Medical professional looking down while writing
Medical professional looking down while writing

Eligibility criteria

A new eligibility criteria change request form is now available as at 14 July 2026 for providers who want to propose changes to existing eligibility criteria. Using the form helps ensure we receive the information needed to review requests in a structured and transparent way.

 

As specified in Southern Cross policy documents, certain healthcare services have eligibility criteria which need to be met before a healthcare service will be covered under a member's policy.

 

What are eligibility criteria?
Eligibility criteria are additional terms and conditions we set from time to time for a particular healthcare service which must be met for the healthcare service to be covered under policy.


You must determine whether the healthcare service you are intending to provide to the member is eligible for cover under the member’s policy before applying for prior approval and claiming on behalf of the member. This includes consideration of eligibility criteria and policy exclusions. Checking these will ensure that prior approvals and claims are correct and ready for assessment.

We need to balance collective affordability with member access to private healthcare services from a range of qualified practitioners. One of the ways we do this is through eligibility criteria and policy exclusions. As an Affiliated Provider, to ensure members’ healthcare services you provide are funded under policy, you are required to provide these services in accordance with eligibility criteria and any policy exclusions. In exceptional circumstances, we may choose (in our absolute discretion) to waive the requirement to meet certain eligibility criteria.

Policy exclusions

General policy exclusions are listed in the policy document for each of our plans.

 

What are policy exclusions?
Policy exclusions(s) are conditions, treatments or situations that the relevant policy does not cover.


Southern Cross will not reimburse you for a service you provide that is for, or relates to, any of the below policy exclusions, any policy exclusions in your AP agreement, or any of the other general exclusions listed in the policy documents. Policy variations are a list of variations to policy terms and conditions that may apply from time to time and may include the way we treat some exclusions and certain benefit terms.

  • Please also ensure you are familiar with all the general policy exclusions including:
    • Acute care means care provided in response to a sign, symptom, condition or disease that requires immediate treatment or monitoring.
    • Certain oral surgery or dental treatments, including:

      • implantation of teeth and/or titanium dental implants except as specifically provided by the Keeping Well and Vision and Dental modules (additions to Wellbeing plans)
      • surgery designed to assist or allow the implementation of orthodontic healthcare services except as specifically provided by the Keeping Well and Vision and Dental modules (additions to Wellbeing plans)
      • diagnosis, management and treatment of developmental or congenital abnormalities of the facial skeleton and associated structures
      • extraction of teeth except as specifically provided by extraction of unerupted or impacted teeth (under oral and maxillofacial in Affiliated Provider surgical procedures) benefit, or by the Keeping Well and Vision
      • and Dental modules (additions to Wellbeing plans).
    • Congenital condition(s) means congenital anomalies or defects which are present at birth and for which the policyholder or dependent had either:

      1. signs or symptoms of the condition prior to the original date of joining, or
      2. signs or symptoms of the condition within three months of birth, as reasonably determined by Southern Cross. Except for umbilical hernia, inguinal hernia, undescended testes, hydrocele, tongue tie, phimosis and squint.
    • Health screening means diagnostic test(s), investigation(s), or consultation(s) in the absence of any sign or symptom suggesting the presence of the illness, disease, or medical condition the screening is designed to detect.
    • Unapproved healthcare services means healthcare services such as specific drugs, devices, techniques, tests, and/or other healthcare services that have not been approved by Southern Cross prior to treatment. Please see the list of unapproved healthcare services.
    • Not detrimental to Health means a medical condition that is not causing significant problems for the physical health of an individual.
Apply eligibility criteria and policy exclusions before applying for prior approval and claiming on behalf of Southern Cross members

As an Affiliated Provider, to ensure members’ healthcare services you provide are funded under policy, you are required to provide these services in accordance with eligibility criteria and any policy exclusions.

Cardiac services (heart disorder diagnosis & treatment)

Gastroenterology (digestive tract examination)

General surgery (breast, gall bladder, hernia)

Gynaecology (reproductive system)

Imaging (scans)

Internal medicine

Interventional radiology 

Neurosurgery

Oncology (cancer diagnosis & treatment)

Ophthalmology (eyes)

Oral & maxillofacial

Orthopaedic

Other

Otolaryngology (ear, nose & throat)

Skin

Urology (kidney, bladder, and prostate)

Vascular surgery (artery & vein surgery)

Eligibility criteria change request form
Eligibility criteria application quick guide

Frequently asked questions

  • Can I still send requests re eligibility criteria by email?

    For new eligibility criteria change requests, please use the dedicated form so we can assess the request efficiently and fairly. If you have a general question, email is still fine and we will direct you to the right place.

  • How long will assessment take?

    Time frames vary depending on the complexity of the proposal and evidence required. The website will provide indicative expectations. Completing the forms thoroughly upfront helps avoid delays.

  • How will my eligibility criteria feedback be used?

    Your submission will be reviewed alongside clinical evidence, safety considerations and financial impact. It will inform the Society’s governance assessment and decision-making process. Submitting feedback does not guarantee a change will be approved, but it ensures your rationale is considered in a structured way.

  • What about privacy and confidentiality of the information I provide?

    The forms include consent statements explaining how information will be used for assessment purposes. We use the information to evaluate proposals and support contracting and implementation planning.

  • What if I cannot estimate utilisation or cost impacts for an eligibility criteria change?

    Provide your best estimate and explain the assumptions. Even indicative ranges are helpful. The form includes prompts to help you think about likely volumes and impacts. If you need help, contact us and we can discuss what is reasonable.

  • What is the new eligibility criteria feedback process?

    Providers can now submit requests for changes to existing eligibility criteria using a dedicated eligibility criteria change request form. The form guides you to provide your proposed change, the clinical rationale and evidence, and an estimate of utilisation and cost impact. This replaces ad hoc requests sent through email.

  • When do I need to start using the new eligibility criteria form?

    From the published effective date on the website. Any new submissions from that date must be made using the new eligibility criteria form.

  • Where can I get more information?

    The For healthcare professionals website pages for eligibility criteria will include the updated forms, step-by-step guidance and FAQs.

  • Who can submit an eligibility criteria change request?

    Affiliated Providers with a valid NZMC number can submit an eligibility criteria change request. If you are unsure, contact us using the support details on the website and we will guide you to the right pathway.

  • Who do I contact if I need help?

    Use the contact details on the eligibility criteria website page. Your Partnership Manager can also help point you to the right resources.

  • Will I be notified when eligibility are updated or if there are new eligibility?

    As per your AP agreement, we will communicate eligibility criteria updates to all APs through our usual provider communications, and we will keep the website up-to-date as the single source of truth.

  • Will you tell me the outcome of my submission?

    We will acknowledge receipt and provide an update on the outcome or next steps through the contact details you provide. Some decisions may take time depending on evidence and governance cycles.