Health funds and HICAPS: how dental claims work

Last reviewed: 1 November 2026

If you have private health insurance with extras cover, you may be able to claim part of the cost of dental care. This guide explains how dental cover generally works, what to check before treatment and how claiming at the practice works. It is general information only. Your health fund can tell you exactly what your policy covers.

Medicare and dental care

Healthdirect says most dental care is not covered by Medicare. Some children may be eligible for Medicare benefits for some dental services. See public and private dental care for the Child Dental Benefits Schedule and public dental services.

How extras cover works for dental

Privatehealth.gov.au, the Australian Government’s private health insurance website, says private health insurance is generally divided into hospital cover, general treatment cover and ambulance cover. General treatment cover is also called ancillary or extras cover, and it can include dental treatment.

Healthdirect says policies vary widely between funds, both in what they cover and how much they pay. Funds use different terms to describe what they will pay for, so you will need to check your policy carefully. Healthdirect describes two broad types of dental cover:

• Routine dental. May include X-rays, examinations, cleaning, fluoride and simple fillings.
• Major dental. May include complex fillings, crowns, veneers, bridgework, implants and dentures.

Limits and waiting periods

Privatehealth.gov.au says nearly all services covered under general treatment are only covered to a limited extent. Limits may apply per service, per year or over your lifetime, and some services may not be covered at all. It recommends checking the Private Health Information Statement for any policy you are considering.

Waiting periods for extras cover are set by individual insurers. Privatehealth.gov.au says they generally vary from two to six months for items such as general dental, and up to 12 months or more for major items such as orthodontics. If you have just joined or changed your cover, ask your fund what waiting periods apply to you before booking treatment.

Preferred providers

Healthdirect says some health funds have preferred providers, which are dentists that the fund recommends. It says this can mean lower fees, higher rebates and more preventive services, but you may have less choice of dentists. Your fund can tell you whether a practice is a preferred provider for your policy.

Item numbers and quotes

Dental services are described using item numbers from the Australian Schedule of Dental Services and Glossary, published by the Australian Dental Association (ADA). Your fund uses these numbers to work out what it will pay.

Before treatment, you can ask the practice for a written estimate that lists the item numbers. The ADA’s policy on informed financial consent says dental practitioners should provide the relevant item numbers where charging is based on an itemised schedule, and that patients should be encouraged to contact their health fund to understand their benefits before treatment starts. It also says an estimate is not guaranteed, and the cost may increase if a procedure takes longer than expected or other procedures are needed.

Healthdirect suggests asking for the item numbers and then contacting a few dentists to compare prices. See dental costs in Australia for more on fees and quotes.

What HICAPS is

HICAPS is a claiming and payment system used by many health practices. HICAPS says it has partnered with all Australian private health insurers.

At a practice with a HICAPS terminal, you can usually claim at the time of your visit. The practice processes the claim through the terminal using your health fund card, and you pay any remaining amount, often called the gap. HICAPS says some funds also support:

• quotes produced on the terminal, so you can see your benefit before treatment
• tapping a digital health fund membership card instead of a plastic card

Which features are available depends on your fund and the practice. If a practice does not offer on-the-spot claiming, ask how to claim, for example by sending an itemised account to your fund.

Questions to ask

Ask your health fund:

• Does my policy include routine and major dental, and what are the annual limits?
• Have I served the waiting periods for the treatment I need?
• What will you pay for these item numbers?

Ask the practice:

• Can you give me a written estimate with item numbers?
• Can I claim on the spot with my fund?
• What will I need to pay on the day?

General information, not medical or dental advice. Speak to a registered dental practitioner about your situation.