Provider FAQs
Here’s what you need to know about the new co-payment requirements, pre-approvals, and claims process.
Frequently asked questions
The following change is being made to make sure we can continue to deliver comprehensive and continued cover in the right areas for your patients – our members.
From 24 November 2025, a 20% co-payment will apply to some benefits that cover specialist consultations and diagnostic tests. The co-payment doesn’t apply to tests listed in the Diagnostics Schedule. You can find a copy of the Diagnostics Schedule by visiting: www.nib.co.nz/am-i-covered.
For example, if your patient is undergoing a covered procedure like a CT scan that costs $2,000, a 20% co-payment is applied first — that’s $400. The remaining $1,600 is then subject to any applicable excess. If their excess is $500, this will be deducted next. Your patient would pay a total of $900, and we’d cover the remaining $1,100.
We’ve also updated policy wording to align with other nib policies and provide clarity that treatment and procedures related to gender reassignment and gender dysphoria are not covered.
Over the past year, we’ve seen a significant increase in the number, frequency, complexity, and cost of claims. More people are using their cover to access care when they need it most – which is exactly what private health insurance is here for.
At the same time, New Zealand’s public health system is under pressure. Wait times for specialist appointments and treatments continue to grow, and more Kiwis are turning to private healthcare as a more reliable option.
This shift has contributed to rising healthcare costs for over a year. We know our members are using their cover to take control of their health – and we’re proud to support that. But to help keep premiums manageable and ensure cover is focused on where it’s needed most, some changes are necessary.
By changing policies now, we can make sure we continue to offer the support that matters most – both now and into the future.
Co-payment means the member (your patient) will be required to pay a portion of the costs of certain benefits in their policy. In this case, if a covered procedure like a CT scan costs $2,000, a 20% co-payment will be applied first — that’s $400. The remaining $1,600 is then subject to any applicable excess. If their excess is $500, this will be deducted next. Your patient would pay a total of $900, and we’d cover the remaining $1,100.
The 20% co-payment will apply to certain benefits that cover specialist consultations and diagnostic tests. The co-payment doesn’t apply to tests listed in the Diagnostics Schedule. You can help your patients find a copy of the Diagnostics Schedule on the "What you’re covered for" page at nib.co.nz. They can access it directly by entering the following URL into their browser: nib.co.nz/am-i-covered
*Please note this list might be updated from time to time. After 24 November 2025, the best way to determine if the co-payment applies is to use the ‘estimate’ function on the nib provider portal.
If affordability is a concern for your patient, please encourage them to get in touch with nib through the my nz nib app, or their insurance adviser. We can discuss their options, including adjusting their policy or excess. Remember, co-payments only apply to some services, and their cover for private hospital admissions remains unchanged.
No, the co-payment only applies to certain diagnostic and specialist services. The co-payment doesn’t apply to services listed in the Diagnostics Schedule. You can help your patients find a copy of the Diagnostics Schedule on the "What you’re covered for" page at nib.co.nz. They can access it directly by entering the following URL into their browser: nib.co.nz/am-i-covered
For procedures where the co-payment is applicable, the co-payment will be applied each time a member has that procedure. For example, if a member needs multiple CT scans, the 20% co-payment will be applied to each scan.
These changes will come into effect on 24 November 2025.
If the patient’s treatment date is before 24 November 2025, the pre-approval will be honored. If the treatment date is on or after 24 November 2025 and the pre-approval is for a diagnostic procedure or a specialist consultation, the co-payment may apply. The easiest way to confirm if a co–payment applies is to use the new ‘estimate’ function on the nib provider portal.
From 24 November 2025, the nib provider portal will allow instant estimate functionality. This will enable you to input the treatment details and receive an instant estimate on how much nib will contribute to the treatment and how much your patient will need to pay. Once you have confirmed the details, you can click ‘submit’ to allow the pre-approval or claim to be processed.
If you are unable to see an estimate for the co-payment amount, this can be due to a number of reasons:
No co-payment is applicable to this claim – this will show as the member needing to pay $0
We require additional checks to process the claim – a message stating “Please note, we are unable to provide an estimate or confirm if we’ll cover this. Additional checks are required by our team” will be shown.
- One common cause for this is not answering all of the questions on the provider portal. Without answers to these questions our system will not be able to generate an estimate.
- There are a number of other reasons, such as the system being unable to identify if the member has cover, or if the member has reached their yearly limit.
If any of these situations apply, please submit the claim and someone from the nib team will get back to you.
For any questions or confirmation of whether the co-payment applies to your patient ’s claims and pre-approvals, please use the nib provider portal to get an instant decision. The portal will be able to provide quicker answers on whether a co-pay applies than calling or emailing us.
For any other questions or concerns, please contact your nib relationship manager or reach out to our support team at [email protected]
For pre-approvals, some questions will be optional, however, to be able to submit the claim you will need to know the answers to all of the questions. The below guide will help you answer them:
Q: Is this ACC related?
Tick YES if the reason for the procedure is:
caused by an injury
or member has an ACC decline letter
or awaiting ACC decision
or a possible treatment injury (injury that was caused by a surgery or infection / any complication caused by a surgery)
Q: Is this related to a surgery the member has already had?
This has to be a surgery that nib has paid for, not one in the public system.
Q: Is this related to a non-surgical treatment the member has already had?
This has to be a treatment that occurred in a private hospital.
If you are experiencing issues with the nib provider portal:
Try clearing your cached data
Then try to access the portal again with this link providerportal.nib.co.nz
The nib provider portal works best in the Google Chrome web browser
If you are still experiencing issues or errors, please take screenshot and send them to [email protected]
Only one administrator (or super user) is allowed per facility. The administrator has the ability to add other users.
They can do this by selecting ‘My Account’ from the top ribbon and entering the new user’s details. The new user will then receive a registration link to create their log-in.
If you are new to the portal or need to add a new administrator, please email us at [email protected] with the facility or provider details, along with the administrator’s full name, mobile number, and email address.
Even if pre-approval or claim advice shows $0 to pay from nib, please still submit the claim to ensure the member’s excess is calculated correctly.
When submitting a pre-approval, please search using the pre-approval number to ensure it can be correctly converted into a payment.
Important: You will only be able to locate the pre-approval number if the provider has submitted the pre-approval. If the member has submitted their own pre-approval directly, the number will not be visible in your system, and you will not be able to search by the pre-approval number or convert it to a payment. You can still submit a claim even if a pre-approval is not logged, or if the member submitted it. Simply click ‘Submit a Claim’ from the top ribbon and search using the member’s details.
When inputting the Provider name, the name needs to be linked to a bank account for payment. It might not be the person actually performing the treatment. If you’re unsure, please speak to your admin manager.
If your patient’s treatment date changes but is within the three-month period, there is no need to let us know. But if the treatment date changes after the three-month period on the pre-approval, please re-apply for pre-approval on the nib provider portal.
Pre-approvals will automatically cancel after three months, so there is no need to let us know if the procedures are not going ahead.
We no longer accept pre-approvals or claims by email. Please submit these through the nib provider portal.
Additional FAQs with Screenshots
Does the co-payment impact my patient’s excess?
If an excess and co-payment both apply to a claim, the co-payment will be applied to the claim first, and then the excess will be deducted from the part of the claim we pay. This will be clearly shown on the pre-approvals and claims page of the nib provider portal. Here is an example of how this will look:
What will this look like on the nib provider portal?
Here is an example of how the co-payment will be applied on the nib provider portal. It will show you how much the member is required to pay.
