Health Insurance (Professional Services Review Content of Investigative Referrals) Guidelines 1999 (Cth)
Health Insurance (Professional Services Review — Content of Investigative Referrals) Guidelines 1999
I, MICHAEL WOOLDRIDGE, Minister for Health and Aged Care, make these Guidelines under subsection 87 (3) of the Health Insurance Act 1973.
Dated 9 December 1999.
MICHAEL WOOLDRIDGE
Minister for Health and Aged Care
Health Insurance (Professional Services Review — Content of Investigative Referrals) Guidelines 1999
made under the
Health Insurance Act 1973
Contents
Page
1 Name of Guidelines 2
2 Commencement 2
3 Definitions 2
4 Content of investigative referral 3
Schedule 1 Information that may be included in a referral 3
Schedule 2 Material that may be included in a referral 4
Name of Guidelines
These Guidelines are the Health Insurance (Professional Services Review — Content of Investigative Referrals) Guidelines 1999.
Commencement
These Guidelines commence on gazettal.
Note These Guidelines have no effect in relation to an old matter within the meaning of item 65 of Pt 2 of Sch 1 to the Health Insurance Amendment (Professional Services Review) Act 1999.
Definitions
(1) In these Guidelines:
Act means the Health Insurance Act 1973.
item means an item in the diagnostic imaging services table, the general medical services table or the pathology services table.
(2) An expression used in these Guidelines that is defined in section 81 of the Act has the same meaning in these Guidelines as in that section.
(3) A reference in these Guidelines to an item, in relation to a service, is a reference to the item as in force at the time the service was rendered.
Note Words and expressions defined in s 81 of the Act include investigative referral, person under review, pharmaceutical benefit, practitioner, profession, referral, referred services and service.
Other words and expressions used in these Guidelines are defined in the Act. For example, diagnostic imaging services table, general medical services table and pathology services table (see subs 3 (1)).
Content of investigative referral
(1) The content of an investigative referral may include any relevant information relating to the person under review and practitioners generally that is available to the Commission and, in particular, may include any of the information mentioned in Schedule 1 and any of the material mentioned in Schedule 2.
(2) The information included may relate to services rendered or initiated by:
(a) any of the persons mentioned in paragraph 86 (4) (a) of the Act; and
(b) for comparative purposes:
(i) a class of practitioners; and
(ii) all practitioners.
Schedule 1 Information that may be included in a referral
(section 4)
1. Details of the professional qualifications and experience of the person under review.
2. The location or locations of the practice of the person under review, and the availability in that location or those locations of services comparable to services of the kind rendered by or on behalf of the person under review.
3. Details of the demographics of persons in the locality or localities of the practice of the person under review.
Example
Relevant demographic information could include age, sex and ethnic background.
4. Details of the statistics of the practice of the person under review, including data relating to patients (individually or by reference to a class), services rendered or initiated and benefits paid or payable for those services.
Examples
1. The number of patients for whom services were rendered or initiated.
2. The number of services rendered, or initiated, by reference to the item in the general medical services table, or combination of items in the table, that describes the service.
3. The number of specialist referrals made.
4. The number of services rendered, or initiated, by reference to the item in the pathology services table, or combination of items in the table, that describes the service.
5. The number of services rendered, or initiated, by reference to the item in the diagnostic imaging services table, or combination of items in the table, that describes the service.
6. The number and type of prescriptions written for any pharmaceutical benefit (within the meaning of Part VII of the National Health Act 1953) prescribed or pharmaceutical benefits supplied, in total or by reference to a person or class of persons.
Schedule 2 Material that may be included in a referral
(section 4)
1. Reports of counselling given to the person under review.
2. Correspondence between the person under review and the Commission, and material provided by the person to the Commission, before the making of the referral.
3. Records of interview with:
(a) the person under review; and
(b) patients of the person; and
(c) any other person involved in the initiating or rendering of the services referred.
4. Statements by patients of the person under review.
5. Reports by relevant consultants and professional organisations.
6. Relevant medical literature.
7. Any determination implemented in relation to the person under review under the Professional Services Review scheme or in accordance with a recommendation of a Medical Services Committee of Inquiry under the former Division 3 of Part V of the Act or an Optometrical Services Committee of Inquiry under the former Division 3A of Part V of the Act.
Note Divisions 3 and 3A were repealed on 1 July 1994.
8. Reports on the person under review, or other advice, from a State or Territory body responsible for registering practitioners or regulating the profession.
9. Any documents relating to claims for medicare benefit submitted to the Commission by, or on behalf of:
(a) the person under review; or
(b) a patient to whom the person rendered a service.
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