Designated service providers (DSP) explained

A DSP is a provider the scheme has arranged to deliver a specific benefit, usually at agreed rates. There are often DSPs for:

• PMB conditions, in hospital and out of hospital
• Chronic medicine, through DSP pharmacies
• Specific procedures or services, depending on the plan

The scheme's rules and benefit guide tell you the DSP for each benefit. Using it means the scheme pays that provider's agreed rate in full. Many entry-level plans also restrict all hospital cover to a network, so the DSP idea can reach beyond PMBs. Check your plan in the benefit guide. See hospital plans explained.

PMBs must be paid in full, without co-payment or deductibles. The Regulations also say the scheme may require you to use its DSP, and a co-payment or deductible set in the scheme rules can be charged if you voluntarily use another provider. That is the catch behind "paid in full".

The CMS explains the cost like this: if you choose not to use the DSP, you may have to pay a percentage co-payment, or the difference between the DSP's tariff and what the provider you chose charged. See prescribed minimum benefits and co-payments and sub-limits.

No co-payment applies if you obtained the service involuntarily from a non-DSP. The Regulations treat that as the case when:

1. The service was not available from the DSP, or would not be provided without unreasonable delay.
2. Immediate treatment for a PMB condition was needed in circumstances or at a place that reasonably stopped you from reaching a DSP.
3. There was no DSP within reasonable proximity of your home or place of work.

The CMS adds that where a DSP is unable to accommodate or treat a member, the scheme remains liable for all the costs of treating the PMB condition at a non-DSP. Keep evidence: dates, the name of who told you the DSP could not help, and any referral letters.

In an emergency or accident you may go to the nearest healthcare facility, even if it is not a DSP, and your scheme has to cover the costs, says the CMS. The Regulations also stop a scheme from prohibiting a provider from starting appropriate treatment for an emergency before authorisation.

Get treated first and tell the scheme afterwards. Your rules set the notification window. See emergency and ambulance cover and pre-authorisation.

Chronic medicine often has to come from a DSP pharmacy, and from the scheme's formulary, to be paid in full. Using a non-DSP pharmacy can trigger a co-payment even though the medicine itself is covered. Many schemes use a courier or retail pharmacy network as the DSP. Register your chronic medicine with the right pharmacy, and check the pharmacy is still the scheme's DSP when your plan renews. See chronic disease benefits.

1. Read the DSP section of your benefit guide or the scheme's rules. The CMS says the DSP is required to be stated in the rules.
2. Ask the scheme, before treatment, whether the doctor, hospital or pharmacy you plan to use is a DSP for your condition.
3. Get it in writing if the answer decides who pays. Write down the name, date and reference number of the call.
4. If there is no DSP within reasonable reach, tell the scheme before you book, and ask it to approve your chosen provider.

If you were charged for using a non-DSP, work out whether the use was involuntary under the three cases above. If it was:

1. Ask the scheme in writing to reverse the co-payment, attaching your evidence. Use our appeal a rejected claim letter.
2. Use the scheme's dispute process.
3. If it is still not fixed, complain to the CMS. See how to complain to the CMS.