health Fund & HICAPS Claiming Guide 2026 is the complete staff reference guide for processing health fund claims, Medicare, CDBS, and DVA payments in an Australian dental practice — covering the full Australian health funding landscape, step-by-step HICAPS claiming, ADA item number reference, CDBS eligibility checking and claiming, Medicare CDM plans, and DVA Gold and White Card claiming. Suitable for both new FOC team members and experienced staff needing a refresher.
The guide is structured across 5 parts:
Part 1 — The Australian Health Funding Landscape A clear, plain-language overview of every funding stream an FOC will encounter — private health insurance (HICAPS), Medicare CDBS, Medicare Chronic Disease Management plans, DVA Gold and White Card, self-funded patients, and payment plans (Afterpay, Zip, DentiCare). Presented as a reference table covering who each stream covers, how it works, and exactly what the FOC does.
Part 2 — HICAPS: The Private Health Claiming System A complete 7-step HICAPS claiming procedure at checkout — including what to watch for at each step, how to handle HICAPS declines and rejections (the most common cause: annual limit exceeded), and how to run HICAPS estimates before the appointment so patients know their gap payment in advance. Includes the key patient communication script for declined claims and the non-negotiable rule: always process the gap payment after HICAPS, not before.
Part 3 — ADA Item Numbers A practical FOC reference table covering 16 of the most commonly used ADA item numbers — examinations (011, 012, 013), radiographs (022, 037), hygiene (111, 114, 121, 131, 141), restorations (311, 322), crowns (521), and extractions (615, 631). Includes the non-negotiable compliance rule: never enter an item number for a service not actually provided — this is fraudulent claiming and a serious offence.
Part 4 — Medicare and CDBS Step-by-step CDBS eligibility checking (via PMS, HPOS, or Medicare phone), processing a CDBS claim including assignment of benefit form requirements, and what to do when the child has no remaining CDBS balance. Covers Medicare Chronic Disease Management plans — referral requirements, registration, bulk-billing vs gap-billing, and MBS item numbers.
Part 5 — DVA Claiming Gold Card vs White Card coverage explained, prior approval requirements for major prosthetic work, how to submit DVA claims, the DVA fee schedule rule (the practice cannot charge more than the DVA scheduled fee for DVA-covered treatment), and record retention requirements.
Who this is for:
- New FOC team members being trained on health fund claiming for the first time
- Experienced FOCs who want a written reference for less common claiming scenarios (DVA, CDM, CDBS)
- Practice Managers who want a written, consistent claiming reference that every FOC team member can access
- Any practice that currently trains health fund claiming verbally with no written guide in place
📄 Format: 7-page editable Microsoft Word document (.docx) — fully customisable with your practice name and team details; designed to be printed and kept at the reception desk as a daily reference
⬇️ Instant digital download — available immediately after purchase
🦷 Built for Australian dental practices — covers HICAPS, Medicare Online Claiming, CDBS, CDM, and DVA
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