Health insurance prior approval in NZ: what to check before treatment

Prior approval checks cover before planned treatment

Prior approval, also called pre-approval, is an insurer's advance assessment of planned healthcare under your policy. A payment claim deals with the expenses to be paid or reimbursed. The two may use the same application route, but asking for approval is not the same as receiving a decision or payment.

Southern Cross's guidance says the process confirms whether the service is covered and what conditions apply. AIA's claims guidance says prior approval is mandatory for some benefits. These examples explain the process; they do not establish a rule for every health policy or confirm James's access to either insurer.

A referral or appointment booking alone does not answer the insurance question. Ask your own insurer whether approval is required for the proposed service and who should arrange it. Insurance administration does not determine which treatment is clinically appropriate; discuss medical decisions and urgency with your healthcare team.

Gather the treatment details through the correct channel

AIA lists referral letters, specialist reports and a treatment estimate among the documents it may need. Southern Cross also says a specialist letter or cost estimate may be requested. Follow your insurer's checklist rather than assuming one document will be sufficient.

Before submitting a request, keep a private preparation note:

• Proposed service: record the treatment or test, provider and planned date exactly as described by the healthcare team.
• Documents: identify the referral, report and itemised estimate you have, along with anything still requested.
• Responsibility: confirm whether you or the provider will apply, and how you will receive the response.
• Follow-up: save the request reference and any outstanding information, without treating acknowledgement as approval.

Send policy details and medical documents only through the insurer's confirmed channel. Gold Star's initial enquiry form is for a conversation with James; it does not lodge a health claim or request insurer approval. Keep health information out of that first message.

Read the written response alongside the estimate

Ask what service and costs the response covers, then mark any amount you may need to pay yourself. Keep these questions together:

What has been confirmed?

Match the named service and provider to the planned treatment. Ask about conditions, relevant limits and the period for which the approval applies.

What remains payable by me?

Clarify the excess and any costs outside the confirmed cover. Ask whether every part of the provider's estimate has been considered.

Who receives payment?

Confirm whether eligible costs go directly to the provider or whether you pay first and seek reimbursement. Ask what invoices or receipts are still needed.

AIA describes provider payment after prior approval, subject to the excess, and a pay-then-claim route when approval has not been received. Southern Cross's claiming guide describes several payment routes, including Affiliated Providers who arrange approval and claim on a member's behalf. Your route depends on your insurer, policy and provider; neither example promises full reimbursement for an unapproved service.

Check again if the treatment plan changes

If the date, service, provider or estimate changes, ask the insurer whether its earlier response still applies. Keep the updated answer with the original request and final invoices. Avoid resolving a discrepancy by assuming the larger amount or different service is included.

Fictional illustration: a policyholder receives an approval response for a planned procedure, then gets a revised estimate containing another item. They ask the insurer to confirm how that item is treated and ask the provider who will invoice them. The example shows an administrative check, not a covered treatment or claim outcome.

For the actual approval decision, claim or urgent administrative question, contact the insurer or the provider arranging it. For a broader discussion of existing cover, explore personal insurance topics, the health and work change scenario and our first adviser meeting checklist. Contact James with a brief general question and ask him to confirm the scope of advice and a secure way to share any documents later.