Untitled document
Health Insurance Regulations 2018
made under the
Health Insurance Act 1973
Compilation No. 4
Compilation date: 1 November 2019
Includes amendments up to: F2019L01256
Registered: 1 November 2019
About this compilation
This compilation
This is a compilation of the Health Insurance Regulations 2018 that shows the text of the law as amended and in force on 1 November 2019 (the compilation date).
The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.
Uncommenced amendments
The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register ( The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.
Application, saving and transitional provisions for provisions and amendments
If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.
Editorial changes
For more information about any editorial changes made in this compilation, see the endnotes.
Modifications
If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.
Self‑repealing provisions
If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.
Contents
Part 1—Preliminary 1
1............ Name............................................................................................................................. 1
3............ Authority....................................................................................................................... 1
4............ Definitions..................................................................................................................... 1
Part 2—Definitional material 3
Division 1—Participating midwives 3
5............ Participating midwives—specified collaborative arrangements and medical practitioners....... 3
6............ Midwife record‑keeping requirements for certain collaborative arrangements............... 4
Division 2—Participating nurse practitioners 6
7............ Participating nurse practitioners—specified collaborative arrangements and medical practitioners...................................................................................................................................... 6
8............ Nurse practitioner record‑keeping requirements for certain collaborative arrangements 7
Division 3—Definition of services 9
9............ Professional services—medical services rendered by approved dental practitioners..... 9
10.......... Meaning of specialist trainee......................................................................................... 9
11.......... Professional services rendered by specialist trainees..................................................... 9
12.......... Health service not specified in an item—meaning of health service............................... 9
Division 4—Recognition of medical practitioners as specialists and consultant physicians 11
13.......... Recognition of medical practitioner domiciled in Australia as specialist—meaning of relevant organisation and relevant qualification......................................................................... 11
14.......... Alternative method of recognition of medical practitioner domiciled in Australia as specialist or consultant physician—application fee.......................................................................... 11
15.......... Recognition of medical practitioner who is not domiciled in Australia—application fee 11
Division 5—General practitioners 12
Subdivision A—Recognised Fellows of the Royal Australian College of General Practitioners 12
16.......... Eligibility for determination as recognised Fellow of RACGP.................................... 12
17.......... Notice from RACGP to Chief Executive Medicare if RACGP does not consider applicant eligible for determination............................................................................................................... 12
18.......... Revocation of determination as recognised Fellow of RACGP................................... 12
Subdivision B—Vocationally registered general practitioners 12
19.......... Eligibility for vocational registration............................................................................ 12
20.......... Notice from RACGP to Chief Executive Medicare if RACGP does not consider applicant eligible for vocational registration.................................................................................................. 12
21.......... Removal from Vocational Register of General Practitioners....................................... 13
Subdivision C—Recognised fellows of the Australian College of Rural and Remote Medicine 13
22.......... Determination as recognised Fellow of ACRRM........................................................ 13
23.......... Eligibility for determination as recognised Fellow of ACRRM................................... 14
24.......... Revocation of determination as recognised Fellow of ACRRM.................................. 14
Subdivision D—General practitioners for the purposes of section 20 of the Act 15
25.......... Medical practitioner who practises in general practice................................................. 15
Division 6—Register of Approved Placements 16
26.......... Specified bodies, courses and programs...................................................................... 16
27.......... Removal from the Register.......................................................................................... 18
Part 3—Medicare benefits 19
Division 1—Amount of medicare benefit 19
28.......... Entitlement to medicare benefit—services for which medicare benefit is 100% of Schedule fee.................................................................................................................................... 19
Division 2—Medicare benefits in relation to pathology services 21
Subdivision A—Simplified outline of this Division 21
29.......... Simplified outline of this Division............................................................................... 21
Subdivision B—Specifying services 21
30.......... Pathology service determined to be necessary by participating midwife...................... 21
31.......... Pathology service determined to be necessary by participating nurse practitioner....... 21
Subdivision C—Requirements for requests for pathology services 22
32.......... Purpose of Subdivision............................................................................................... 22
33.......... Information about requesting practitioner.................................................................... 22
34.......... Information about patient............................................................................................. 22
35.......... Information about pathology service........................................................................... 23
36.......... Requests that specify an approved pathology practitioner........................................... 23
37.......... Further requests........................................................................................................... 23
Division 3—Medicare benefits in relation to R‑type diagnostic imaging services 24
Subdivision A—Simplified outline of this Division 24
38.......... Simplified outline of this Division............................................................................... 24
Subdivision B—Specifying services for effective requests 24
39.......... Requests by dental practitioners.................................................................................. 24
40.......... Requests by chiropractors........................................................................................... 27
41.......... Requests by physiotherapists or osteopaths................................................................ 27
42.......... Requests by podiatrists................................................................................................ 27
43.......... Requests by participating midwives............................................................................ 27
44.......... Requests by participating nurse practitioners............................................................... 28
Subdivision C—Specifying services for pre‑existing diagnostic imaging practices 28
45.......... Exemption from subsection 16B(1) of the Act—pre‑existing diagnostic imaging practices 28
Division 4—Medicare benefits in relation to radiation oncology services 29
46.......... Meaning of radiation oncology service....................................................................... 29
Division 5—Particulars of professional services 30
47.......... Simplified outline of this Division............................................................................... 30
48.......... Purpose of Division.................................................................................................... 30
49.......... All services—particulars of patient, date of service and fees....................................... 30
50.......... All services—particulars of professional service rendered.......................................... 30
51.......... Most general medical services and Group P9 pathology services—particulars of person rendering service......................................................................................................................... 31
52.......... Certain radiation or nuclear services—particulars of person rendering service and person claiming or receiving fees............................................................................................................... 31
53.......... Certain radiation oncology services—use of equipment.............................................. 32
54.......... Pathology services (other than Group P9)—particulars of person rendering service.. 32
55.......... Pathology services—other particulars......................................................................... 32
56.......... Diagnostic imaging services—particulars of person rendering service and person claiming or receiving fees.............................................................................................................................. 33
57.......... Diagnostic imaging services—other particulars........................................................... 34
58.......... Services provided upon referral................................................................................... 35
59.......... Multiple professional services in a single day............................................................. 36
60.......... Anaesthesia................................................................................................................. 36
Division 6—Professional services rendered by or on behalf of certain medical practitioners 38
61.......... Other circumstances in which subparagraphs 19AA(1)(b)(iv) and (2)(b)(iv) of the Act apply.................................................................................................................................... 38
62.......... Meaning of intern........................................................................................................ 38
Division 7—Payments to medical practitioners and approved billing agents 39
63.......... Circumstances for electronic payments to medical practitioners.................................. 39
64.......... Requirements for payments to specialists and consultant physicians........................... 39
65.......... Approved billing agents—application requirements and fee........................................ 40
Division 8—Eligible midwives 41
66.......... Meaning of eligible midwife—requirements................................................................ 41
Part 4—Special provisions relating to pathology 42
67.......... Giving notice of termination of undertaking................................................................ 42
68.......... Approved pathology authorities—other records of pathology services....................... 42
69.......... Offences in relation to request forms—branded pathology request forms................... 42
Part 5—Special provisions relating to diagnostic imaging services 44
70.......... Requests for diagnostic imaging services—information and form requirements......... 44
71.......... Medical practitioners rendering diagnostic imaging services—other records of services 45
72.......... Diagnostic Imaging Register—other information to be included in application for registration.................................................................................................................................... 45
73.......... Diagnostic Imaging Register—other information to be included on Register.............. 46
74.......... Primary information—types of diagnostic imaging equipment.................................... 46
75.......... Diagnostic imaging accreditation—information to be included on Diagnostic Imaging Register.................................................................................................................................... 47
Part 6—Prohibited practices in relation to pathology services and diagnostic imaging services 48
76.......... Meaning of permitted benefit—method for determining substantial difference from market value.................................................................................................................................... 48
77.......... Meaning of permitted benefit—method for determining market value......................... 48
Part 7—Radiation Oncology Register 49
78.......... Radiation Oncology Register—other information to be included in application for registration.................................................................................................................................... 49
79.......... Radiation Oncology Register—other information to be included on the Register........ 49
80.......... Primary information—types of radiation oncology equipment.................................... 49
Part 8—Health program grants 50
81.......... Form for application for approval as an organization under Part IV of the Act........... 50
82.......... Form for application for approval of health service..................................................... 50
Part 9—Medicare Participation Review Committees 51
83.......... Meaning of professional organisation........................................................................ 51
Part 10—Quality assurance confidentiality 52
Division 1—Quality assurance activities—application for declaration 52
84.......... Application for declaration that quality assurance activity is activity to which Part VC of the Act applies.................................................................................................................................... 52
Division 2—Quality assurance activities—public interest criteria 53
85.......... Purpose of Division.................................................................................................... 53
86.......... Disclosure of information about quality assurance activities....................................... 53
87.......... Quality assurance activities engaged in in a single State or Territory........................... 53
88.......... Quality assurance activities of a kind that has not previously been engaged in in Australia 54
89.......... Quality assurance activities of a kind that has previously been engaged in in Australia 54
Part 11—Miscellaneous provisions 55
Division 1—Charging of fees for provision of public hospital services to public patients 55
90.......... Circumstances in which fees must not be charged for provision of public hospital services to public patients........................................................................................................................ 55
Division 2—Recovery of amounts 56
91.......... Recovery of debts due to the Commonwealth—prescribed rate of interest.................. 56
Division 3—Divulging and using information 57
92.......... Divulging information—treatment provided to veterans.............................................. 57
93.......... Divulging information—complaints and investigations............................................... 57
94.......... Professional disciplinary and regulatory bodies.......................................................... 59
Division 4—Manner of patient referrals 60
95.......... Purpose and application of Division............................................................................ 60
96.......... Who can make referral................................................................................................. 60
97.......... Requirement to consider need for referral.................................................................... 60
98.......... Requirements for form of referral................................................................................ 60
99.......... Requirements for contents of referral.......................................................................... 61
100........ Requirement to record certain referrals in hospital records.......................................... 61
101........ Receipt of referral by specialist or consultant physician.............................................. 61
102........ Period of validity for referrals..................................................................................... 62
Part 12—Transitional provisions 64
Division 1—Transitional matters relating to the repeal of the Health Insurance Regulations 1975 64
103........ Things done under the Health Insurance Regulations 1975........................................ 64
Schedule 1—Specialists 65
1............ Organisations, specialties and qualifications................................................................ 65
Schedule 2—Forms 70
Form 1—Application for approval as an organization under Part IV of the Act 70
Form 2—Application for approval of a health service 71
Endnotes72
Endnote 1—About the endnotes 72
Endnote 2—Abbreviation key 73
Endnote 3—Legislation history 74
Endnote 4—Amendment history 75
Part 1—Preliminary
1 Name
This instrument is the Health Insurance Regulations 2018.
3 Authority
This instrument is made under the Health Insurance Act 1973.
4 Definitions
Note: A number of expressions used in this instrument are defined in the Act, including the following:
(a) consultant physician;
(b) eligible midwife;
(c) eligible nurse practitioner;
(d) general practitioner;
(e) medical practitioner;
(f) participating midwife;
(g) participating nurse practitioner;
(h) specialist.
In this instrument:
accredited training: see subsection 23(4).
ACRRM means the Australian College of Rural and Remote Medicine.
Act means the Health Insurance Act 1973.
approved collection centre has the same meaning as in Part IIA of the Act.
authorised officer: see subsection 22(8).
diagnostic imaging provider: see subsection 70(5).
hospital‑authorised medical practitioner means a medical practitioner employed or engaged by a hospital authority (within the meaning of subsection 84(1) of the National Health Act 1953) who is authorised by the hospital authority to participate in a collaborative arrangement with a midwife.
identification number, in relation to an approved collection centre, means the identification number allocated to the centre under section 23DNBB of the Act.
obstetrician means a medical practitioner who is a specialist in the specialty of obstetrics and gynaecology (however described).
obstetric medical practitioner means:
(a) an obstetrician; or
(b) a medical practitioner who provides obstetric services.
paediatrician means a medical practitioner who is a specialist in the specialty of paediatrics and child health (however described).
pathology provider: see subsection 69(3).
predominantly general practice, in relation to a medical practitioner’s medical practice, means that more than 50% of the practitioner’s clinical time, and more than 50% of the services for which medicare benefits are claimed, are in general practice.
provider number means a number that:
(a) is allocated by the Chief Executive Medicare to a medical practitioner, dental practitioner, approved pathology practitioner, optometrist, participating midwife or participating nurse practitioner; and
(b) identifies the person and a place where the person practises the person’s profession.
quarter means a period of 3 months beginning on 1 January, 1 April, 1 July or 1 October.
RACGP means the Royal Australian College of General Practitioners.
referring practitioner, in relation to a referral, means the person making the referral.
registered sonographer: see subsection 71(6).
requester number means the number allocated by the Chief Executive Medicare to a chiropractor, osteopath, physiotherapist or podiatrist.
service time: see subsection 60(5).
treating practitioner, in relation to a pathology service, has the same meaning as in section 16A of the Act.
ultrasound service: see subsection 71(6).
usual general practitioner, for a patient, includes a medical practitioner nominated by the patient.
Part 2—Definitional material
Division 1—Participating midwives
5 Participating midwives—specified collaborative arrangements and medical practitioners
(1) For the purposes of the definition of participating midwife in subsection 3(1) of the Act (which deals with eligible midwives rendering services in collaborative arrangements with medical practitioners):
(a) a kind of collaborative arrangement is specified if:
(i) it is of a kind described in subsection (2); and
(ii) it complies with subsection (3); and
(b) a medical practitioner of the kind mentioned in a description of a kind of collaborative arrangement in subsection (2) is specified in relation to that kind of collaborative arrangement.
(2) For the purposes of subparagraph (1)(a)(i), the kinds of collaborative arrangements are the following:
(a) a collaborative arrangement in which the eligible midwife:
(i) is employed or engaged by one or more obstetric medical practitioners; or
(ii) is employed or engaged by an entity that employs or engages one or more obstetric medical practitioners; or
(iii) has an agreement in writing with an entity (other than a hospital) that employs or engages one or more obstetric medical practitioners;
(b) a collaborative arrangement in which an obstetric medical practitioner or hospital‑authorised medical practitioner refers a patient to the eligible midwife in writing;
(c) a collaborative arrangement in which the eligible midwife and one or more obstetric medical practitioners or hospital‑authorised medical practitioners make an agreement in writing, signed by each party;
(d) a collaborative arrangement in which the eligible midwife:
(i) has acknowledgement from one or more obstetric medical practitioners or hospital‑authorised medical practitioners that the practitioner will be collaborating in the care of a patient or patients; and
(ii) tells each patient to whom the arrangement applies that the midwife will be providing care to the patient within an arrangement with one or more medical practitioners that provides for consultation, referral of the patient and transfer of the patient’s care (as required by subsection (3)); and
(iii) makes the records required by section 6 in relation to each patient to whom the arrangement applies;
(e) a collaborative arrangement in which a hospital that employs or engages one or more obstetric medical practitioners:
(i) formally assesses the eligible midwife’s competence, performance and professional suitability; and
(ii) gives the eligible midwife clinical privileges for a defined scope of clinical practice; and
(iii) permits the eligible midwife to provide care to the midwife’s own patients at the hospital.
(3) For the purposes of subparagraph (1)(a)(ii), the collaborative arrangement must provide for:
(a) consultation between the midwife and an obstetric medical practitioner; and
(b) referral of a patient by the midwife to an obstetric medical practitioner or hospital‑authorised medical practitioner; and
(c) transfer of a patient’s care by the midwife to an obstetric medical practitioner.
(4) A collaborative arrangement may apply to more than one patient.
6 Midwife record‑keeping requirements for certain collaborative arrangements
General
(1) For the purposes of subparagraph 5(2)(d)(iii), the eligible midwife must record the following in the midwife’s written records in relation to the patient:
(a) the name of at least one obstetric medical practitioner or hospital‑authorised medical practitioner who has given the midwife an acknowledgement mentioned in subparagraph 5(2)(d)(i) that applies to the patient (a named medical practitioner);
(b) that the midwife has told the patient that the midwife will be providing care to the patient within an arrangement with one or more medical practitioners that provides for consultation, referral of the patient and transfer of the patient’s care (as required by subsection 5(3));
(c) the circumstances in which the midwife will do any of the following:
(i) consult with an obstetric medical practitioner about the patient’s care;
(ii) refer the patient to an obstetric medical practitioner or hospital‑authorised medical practitioner;
(iii) transfer the patient’s care to an obstetric medical practitioner.
Particular events
(2) For the purposes of subparagraph 5(2)(d)(iii), the eligible midwife must record the following in the midwife’s written records as soon as practicable after the event occurs:
(a) any consultation or other communication between the midwife and an obstetric medical practitioner about the patient’s care;
(b) any referral of the patient by the midwife to an obstetric medical practitioner or hospital‑authorised medical practitioner;
(c) any transfer by the midwife of the patient’s care to an obstetric medical practitioner;
(d) when the midwife gives a copy of the hospital booking letter (however described) for the patient to a named medical practitioner—acknowledgement that the named medical practitioner has received the copy;
(e) when the midwife gives a copy of the patient’s maternity care plan prepared by the midwife to a named medical practitioner—acknowledgement that the named medical practitioner has received the copy;
(f) if the midwife requests diagnostic imaging or pathology services for the patient—when the midwife gives the results of the services to a named medical practitioner;
(g) when the midwife gives a discharge summary (however described) at the end of the midwife’s care for the patient to:
(i) a named medical practitioner; or
(ii) the patient’s usual general practitioner.
Division 2—Participating nurse practitioners
7 Participating nurse practitioners—specified collaborative arrangements and medical practitioners
(1) For the purposes of the definition of participating nurse practitioner in subsection 3(1) of the Act (which deals with eligible nurse practitioners rendering services in collaborative arrangements with medical practitioners):
(a) a kind of collaborative arrangement is specified if:
(i) it is of a kind described in subsection (2); and
(ii) it complies with subsection (3); and
(b) all medical practitioners are specified.
(2) For the purposes of subparagraph (1)(a)(i), the kinds of collaborative arrangements are the following:
(a) a collaborative arrangement in which the eligible nurse practitioner is employed or engaged by:
(i) one or more medical practitioners; or
(ii) an entity that employs or engages one or more medical practitioners;
(b) a collaborative arrangement in which a medical practitioner refers a patient to the eligible nurse practitioner in writing;
(c) a collaborative arrangement in which the eligible nurse practitioner and one or more medical practitioners make an agreement in writing, signed by each party;
(d) a collaborative arrangement in which the eligible nurse practitioner:
(i) has acknowledgement from one or more medical practitioners that the practitioner will be collaborating in the care of a patient or patients; and
(ii) tells each patient to whom the arrangement applies that the nurse practitioner will be providing care to the patient within an arrangement with one or more medical practitioners that provides for consultation, referral of the patient and transfer of the patient’s care (as required by subsection (3)); and
(iii) makes the records required by section 8 in relation to each patient to whom the arrangement applies.
(3) For the purposes of subparagraph (1)(a)(ii), the collaborative arrangement must provide for:
(a) consultation between the nurse practitioner and a medical practitioner; and
(b) referral of a patient by the nurse practitioner to a medical practitioner; and
(c) transfer of a patient’s care by the nurse practitioner to a medical practitioner.
(4) A collaborative arrangement may apply to more than one patient.
8 Nurse practitioner record‑keeping requirements for certain collaborative arrangements
General
(1) For the purposes of subparagraph 7(2)(d)(iii), the nurse practitioner must record the following in the nurse practitioner’s written records in relation to the patient:
(a) the name of at least one medical practitioner who has given the midwife an acknowledgement mentioned in subparagraph 7(2)(d)(i) that applies to the patient (a named medical practitioner);
(b) that the nurse practitioner has told the patient that the nurse practitioner will be providing care to the patient within an arrangement with one or more medical practitioners that provides for consultation, referral of the patient and transfer of the patient’s care (as required by subsection 7(3));
(c) the circumstances in which the nurse practitioner will do any of the following:
(i) consult with a medical practitioner about the patient’s care;
(ii) refer the patient to a medical practitioner;
(iii) transfer the patient’s care to a medical practitioner.
Particular events
(2) For the purposes of subparagraph 7(2)(d)(iii), the eligible nurse practitioner must record the following in the nurse practitioner’s written records as soon as practicable after the event occurs:
(a) any consultation or other communication between the nurse practitioner and a medical practitioner about the patient’s care;
(b) any referral of the patient by the nurse practitioner to a medical practitioner;
(c) any transfer by the nurse practitioner of the patient’s care to a medical practitioner;
(d) if the nurse practitioner gives a copy of a document mentioned in subsection (4) to a named medical practitioner or the patient’s usual general practitioner—when the copy is given.
(3) The eligible nurse practitioner must give a copy of a document mentioned in subsection (4):
(a) to a named medical practitioner, if the nurse practitioner does any of the following and the named medical practitioner asks for a copy of the document:
(i) consults with the named medical practitioner about the patient’s care;
(ii) refers the patient to the named medical practitioner;
(iii) transfers the patient’s care to the named medical practitioner; and
(b) to the patient’s usual general practitioner, if:
(i) the patient’s usual general practitioner is not a named medical practitioner for the patient; and
(ii) the patient consents.
(4) The documents are the following:
(a) a referral of the patient by the nurse practitioner to a specialist or consultant physician;
(b) the results of diagnostic imaging or pathology services for the patient requested by the nurse practitioner;
(c) a record of services rendered by the nurse practitioner to the patient.
Division 3—Definition of services
9 Professional services—medical services rendered by approved dental practitioners
For the purposes of paragraph (b) of the definition of professional service in subsection 3(1) of the Act, a service specified in any item in Groups O1 to O11 of the general medical services table is prescribed.
10 Meaning of specialist trainee
For the purposes of subsection 3(20) of the Act, specialist trainee means a medical practitioner who is enrolled in and undertaking a training program with:
(a) an organisation mentioned in column 1 of an item in the table in clause 1 in Schedule 1 to this instrument; or
(b) the RACGP.
11 Professional services rendered by specialist trainees
For the purposes of paragraph 3(18)(a) of the Act, a professional service specified in any of the following items of the general medical services table is prescribed:
(a) all items in Group T1 except item 13209;
(b) all items in Groups T2, T3, T4, T5, T6, T7, T11, T10, T8 and T9.
Note: Subsection 3(18) of the Act applies when a specialist trainee renders a service under the supervision of another medical practitioner.
12 Health service not specified in an item—meaning of health service
For the purposes of paragraph (b) of the definition of health service in subsection 3C(8) of the Act, the following classes of services are prescribed:
(a) Aboriginal or Torres Strait Islander health services;
(b) audiology;
(c) chiropractic services;
(d) diabetes education;
(e) dietetics;
(f) exercise physiology;
(g) focussed psychological strategies;
(h) mental health services;
(i) midwifery;
(j) non‑directive pregnancy support counselling;
(k) nurse practitioner services;
(l) occupational therapy;
(m) orthoptics;
(n) osteopathy;
(o) physiotherapy;
(p) podiatry;
(q) psychological therapy;
(r) psychology;
(s) speech pathology.
Division 4—Recognition of medical practitioners as specialists and consultant physicians
13 Recognition of medical practitioner domiciled in Australia as specialist—meaning of relevant organisation and relevant qualification
(1) For the purposes of the definition of relevant organisation in subsection 3D(5) of the Act, an organisation mentioned in column 1 of an item in the table in clause 1 in Schedule 1 to this instrument is declared to be a professional organisation in relation to each specialty mentioned in column 2 of the item.
(2) For the purposes of the definition of relevant qualification in subsection 3D(5) of the Act, a qualification mentioned in column 3 of an item in the table in clause 1 in Schedule 1 to this instrument is declared to be a relevant qualification in relation to the organisation mentioned in column 1 of the item.
14 Alternative method of recognition of medical practitioner domiciled in Australia as specialist or consultant physician—application fee
For the purposes of paragraph 3DB(3)(b) of the Act, the fee is $30.
15 Recognition of medical practitioner who is not domiciled in Australia—application fee
For the purposes of subsection 3E(2) of the Act, the fee is $30.
Division 5—General practitioners
Subdivision A—Recognised Fellows of the Royal Australian College of General Practitioners
16 Eligibility for determination as recognised Fellow of RACGP
For the purposes of paragraph 3EA(2)(b) of the Act, an applicant is eligible for a determination under section 3EA of the Act if the applicant meets the minimum requirements of the RACGP for taking part in continuing medical education and quality assurance.
17 Notice from RACGP to Chief Executive Medicare if RACGP does not consider applicant eligible for determination
(1) If the RACGP declines to give the Chief Executive Medicare written notice under subsection 3EA(2) of the Act in relation to an applicant for a determination under section 3EA of the Act, the RACGP must give the Chief Executive Medicare written notice that it so declines.
(2) If the Chief Executive Medicare receives a notice under subsection (1) in relation to an applicant, the Chief Executive Medicare must give the applicant written notice that such a notice has been received.
18 Revocation of determination as recognised Fellow of RACGP
For the purposes of subsection 3EB(1) of the Act, a determination under section 3EA of the Act in respect of a medical practitioner must be revoked if the practitioner does not meet the minimum requirements of the RACGP for taking part in continuing medical education and quality assurance.
Subdivision B—Vocationally registered general practitioners
19 Eligibility for vocational registration
For the purposes of subsection 3F(6) of the Act, a medical practitioner whose name has been removed from the Vocational Register of General Practitioners is eligible for registration under section 3F of the Act if:
(a) the practitioner’s medical practice is, or will be within 28 days, predominantly general practice; and
(b) the practitioner meets the minimum requirements of the RACGP for taking part in continuing medical education and quality assurance programs.
20 Notice from RACGP to Chief Executive Medicare if RACGP does not consider applicant eligible for vocational registration
(1) If the RACGP declines to give the Chief Executive Medicare written notice under subsection 3F(6) of the Act in relation to an applicant for registration under section 3F of the Act, the RACGP must give the Chief Executive Medicare written notice that it so declines.
(2) If the Chief Executive Medicare receives a notice under subsection (1) in relation to an applicant, the Chief Executive Medicare must give the applicant written notice that such a notice has been received.
21 Removal from Vocational Register of General Practitioners
(1) For the purposes of subsection 3G(1) of the Act, a medical practitioner must be removed from the Vocational Register of General Practitioners if:
(a) the RACGP is satisfied that the practitioner’s medical practice was not predominantly general practice in the previous quarter; or
(b) the practitioner does not meet the minimum requirements of the RACGP for taking part in continuing medical education and quality assurance programs.
Subdivision C—Recognised fellows of the Australian College of Rural and Remote Medicine
22 Determination as recognised Fellow of ACRRM
(1) For the purposes of paragraph (c) of the definition of general practitioner in subsection 3(1) of the Act, a medical practitioner in respect of whom a determination is in force under this section is specified.
(2) A medical practitioner may apply to the Chief Executive Medicare for a determination under this section.
(3) After receiving an application, the Chief Executive Medicare must determine that the applicant is a recognised Fellow of the ACRRM if the ACRRM gives the Chief Executive Medicare written notice stating that the applicant:
(a) is a Fellow of the ACRRM; and
(b) is eligible for a determination under this section in accordance with section 23.
(4) The Chief Executive Medicare must make the determination within the period of:
(a) 14 days after the notice from the ACRRM was received; or
(b) if the application was made after the notice was received—14 days after the application was received.
(5) The Chief Executive Medicare must give the applicant written notice of the day on which the determination will come into force.
(6) The Chief Executive Medicare may give the ACRRM information about whether or not determinations under this section are in force for particular persons.
(7) The Chief Executive Medicare or an authorised officer may make available to members of the public, on request:
(a) the names of medical practitioners in respect of whom determinations under this section are in force; and
(b) the addresses at which they practise.
(8) In this section:
authorised officer means a Departmental employee (within the meaning given by section 3 of the Human Services (Medicare) Act 1973) authorised in writing by the Chief Executive Medicare for the purposes of this section.
23 Eligibility for determination as recognised Fellow of ACRRM
(1) This section is made for the purposes of paragraph 22(3)(b) of this instrument and deals with eligibility for a determination under section 22.
Note: Under section 22, the ACRRM gives the Chief Executive Medicare written notice that an applicant for a determination is eligible.
(2) An applicant who attained Fellowship of the ACRRM after the requirement to undergo accredited training was first introduced is eligible if the applicant:
(a) either:
(i) has successfully completed accredited training; or
(ii) has been assessed by the ACRRM as having training and experience equivalent to successful completion of accredited training; and
(b) meets the minimum requirements that apply to a Fellow of the ACRRM for taking part in continuing medical education and quality assurance.
(3) An applicant who attained Fellowship of the ACRRM before the requirement to undergo accredited training was first introduced is eligible for a determination if the applicant:
(a) either:
(i) has been assessed by the ACRRM, using an assessment model approved by the Department, as having training and experience equivalent to successful completion of accredited training; or
(ii) is a vocationally registered general practitioner; and
(b) meets the minimum requirements that apply to a Fellow of the ACRRM for taking part in continuing medical education and quality assurance.
(4) In this section:
accredited training means a training program and assessments for Fellowship of the ACRRM accredited by the Australian Medical Council.
24 Revocation of determination as recognised Fellow of ACRRM
(1) The Chief Executive Medicare must revoke a determination under section 22 in respect of a medical practitioner if:
(a) the medical practitioner requests the Chief Executive Medicare to do so; or
(b) the ACRRM gives the Chief Executive Medicare written notice that:
(i) the medical practitioner does not meet the minimum requirements that apply to a Fellow of the ACRRM for taking part in continuing medical education and quality assurance; or
(ii) the medical practitioner is not a Fellow of the ACRRM; or
(c) the Chief Executive Medicare becomes aware that the medical practitioner is no longer a medical practitioner.
(2) The ACRRM must, before giving the Chief Executive Medicare a notice under subparagraph (1)(b)(i) in relation to a medical practitioner:
(a) inform the medical practitioner about the proposed notice; and
(b) give the medical practitioner at least 14 days to show why the proposed notice should not be given.
(3) Before revoking the determination, the Chief Executive Medicare must give the medical practitioner written notice that the determination is to be revoked.
(4) The notice must specify the day on which the determination is to be revoked.
(5) The day specified under subsection (4) must not be less than 14 days after the day on which the notice is given.
Subdivision D—General practitioners for the purposes of section 20 of the Act
25 Medical practitioner who practises in general practice
For the purposes of paragraph (c) of the definition of general practitioner in subsection 3(1) of the Act, a medical practitioner (other than a specialist or consultant physician) who practises in general practice is specified for the purposes of section 20 of the Act.
Division 6—Register of Approved Placements
26 Specified bodies, courses and programs
Bodies and courses
(1) For the purposes of paragraph 3GA(5)(a) of the Act:
(a) a body mentioned in column 1 of an item in the following table is specified; and
(b) a course that leads to a qualification mentioned in column 2 of the item from the body is specified for the body.
| Specified bodies and qualifications that specified courses lead to | ||
| Item | Column 1 Body | Column 2 Qualification that course leads to |
| 1 | Australasian College for Emergency Medicine | FACEM |
| 2 | Australasian College of Sport and Exercise Physicians | FACSEP |
| 3 | Australian and New Zealand College of Anaesthetists | FANZCA FFPMANZCA |
| 4 | College of Intensive Care Medicine of Australia and New Zealand | FCICM |
| 5 | Royal Australasian College of Surgeons | FRACS |
| 6 | The Australasian College of Dermatologists | FACD |
| 7 | The Royal Australasian College of Physicians | FAChAM FAChPM FAChSHM FAFOEM FAFPHM FAFRM FRACP |
| 8 | The Royal Australian and New Zealand College of Obstetricians and Gynaecologists | FRANZCOG |
| 9 | The Royal Australian and New Zealand College of Ophthalmologists | FRANZCO |
| 10 | The Royal Australian and New Zealand College of Psychiatrists | FRANZCP |
| 11 | The Royal Australian and New Zealand College of Radiologists | FRANZCR |
| 12 | The Royal College of Pathologists of Australasia | FRCPA |
Bodies and programs
(2) For the purposes of paragraph 3GA(5)(a) of the Act:
(a) a body mentioned in column 1 of an item in the following table is specified; and
(b) a program mentioned in column 2 of the item is specified for the body.
| Specified bodies and programs | ||
| Item | Column 1 Body | Column 2 Program |
| 1 | Australian College of Rural and Remote Medicine | (a) Australian College of Rural and Remote Medicine Fellowship Program (b) Australian General Practice Training Program (c) Independent Pathway (d) Remote Vocational Training Scheme |
| 2 | The Department | (a) Approved Medical Deputising Services Program (b) Approved Private Emergency Department Program (c) Australian College of Rural and Remote Medicine Fellowship Program (d) Australian General Practice Training Program (e) More Doctors for Rural Australia Program (f) Remote Vocational Training Scheme (g) Royal Australian College of General Practitioners Fellowship Program (h) Rural Locum Relief Program (i) Special Approved Placements Program (j) Temporary Resident Other Medical Practitioners Program |
| 3 | General Practice Workforce Inc, trading as Health Recruitment Plus | (a) More Doctors for Rural Australia Program (b) Rural Locum Relief Program |
| 4 | Health Network Northern Territory Ltd (ACN 158 970 480) | (a) More Doctors for Rural Australia Program (b) Rural Locum Relief Program |
| 5 | Health Workforce Queensland Ltd (ACN 065 574 996) | (a) More Doctors for Rural Australia Program (b) Rural Locum Relief Program |
| 6 | NSW Rural Doctors Network Ltd (ACN 081 388 810) | (a) More Doctors for Rural Australia Program (b) Rural Locum Relief Program |
| 7 | Queensland Department of Health | Queensland Country Relieving Doctors Program |
| 8 | Remote Vocational Training Scheme Ltd (ACN 122 891 838) | Remote Vocational Training Scheme |
| 9 | Royal Australian College of General Practitioners | (a) Australian General Practice Training Program (b) Remote Vocational Training Scheme (c) Royal Australian College of General Practitioners Fellowship Program |
| 10 | Rural Doctors Workforce Agency Incorporated | (a) More Doctors for Rural Australia Program (b) Rural Locum Relief Program |
| 11 | Rural Workforce Agency, Victoria Limited (ACN 081 163 519) | (a) More Doctors for Rural Australia Program (b) Rural Locum Relief Program |
| 12 | Western Australian Centre for Remote and Rural Medicine Ltd (ACN 123 188 367) | (a) More Doctors for Rural Australia Program (b) Rural Locum Relief Program |
27 Removal from the Register
For the purposes of paragraph 3GB(1)(c) of the Act, a medical practitioner’s name must be removed from the Register if:
(a) the medical practitioner is recognised as a specialist under section 3D of the Act; or
(b) a determination under section 3EA of the Act or section 22 of this instrument is in force in respect of the medical practitioner; or
(c) the Chief Executive Medicare receives a written notice from a relevant organisation (within the meaning of section 3D of the Act) that it declines to give a written notice under subsection 3D(1) of the Act in relation to the medical practitioner; or
(d) the Chief Executive Medicare receives a written notice from the RACGP under subsection 17(1) of this instrument in relation to the medical practitioner; or
(e) the Chief Executive Medicare receives a written notice from the ACRRM that it declines to give a written notice under subsection 22(3) of this instrument in relation to the medical practitioner.
Part 3—Medicare benefits
Division 1—Amount of medicare benefit
28 Entitlement to medicare benefit—services for which medicare benefit is 100% of Schedule fee
Services specified in the general medical services table
(1) For the purposes of paragraph 10(2)(aa) of the Act, a service specified in an item of the general medical services table that is listed in the following table is prescribed.
Note: Some services are specified in a determination made under subsection 3C(1) of the Act.
| Services for which medicare benefit is 100% of Schedule fee—items of the general medical services table | ||
| Item | Column 1 Group or subgroup | Column 2 Items of the general medical services table |
| 1 | A1 | 3, 4, 23, 24, 36, 37, 44, 47 |
| 2 | A2 | 52, 53, 54, 57, 58, 59, 60, 65 |
| 3 | A5 | 160, 161, 162, 163, 164 |
| 4 | A6 | 170, 171, 172 |
| 5 | Subgroup 1 of Group A7 | 173, 193, 195, 197, 199 |
| 6 | Subgroup 2 of Group A7 | 179, 181, 185, 187, 189, 191, 203, 206 |
| 7 | Subgroup 3 of Group A7 | 214, 215, 218, 219, 220 |
| 8 | Subgroup 4 of Group A7 | 221, 222, 223 |
| 9 | Subgroup 5 of Group A7 | 177, 224, 225, 226, 227, 228 |
| 10 | Subgroup 6 of Group A7 | 229, 230, 231, 232, 233, 235, 236, 237, 238, 239, 240, 243, 244 |
| 11 | Subgroup 7 of Group A7 | 245, 249 |
| 12 | Subgroup 8 of Group A7 | 251, 252, 253, 254, 255, 256, 257, 259, 260, 261, 262, 263, 264, 265, 266, 268, 269, 270, 271 |
| 13 | Subgroup 9 of Group A7 | 272, 276, 277, 279, 281, 282, 283, 285, 286, 287, 371, 372 |
| 14 | Subgroup 10 of Group A7 | 733, 737, 741, 745, 761, 763, 766, 769, 772, 776, 788, 789 |
| 15 | Subgroup 11 of Group A7 | 792 |
| 16 | Subgroup 12 of Group A7 | 812, 827, 829, 867, 868, 869, 873, 876, 881, 885, 891, 892 |
| 17 | A11 | 585, 588, 591, 594, 599, 600 |
| 18 | A14 | 699, 701, 703, 705, 707, 715 |
| 19 | A15 | 721, 723, 729, 731, 732, 735, 739, 743, 747, 750, 758 |
| 20 | A17 | 900, 903 |
| 21 | A18 | 2497, 2501, 2503, 2504, 2506, 2507, 2509, 2517, 2518, 2521, 2522, 2525, 2526, 2546, 2547, 2552, 2553, 2558, 2559 |
| 22 | A19 | 2598, 2600, 2603, 2606, 2610, 2613, 2616, 2620, 2622, 2624, 2631, 2633, 2635, 2664, 2666, 2668, 2673, 2675, 2677 |
| 23 | A20 | 2700, 2701, 2712, 2713, 2715, 2717, 2721, 2723, 2725, 2727, 2729, 2731 |
| 24 | A22 | 5000, 5003, 5010, 5020, 5023, 5028, 5040, 5043, 5049, 5060, 5063, 5067 |
| 25 | A23 | 5200, 5203, 5207, 5208, 5220, 5223, 5227, 5228, 5260, 5263, 5265, 5267 |
| 26 | A27 | 4001 |
| 27 | A29 | 139 |
| 28 | A30 | 2100, 2122, 2125, 2126, 2137, 2138, 2143, 2147, 2179, 2195, 2199, 2220, 2461, 2463, 2464, 2465, 2471, 2472, 2475, 2478, 2480, 2481, 2482, 2483 |
| 28A | A35 | 90020, 90035, 90043, 90051, 90092, 90093, 90095, 90096, 90183, 90188, 90202, 90212 |
| 28B | A36 | 90250, 90251, 90252, 90253, 90254, 90255, 90256, 90257, 90264, 90265, 90271, 90272, 90273, 90274, 90275, 90276, 90277, 90278, 90279, 90280, 90281, 90282 |
| 29 | M12 | 10983, 10984, 10987, 10988, 10989, 10997 |
| 30 | T1 | 13105 |
Services specified in the diagnostic imaging services table
(2) For the purposes of paragraph 10(2)(aa) of the Act, a service specified in an item of the diagnostic imaging services table to which clause 1.2.9 or 1.2.10 of that table applies is prescribed.
Division 2—Medicare benefits in relation to pathology services
Subdivision A—Simplified outline of this Division
29 Simplified outline of this Division
Section 16A of the Act sets out conditions on medicare benefit being payable in relation to a pathology service.
Some of these conditions include a requirement for the service to be specified in the regulations. Subdivision B specifies services for these purposes.
Section 16A of the Act also enables the regulations to prescribe requirements for a request for a pathology service. Subdivision C prescribes requirements for these purposes.
Subdivision B—Specifying services
30 Pathology service determined to be necessary by participating midwife
For the purposes of subparagraph 16A(1)(aa)(ii) of the Act, a service specified in an item of the pathology services table that is listed in the following table is specified.
| Pathology services—participating midwives | ||
| Item | Column 1 Group | Column 2 Items of the pathology services table |
| 1 | P1 | 65060, 65070, 65090 to 65099, 65114 |
| 2 | P2 | 66500 to 66512, 66545, 66548, 66566, 66743, 66750, 66751 |
| 3 | P3 | 69303 to 69317, 69324, 69384 to 69415 |
| 4 | P6 | 73070, 73071, 73075, 73076 |
| 5 | P8 | 73529 |
31 Pathology service determined to be necessary by participating nurse practitioner
For the purposes of subparagraph 16A(1)(ab)(ii) of the Act, a service specified in an item in any of Groups P1 to P8 or in any of items 73828 to 73837 of the pathology services table is specified.
Note: Items 73828 to 73837 are specified in a determination made under subsection 3C(1) of the Act.
Subdivision C—Requirements for requests for pathology services
32 Purpose of Subdivision
This Subdivision is made for the purposes of paragraph 16A(4)(b) of the Act.
33 Information about requesting practitioner
A request for a pathology service must include the following information in relation to the treating practitioner or approved pathology practitioner who makes the request (the requesting practitioner):
(a) the name of the requesting practitioner;
(b) if the request was made at a place of practice of the requesting practitioner:
(i) the address of the place of practice; or
(ii) if the requesting practitioner has been allocated a provider number in respect of the place of practice—the provider number;
(c) if the request was not made at such a place of practice:
(i) the address of any place of practice of the requesting practitioner; or
(ii) the provider number of the requesting practitioner in respect of any place of practice.
34 Information about patient
(1) A request for a pathology service must, subject to subsection 37(3), include the following information in respect of the person in relation to whom the service is requested:
(a) the name of the person;
(b) the address of the person;
(c) whether the person is a public patient in a hospital;
(d) whether the person is a private patient in a hospital;
(e) whether the request is made in the course of the provision to the person of an out‑patient service at a recognised hospital.
(2) If the person is a private patient in relation to a hospital, the request may, with the consent of the person, include the following information:
(a) the name of the person’s private health insurer (if any);
(b) the membership number or other unique identifier allocated to the person by the insurer.
(3) If the person does not consent to the inclusion of the information mentioned in subsection (2):
(a) the request must not include the information; and
(b) the person’s failure to consent does not affect any entitlement the person may have to a medicare benefit, or a benefit payable by a private health insurer, in respect of the service.
35 Information about pathology service
A request for a pathology service must, subject to subsection 37(3), include the following information in respect of the service:
(a) a description of the service in terms or symbols that:
(i) would be generally understood by medical practitioners; and
(ii) are sufficient to identify the service for the purpose of ascertaining the item (if any) in which the service is specified;
(b) the date on which the service was determined to be necessary;
(c) whether the service is a pathology service that:
(i) relates to a bodily specimen obtained from a person while the person was an in‑patient of a hospital; and
(ii) is to be performed after the person has ceased to be such a patient.
36 Requests that specify an approved pathology practitioner
If a treating practitioner specifies an approved pathology practitioner on a request for a pathology service, the request must include:
(a) the clinical grounds for specifying an approved pathology practitioner; or
(b) a statement that the specification is on clinical grounds.
37 Further requests
(1) This section applies if:
(a) a treating practitioner makes a request (the first request) for a pathology service; and
(b) the first request is received by an approved pathology practitioner (the referring pathologist); and
(c) the referring pathologist makes a request (the further request) for the service.
(2) The further request must, subject to subsection (3), include the information relating to the treating practitioner that was included in the first request under section 33.
(3) The further request is not required to comply with sections 34 and 35 and subsection (2) of this section if:
(a) the further request relates only to the pathology service to which the first request relates; and
(b) the first request is attached to the further request.
Division 3—Medicare benefits in relation to R‑type diagnostic imaging services
Subdivision A—Simplified outline of this Division
38 Simplified outline of this Division
Section 16B of the Act sets out conditions on medicare benefit being payable in relation to an R‑type diagnostic imaging service.
Some of these conditions include a requirement for the service to be specified in the regulations. Subdivision B specifies services for these purposes.
Section 16B of the Act also contains an exemption which includes a requirement for a service to be specified in the regulations. Subdivision C specifies services for these purposes.
Subdivision B—Specifying services for effective requests
39 Requests by dental practitioners
(1) For the purposes of subsection 16B(2) of the Act, this section specifies R‑type diagnostic imaging services.
All dental practitioners
(2) A service specified in an item of the diagnostic imaging services table that is listed in the following table is specified in relation to all dental practitioners.
| R‑type diagnostic imaging service—request by any dental practitioner | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I3 | 57509, 57515, 57521, 57523, 57527, 57530, 57533, 57536, 57539, 57540, 57901 to 57969, 58100, 58102, 58300, 58302, 58503, 58505, 58903, 58905, 59733, 59734, 59739, 59740, 59751, 59752, 60100, 60101, 60500, 60501, 60503, 60504 |
Dental practitioners approved for professional services
(3) A service specified in an item of the diagnostic imaging services table that is listed in the following table is specified in relation to a dental practitioner who is approved by the Minister under paragraph (b) of the definition of professional service in subsection 3(1) of the Act.
| R‑type diagnostic imaging service—request by approved dental practitioner | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I1 | 55005, 55008, 55011, 55028, 55030, 55032 |
| 2 | I2 | 56001 to 56220, 56224, 56227, 56230, 56259, 56301 to 56507, 56541, 56547, 56801 to 57007, 57041, 57047, 57341, 57345 |
| 3 | I3 | 57703, 57705, 57709, 57711, 57712, 57714, 57715, 57717, 58103 to 58115, 58117, 58123, 58124, 58306, 58308, 58506, 58508, 58521 to 58527, 58529, 58909, 58911, 59103, 59104, 59703, 59704, 60000 to 60010, 60506, 60507, 60509, 60510, 61109, 61110 |
| 4 | I4 | 61372, 61421, 61425, 61429, 61430, 61433, 61434, 61446, 61449, 61450, 61453, 61454, 61457, 61462, 61672, 61690, 61691, 61693, 61694, 61695, 61696, 61702, 61703, 61704, 61705, 61706, 61707, 61710 |
| 5 | I5 | 63007, 63008, 63016, 63329, 63334, 63346 |
Note: Items 63008 and 63329 are specified in a determination made under subsection 3C(1) of the Act.
Prosthodontists
(4) A service specified in an item of the diagnostic imaging services table that is listed in the following table is specified in relation to a dental practitioner who is:
(a) registered or licensed as a prosthodontist under a law of a State or Territory; or
(b) registered or licensed as a dentist or dental practitioner under a law of State or Territory and recognised by the registering or licensing authority as a person who practises in the specialty of prosthodontics.
| R‑type diagnostic imaging service—request by prosthodontist | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I1 | 55005, 55028 |
| 2 | I2 | 56013, 56016, 56022, 56028, 56053, 56056, 56062, 56068, 57362, 57363 |
| 3 | I3 | 58306, 58308 |
| 4 | I4 | 61421, 61425, 61429, 61430, 61433, 61434, 61446, 61449, 61450, 61453, 61454, 61457, 61462, 61690, 61691, 61693, 61694, 61695, 61696, 61702, 61703, 61704, 61705, 61706, 61707, 61710 |
| 5 | I5 | 63329, 63334, 63346 |
Note: Item 63329 is specified in a determination made under subsection 3C(1) of the Act.
Periodontists, endodontists, pedeodontists and orthodontists
(5) A service specified in an item of the diagnostic imaging services table that is listed in the following table is specified in relation to a dental practitioner who is:
(a) registered or licensed as a periodontist, endodontist, pedeodontist or orthodontist under a law of a State or Territory; or
(b) registered or licensed as a dental specialist under a law of a State or Territory and recognised by the registering or licensing authority as a person who practises in the specialty of periodontics, endodontics, pedeodontics, or orthodontics.
| R‑type diagnostic imaging service—request by periodontist, endodontist, pedeodontist or orthodontist | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I2 | 56022, 56062, 57362, 57363 |
| 2 | I3 | 58306, 58308 |
| 3 | I4 | 61421, 61454, 61457, 61690, 61706, 61707 |
| 4 | I5 | 63329, 63334, 63346 |
Note: Item 63329 is specified in a determination made under subsection 3C(1) of the Act.
Oral medicine and oral pathology specialists
(6) A service specified in an item of the diagnostic imaging services table that is listed in the following table is specified in relation to a dental practitioner who is:
(a) registered or licensed as an oral medicine specialist or oral pathology specialist under a law of a State or Territory; or
(b) registered or licensed as a dental specialist under a law of a State or Territory and recognised by the registering or licensing authority as a person who practises in the specialty of oral medicine or oral pathology.
| R‑type diagnostic imaging service—request by oral medicine or oral pathology specialist | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I1 | 55005, 55008, 55011, 55028, 55030, 55032 |
| 2 | I2 | 56001, 56007, 56010, 56013, 56016, 56022, 56028, 56041, 56047, 56050, 56053, 56056, 56062, 56068, 56101, 56107, 56141, 56147, 56301, 56307, 56341, 56347, 56401, 56407, 56441, 56447, 57341, 57345, 57362, 57363 |
| 3 | I3 | 58306, 58308, 58506, 58508, 58909, 58911, 59103, 59104, 59703, 59704, 60000 to 60010, 60506, 60507, 60509, 60510, 61109, 61110 |
| 4 | I4 | 61372, 61421, 61425, 61429, 61430, 61433, 61434, 61446, 61449, 61450, 61453, 61454, 61457, 61462, 61672, 61690, 61691, 61693, 61694, 61695, 61696, 61702, 61703, 61704, 61705, 61706, 61707, 61710 |
| 5 | I5 | 63007, 63008, 63016, 63329, 63334, 63346 |
Note: Items 63008 and 63329 are specified in a determination made under subsection 3C(1) of the Act.
40 Requests by chiropractors
For the purposes of subsection 16B(3) of the Act, a service specified in an item of the diagnostic imaging services table that is listed in the following table is specified.
| R‑type diagnostic imaging service—request by chiropractor | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I3 | 57712, 57714, 57715, 57717, 58100 to 58106, 58109, 58111, 58112, 58117, 58123 |
41 Requests by physiotherapists or osteopaths
For the purposes of subsections 16B(3A) and (3C) of the Act, a service specified in an item of the diagnostic imaging services table that is listed in the following table is specified.
| R‑type diagnostic imaging service—request by physiotherapist or osteopath | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I3 | 57712, 57714, 57715, 57717, 58100 to 58106, 58109, 58111, 58112, 58117, 58120, 58121, 58123, 58126, 58127 |
42 Requests by podiatrists
For the purposes of subsection 16B(3B) of the Act, a service specified in an item of the diagnostic imaging services table that is listed in the following table is specified.
| R‑type diagnostic imaging service—request by podiatrist | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I1 | 55836, 55837, 55840, 55841, 55844, 55845 |
| 2 | I3 | 57521, 57523, 57527, 57536, 57539, 57540 |
43 Requests by participating midwives
For the purposes of subsection 16B(3D) of the Act, a service specified in an item of the diagnostic imaging services table that is listed in the following table is specified.
| R‑type diagnostic imaging service—request by participating midwife | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I1 | 55700, 55701, 55704, 55706, 55707, 55710, 55713, 55714, 55718, 55722 |
44 Requests by participating nurse practitioners
For the purposes of subsection 16B(3E) of the Act, a service specified in an item of the diagnostic imaging services table that is listed in the following table is specified.
| R‑type diagnostic imaging service—request by participating nurse practitioner | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I1 | 55014, 55036, 55059, 55061, 55070, 55076, 55600, 55601, 55768, 55769, 55800, 55801, 55804, 55805, 55808, 55809, 55812, 55813, 55816, 55817, 55820, 55821, 55824, 55825, 55828, 55829, 55832, 55833, 55836, 55837, 55840, 55841, 55844, 55845, 55848, 55849, 55850, 55851, 55852, 55853 |
| 2 | I3 | 57509, 57515, 57521, 57523, 57527, 57530, 57533, 57536, 57540, 57703, 57705, 57709, 57711, 57712, 57714, 57715, 57717, 57721, 58503 to 58527, 58529 |
Subdivision C—Specifying services for pre‑existing diagnostic imaging practices
Exemption from subsection 16B(1) of the Act—pre‑existing diagnostic imaging practices
For the purposes of subsection 16B(11) of the Act, a service specified in an item of the diagnostic imaging services table that is listed in the following table is specified.
| Exemption—pre‑existing diagnostic imaging practices | ||
| Item | Column 1 Group | Column 2 Items of the diagnostic imaging services table |
| 1 | I3 | 57712, 57714, 57715, 57717, 57901, 57902, 57903, 57911, 57912, 57914, 57915, 57917, 57921, 57926, 57929, 57935, 58100 to 58115, 58117, 58123, 58124, 58521, 58523, 58524, 58526, 58527, 58529, 58700, 58702, 59103, 59104 |
Division 4—Medicare benefits in relation to radiation oncology services
46 Meaning of radiation oncology service
For the purposes of subsection 16F(2) of the Act, a radiation oncology service is a service specified in an item in Subgroup 3, 4 or 5 of Group T2 in the general medical services table.
Division 5—Particulars of professional services
47 Simplified outline of this Division
Under subsection 19(6) of the Act, a medicare benefit is not payable in respect of a professional service unless prescribed particulars are recorded on:
(a) an account for the professional service; or
(b) a receipt for the professional service; or
(c) the form of an assignment or agreement under section 20A of the Act in relation to the professional service.
This Division prescribes particulars for the purposes of subsection 19(6) of the Act. The particulars are divided into different kinds, including kinds of particulars that are only required for a certain class of professional service.
48 Purpose of Division
For the purposes of subsection 19(6) of the Act, this Division prescribes particulars in relation to professional services.
49 All services—particulars of patient, date of service and fees
The following particulars are prescribed in relation to a professional service:
(a) the name of the patient to whom the service was rendered;
(b) the date on which the service was rendered;
(c) the amount charged in respect of the service;
(d) the total amount paid in respect of the service;
(e) any amount outstanding in respect of the service.
50 All services—particulars of professional service rendered
General
(1) Subject to this section, a prescribed particular in relation to a professional service is a description of the service sufficient to identify the item that specifies the service.
Hospital treatment
(2) If the professional service is rendered as part of an episode of hospital treatment, then:
(a) the description mentioned in subsection (1) must indicate that the service was rendered as part of an episode of hospital treatment; or
(b) a briefer description of the service may be used together with the number of the item that specifies the service, followed by an asterisk or the letter “H”.
Hospital‑substitute treatment
(3) If the professional service is rendered as part of an episode of hospital‑substitute treatment, and the person who receives the treatment chooses to receive a benefit from a private health insurer in respect of the professional service, then:
(a) the description mentioned in subsection (1) must be preceded by the words “hospital‑substitute treatment”; or
(b) a briefer description of the service may be used together with the number of the item that specifies the service, followed by the words “hospital‑substitute treatment”.
51 Most general medical services and Group P9 pathology services—particulars of person rendering service
(1) This section applies to a professional service that is specified:
(a) in an item in the general medical services table, except items 12500 to 12533, 15000 to 15600 and 16003 to 16015; or
(b) in an item in Group P9 of the pathology services table.
(2) Subject to subsection (3), prescribed particulars are:
(a) the name of the person who rendered the service and the address of the place of practice where the service was rendered; or
(b) if the service was rendered at a place of practice for which the person rendering the service has been allocated a provider number—the provider number; or
(c) if the service was not rendered at such a place of practice—the provider number allocated to the person for any place where the person practises;
and a statement that the professional service was provided by that person.
(3) If the service is rendered by a medical practitioner who is an overseas trained doctor or a foreign graduate of an accredited medical school (within the meaning of section 19AB of the Act), then:
(a) the particulars mentioned in paragraph (2)(a) are prescribed; and
(b) the particulars mentioned in paragraph (2)(b) or paragraph (2)(c), as the case requires, are also prescribed; and
(c) a statement that the professional service was provided by the medical practitioner is a prescribed particular.
52 Certain radiation or nuclear services—particulars of person rendering service and person claiming or receiving fees
(1) This section applies to a professional service that is specified in any of items 12500 to 12533, 15000 to 15600 and 16003 to 16015 in the general medical services table.
(2) Prescribed particulars are:
(a) the name of the medical practitioner who rendered the service and the address of the place of practice where the service was rendered; or
(b) if the service was rendered at a place of practice for which the medical practitioner has been allocated a provider number—the provider number.
(3) If a medical practitioner (the billing practitioner) other than the medical practitioner who rendered the service is:
(a) claiming or receiving payment of fees in relation to the service; or
(b) the assignee under an assignment or agreement, made or entered into in accordance with section 20A of the Act, in relation to the medicare benefit in respect of the service;
then additional prescribed particulars are either the name of the billing practitioner and the address of a place of practice of the billing practitioner, or the provider number in respect of a place of practice of the billing practitioner.
53 Certain radiation oncology services—use of equipment
(1) This section applies to a professional service that is a radiation oncology service rendered using:
(a) radiation oncology equipment that is ordinarily located at registered radiation oncology premises; or
(b) radiation oncology equipment that, when not in use, is ordinarily located at a registered base for mobile radiation oncology equipment.
(2) A prescribed particular is the location specific practice number for the premises or base.
54 Pathology services (other than Group P9)—particulars of person rendering service
(1) This section applies to a professional service that is specified in an item in the pathology services table, other than an item in Group P9.
(2) Prescribed particulars are either the name of one of the following persons and the address of the person’s place of practice, or the provider number of one of the following persons in respect of the person’s place of practice:
(a) the approved pathology practitioner by whom, or on whose behalf, the service was rendered;
(b) if the service was rendered completely in a single accredited pathology laboratory—any approved pathology practitioner rendering professional services in the accredited pathology laboratory;
(c) if the service was rendered in more than one accredited pathology laboratory owned and controlled by an approved pathology authority—any approved pathology practitioner rendering professional services in one of the laboratories where the service was partly rendered.
55 Pathology services—other particulars
(1) This section applies to a professional service that is a pathology service.
Requested pathology services
(2) If the service is rendered in accordance with subsections 16A(2) and (3) of the Act, the following particulars are prescribed:
(a) the name of the treating practitioner who requested the service;
(b) if the request was made at a place of practice of the treating practitioner:
(i) the address of the place of practice; or
(ii) if the treating practitioner has been allocated a provider number in respect of the place of practice—the provider number;
(c) if the request was not made at such a place of practice:
(i) the address of any place of practice of the treating practitioner; or
(ii) the provider number of the treating practitioner in respect of any place of practice;
(d) the date on which the treating practitioner determined that the service was necessary.
Pathologist‑determinable services
(3) If the service is a pathologist‑determinable service that was determined to be necessary by the approved pathology practitioner by whom, or on whose behalf, the service was performed, a prescribed particular is an indication that the service was determined to be necessary by that approved pathology practitioner.
Services rendered by a member of a group of medical practitioners
(4) If the service is rendered in the circumstances described in paragraph 16A(7)(b) of the Act, the following particulars are prescribed:
(a) the name of the treating practitioner who requested the service;
(b) the date on which the treating practitioner made the request.
Initiation of a patient episode by collection of a specimen
(5) If the service is initiation of a patient episode by collection of a specimen, a prescribed particular is an identification of the collection point as follows:
(a) for a collection made at an approved collection centre—the identification number of the centre;
(b) for a collection made at a recognised hospital—the recognised hospital collection point identification number assigned by the Chief Executive Medicare;
(c) for any other collection—“A01”.
56 Diagnostic imaging services—particulars of person rendering service and person claiming or receiving fees
(1) This section applies to a professional service that is a diagnostic imaging service.
(2) Prescribed particulars in relation to the medical practitioner who is:
(a) claiming or receiving payment of fees in relation to the service; or
(b) the assignee under an assignment or agreement, made or entered into in accordance with section 20A of the Act, in relation to the medicare benefit in respect of the service;
are either the name of the medical practitioner and the address of a place of practice of the medical practitioner, or the provider number in respect of a place of practice of the medical practitioner.
(3) If the medical practitioner mentioned in subsection (2) (the billing practitioner) is not the medical practitioner that rendered the service (the service practitioner), then, subject to subsection (4), additional prescribed particulars are:
(a) the name of the service practitioner and the address of the place of practice where the service was rendered; or
(b) if the service was rendered at a place of practice for which the service practitioner has been allocated a provider number—the provider number.
(4) Subsection (3) does not apply if the particulars mentioned in paragraph (3)(a) or (b), and the date on which the service was requested, are recorded at the billing practitioner’s place of practice.
57 Diagnostic imaging services—other particulars
(1) This section applies to a professional service that is a diagnostic imaging service.
R‑type diagnostic imaging services
(2) For an R‑type diagnostic imaging service, the following particulars are prescribed:
(a) the name of the person who requested the service;
(b) the address of the place of practice, or the provider number in respect of the place of practice, or the requester number, of the person who requested the service;
(c) the date on which the service was requested.
Use of equipment
(3) If the service is rendered using a diagnostic imaging procedure that is carried out using:
(a) diagnostic imaging equipment that is ordinarily located at registered diagnostic imaging premises; or
(b) diagnostic imaging equipment that, when not in use, is ordinarily located at a registered base for mobile diagnostic imaging equipment;
a prescribed particular is the location specific practice number for the premises or base.
Recording application of exemptions
(4) If the service is rendered in the circumstances mentioned in:
(a) subsection 16B(6) of the Act (consultant physicians and specialists); or
(b) subsection 16B(7) of the Act (remote area); or
(c) subsection 16B(10) of the Act (additional services); or
(d) subsection 16B(11) of the Act (pre‑existing diagnostic imaging practices);
a prescribed particular is the letters “SD” (for self‑determined).
(5) If the service is rendered in the circumstances mentioned in subsection 16B(8) of the Act (emergencies), a prescribed particular is the word “emergency”.
(6) If the service is rendered in the circumstances mentioned in subsection 16B(9) of the Act (lost requests), a prescribed particular is the words “lost request”.
(7) If the service is rendered in the circumstances mentioned in subsection 16B(10A) of the Act (substituted services), a prescribed particular is the letters “SS”.
58 Services provided upon referral
(1) This section applies to a professional service if:
(a) the service is rendered to a patient by a specialist or consultant physician; and
77 Meaning of permitted benefit—method for determining market value
(1) For the purposes of subsection 23DZZIF(9) of the Act, the market value of property, goods or services is the amount that a willing purchaser would have had to pay, at the time mentioned in subsection (2), to a vendor who was willing, but not anxious, to sell.
(2) The time is, for an offence or contravention of a civil penalty provision that involves:
(a) a person asking for a benefit that is not a permitted benefit—when the person asked for the benefit; or
(b) a person accepting a benefit that is not a permitted benefit—when the person accepted the benefit; or
(c) a person offering a benefit that is not a permitted benefit—when the person offered the benefit; or
(d) a person providing a benefit that is not a permitted benefit—when the person provided the benefit.
Part 7—Radiation Oncology Register
78 Radiation Oncology Register—other information to be included in application for registration
For the purposes of paragraph 23DZZO(1)(d) of the Act, the other information that must be included in an application for registration of radiation oncology premises or a base for mobile radiation oncology equipment is the following:
(a) the nature of the practice at the premises or base;
(b) for radiation oncology premises—the quantity of each type of radiation oncology equipment ordinarily located at the premises;
(c) for each piece of radiation oncology equipment ordinarily located at the premises or base that has a serial number or other identifying number—that number;
(d) the functionality of each piece of radiation oncology equipment ordinarily located at the premises or base.
Example: For paragraph (a), the practice might be a base for mobile equipment, a specialist radiation oncology practice (either on a stand‑alone practice site or co‑located with a primary care practice or group), a primary care practice, a sports medicine clinic or a public hospital.
79 Radiation Oncology Register—other information to be included on the Register
For the purposes of subparagraph 23DZZP(1)(b)(iv) of the Act, the other information that must be included on the Radiation Oncology Register for premises or a base is the information mentioned in section 78 of this instrument that was included in the application for registration.
80 Primary information—types of radiation oncology equipment
For the purposes of subsection 23DZZQ(2) of the Act, each of the following is a type of radiation oncology equipment:
(a) megavoltage equipment, that is, equipment that is primarily used in the rendering of a service specified in any item in Subgroup 3 of Group T2 in the general medical services table;
(b) brachytherapy equipment, that is, equipment that is primarily used in the rendering of a service specified in any item in Subgroup 4 of Group T2 in the general medical services table;
(c) planning equipment, that is, equipment that is primarily used in the rendering of a service specified in any item in Subgroup 5 of Group T2 in the general medical services table.
Part 8—Health program grants
Form for application for approval as an organization under Part IV of the Act
(1) For the purposes of subsection 40(1) of the Act, the prescribed form is Form 1 in Schedule 2 to this instrument.
(2) An application under subsection 40(1) of the Act by an organization must be signed by a person who is:
(a) one of the persons responsible for the management of the organization; and
(b) authorised in writing by the organization to sign that application.
82 Form for application for approval of health service
(1) For the purposes of subsection 41(1) of the Act, the prescribed form is Form 2 in Schedule 2 to this instrument.
(2) An application under subsection 41(1) of the Act by an organization must be signed by a person who is:
(a) one of the persons responsible for the management of the organization; and
(b) authorised in writing by the organization to sign that application.
Part 9—Medicare Participation Review Committees
83 Meaning of professional organisation
For the purposes of the definition of professional organisation in subsection 124B(1) of the Act, each of the following is declared to be a professional organisation:
(a) Australian Dental Association Incorporated;
(b) Australian Medical Association Limited;
(c) Optometrists Association Australia.
Part 10—Quality assurance confidentiality
Division 1—Quality assurance activities—application for declaration
Application for declaration that quality assurance activity is activity to which Part VC of the Act applies
(1) A person who wants the Minister to declare that a quality assurance activity is an activity to which Part VC of the Act applies must apply to the Minister using the form approved by the Minister for the purposes of this section.
(2) The form must require the applicant to give:
(a) an undertaking that the applicant will inform the Minister of a change to the purposes of the quality assurance activity to which the application relates as soon as practicable after the change occurs; and
(b) if the quality assurance activity to which the application relates is to be engaged in by a body of persons—an undertaking that the applicant will inform the Minister of any significant change to the composition or purposes of the body that is likely to affect the activity as soon as practicable after the change occurs.
Division 2—Quality assurance activities—public interest criteria
85 Purpose of Division
For the purposes of paragraph 124X(3)(b) of the Act, this Division prescribes criteria to which the Minister must have regard in deciding whether it is in the public interest that Part VC of the Act should apply to a quality assurance activity.
86 Disclosure of information about quality assurance activities
(1) A quality assurance activity must include the disclosure (without identifying particular individuals expressly or by implication) of information that concerns:
(a) the quality of the health services assessed, evaluated or studied; or
(b) the conditions or circumstances affecting the quality of the services;
unless it is not appropriate to disclose such information.
(2) The disclosure of information must take place at appropriate times and in an appropriate manner.
87 Quality assurance activities engaged in in a single State or Territory
Ifa quality assurance activity is engaged in in only one State or Territory, one of the following paragraphs must apply to the activity:
(a) the government of the State or Territory has advised the Minister that:
(i) the activity is not subject to legislation of the State or Territory that is similar to Part VC of the Act; and
(ii) in the opinion of the government of the State or Territory, it is in the public interest that Part VC of the Act should apply to the activity;
(b) the activity includes a methodology that has not been used previously in Australia;
(c) the activity is a pilot study for the purpose of investigating whether a methodology of a particular kind can be used in Australia;
(d) the activity addresses a subject matter that has not previously been addressed in Australia;
(e) the activity has the potential to affect the quality of health care on a national scale;
(f) the activity is a pilot study for the purpose of investigating whether the activity has the potential to affect the quality of health care on a national scale;
(g) the activity is of national importance.
88 Quality assurance activities of a kind that has not previously been engaged in in Australia
If a quality assurance activity is of a kind that has not previously been engaged in in Australia, application of Part VC of the Act to the activity must be likely to encourage:
(a) participation in the activity by persons who provide health services; and
(b) if the activity involves the making of a recommendation about the provision of health services—the acceptance and implementation of the recommendation by persons who provide health services; and
(c) if the activity involves monitoring of the implementation of a recommendation about the provision of health services—the participation of persons who provide health services in monitoring the implementation.
89 Quality assurance activities of a kind that has previously been engaged in in Australia
If a quality assurance activity (the current activity) is of the same kind as an activity that has previously been engaged in in Australia (the previous activity), application of Part VC of the Act to the current activity must be likely to encourage:
(a) participation in the current activity by persons who provide health services, to an extent greater than the extent to which such persons participated in the previous activity; and
(b) if the activity involves the making of a recommendation about the provision of health services—the acceptance and implementation of the recommendation by persons who provide health services, to an extent greater than the extent to which such persons accepted and implemented recommendations made during the previous activity; and
(c) if the activity involves monitoring of the implementation of a recommendation about the provision of health services—the participation of persons who provide health services in monitoring the implementation, to an extent greater than the extent to which such persons participated in monitoring the implementation of recommendations during the previous activity.
Part 11—Miscellaneous provisions
Division 1—Charging of fees for provision of public hospital services to public patients
90 Circumstances in which fees must not be charged for provision of public hospital services to public patients
For the purposes of subsection 128C(1) of the Act, the circumstances in which a fee must not be charged, and payment or other consideration must not be received, for the provision of a public hospital service are that the service is:
(a) for attendance at, or associated with, the delivery of a baby; or
(b) requested or required by the person to whom the service is provided in connection with the delivery of a baby.
Division 2—Recovery of amounts
91 Recovery of debts due to the Commonwealth—prescribed rate of interest
For the purposes of subsection 129AC(2) of the Act, the prescribed rate of interest is 15% per annum.
Division 3—Divulging and using information
92 Divulging information—treatment provided to veterans
For the purposes of subsection 130(3A) of the Act:
(a) an APS employee in the Veterans’ Affairs Department who performs functions under any of the following laws in relation to treatment or medical treatment (within the meaning of those laws) is a prescribed person:
(i) the Australian Participants in British Nuclear Tests and British Commonwealth Occupation Force (Treatment) Act 2006;
(ii) Chapter 6 of the Military Rehabilitation and Compensation Act 2004;
(iii) the Papua New Guinea (Members of the Forces Benefits) Act 1957;
(iv) the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988;
(v) Part V of the Veterans’ Entitlements Act 1986; and
(b) the information that may be provided to such an employee is information that would enable the employee to perform those functions.
93 Divulging information—complaints and investigations
(1) For the purposes of subsection 130(3A) of the Act:
(a) each of the following authorities or persons is a prescribed authority or person:
(i) the Medical Board of Australia;
(ii) each State or Territory Board of the Medical Board of Australia;
(iii) the Health Care Complaints Commission of New South Wales;
(iv) the Office of the Health Ombudsman of Queensland;
(v) an APS employee mentioned in paragraph 92(a); and
(b) this section sets out the circumstances in which information may be provided to a prescribed authority or person and the kind of information that may be provided.
Circumstances in which information may be provided
(2) Information may be provided to an authority mentioned in any of subparagraphs (1)(a)(i) to (iv) if:
(a) a patient has complained to the Chief Executive Medicare about a medical practitioner; and
(b) the Chief Executive Medicare reasonably believes that the complaint should be referred to the authority for possible investigation.
(3) Information may be provided to an authority mentioned in any of subparagraphs (1)(a)(i) to (iv) if the authority tells the Chief Executive Medicare that a patient has made a complaint to the authority about a medical practitioner.
(4) Information may also be provided to a person mentioned in subparagraph (1)(a)(v) in the circumstances mentioned in subsection (2) or (3).
(5) Information may be provided to an authority or person mentioned in paragraph (1)(a) if a medical practitioner is the subject of an investigation by the Chief Executive Medicare relating to the rendering of services.
(6) However, information may only be provided to a State or Territory authority under subsection (5) if:
(a) the medical practitioner is, was, or is applying to be, registered or licensed to practice in that State or Territory; or
(b) the medical practitioner is or was practising in that State or Territory.
Information that may be provided
(7) The following information may be provided in relation to a medical practitioner who is the subject of a complaint or investigation mentioned in subsection (2), (3) or (5):
(a) name;
(b) for each location at which the medical practitioner renders services (including any former location at which the medical practitioner rendered services in the period that is the subject of the complaint or investigation):
(i) address; and
(ii) provider number allocated to the medical practitioner for that location.
(8) Information relating to a service rendered by a medical practitioner who is the subject of a complaint or investigation mentioned in subsection (2), (3) or (5) may be provided if the Chief Executive Medicare reasonably believes that the service is relevant to the complaint or investigation.
(9) The information mentioned in subsection (10) relating to a patient may be provided if:
(a) the patient has made a complaint mentioned in subsection (2) or (3); or
(b) both:
(i) the patient has received a service rendered by a medical practitioner who is the subject of a complaint or investigation mentioned in subsection (2), (3) or (5); and
(ii) the Chief Executive Medicare reasonably believes that the service is relevant to the complaint or investigation.
(10) For the purposes of subsection (9), the information relating to the patient is the following:
(a) name;
(b) contact information;
(c) sex;
(d) date of birth;
(e) medicare number;
(f) if the patient is not a permanent Australian resident:
(i) date of last entry into Australia;
(ii) expected date of departure from Australia;
(iii) name of country of residence.
94 Professional disciplinary and regulatory bodies
For the purposes of subparagraph 130(4A)(c)(i) of the Act, the bodies mentioned in subparagraphs 93(1)(a)(i) to (iv) of this instrument are prescribed.
Division 4—Manner of patient referrals
95 Purpose and application of Division
(1) For the purposes of section 132A of the Act, this Division prescribes the manner in which a patient is to be referred to a practitioner.
(2) This Division applies to a referral of a patient to a specialist or consultant physician for the purposes of:
(a) an item in the general medical services table; or
(b) an item in a determination made under subsection 3C(1) of the Act for a service that is treated as if there were an item in the general medical services table for the service.
96 Who can make referral
(1) A medical practitioner may refer a patient to a specialist or consultant physician.
(2) An optometrist may refer a patient to a specialist who is an ophthalmologist.
(3) A dental practitioner who is approved by the Minister for the purposes of paragraph (b) of the definition of professional service in subsection 3(1) of the Act may refer a patient to a specialist or consultant physician.
(4) A dental practitioner to whom subsection (3) does not apply may refer a patient to a specialist (but not a consultant physician).
(5) A participating midwife may refer a patient to an obstetrician or paediatrician.
(6) A participating nurse practitioner may refer a patient to a specialist or consultant physician.
97 Requirement to consider need for referral
The referring practitioner must consider the need for the referral.
98 Requirements for form of referral
(1) Subject to subsection (2), a referral must be:
(a) in writing; and
(b) signed by the referring practitioner; and
(c) dated.
Emergencies
(2) Subsection (1) does not apply if:
(a) the referring practitioner decides that it is necessary in the patient’s interests for the patient to be referred to the specialist or consultant physician as soon as practicable; and
(b) subsection (3) applies to the patient.
(3) This subsection applies to a patient who is:
(a) at risk of serious morbidity or mortality requiring urgent assessment and resuscitation; or
(b) suffering from suspected acute organ or system failure; or
(c) suffering from an illness or injury where the viability or function of a body part or organ is acutely threatened; or
(d) suffering from a drug overdose, toxic substance or toxin effect; or
(e) experiencing severe psychiatric disturbance which puts the health of the patient or other people at immediate risk; or
(f) suffering acute severe pain where the viability or function of a body part or organ is suspected to be acutely threatened; or
(g) suffering acute significant haemorrhage requiring urgent assessment and treatment.
99 Requirements for contents of referral
General
(1) A referral must explain the reasons for referring the patient, including any information about the patient’s condition that the referring practitioner considers necessary to give to the specialist or consultant physician.
Additional content if referring practitioner is a specialist or consulting physician
(2) If the referring practitioner is a specialist or consulting physician, a written referral must:
(a) includethe name of a general practitioner, participating midwife or participating nurse practitioner nominated by the patient; or
(b) if the patient is unwilling or unable to nominate a general practitioner, participating midwife or participating nurse practitioner for the purposes of paragraph (a)—include a statement to that effect.
100 Requirement to record certain referrals in hospital records
If a referral is for a patient in a hospital who is not a public patient, approval of the referral by the referring practitioner must be included in the hospital records. The approval must be signed by the referring practitioner.
101 Receipt of referral by specialist or consultant physician
(1) Subject to this section, a referral for the rendering of a service to a patient must be received by the specialist or consultant physician before the service is rendered to the patient.
Lost, stolen or destroyed referral
(2) Subsection (1) does not apply if the patient tells the specialist or consultant physician:
(a) that a written referral referring the patient to the specialist or consultant physician has been completed by a referring practitioner; and
(b) the name of the referring practitioner; and
(c) that the referral has been lost, stolen or destroyed.
Emergencies
(3) Subsection (1) and a requirement for a referral in an item do not apply if:
(a) a specialist or consultant physician decides that it is necessary in the patient’s interests to render the professional service specified in the item as soon as practicable; and
(b) subsection 98(3) applies to the patient; and
(c) the specialist or consultant physician begins rendering the service to the patient within 30 minutes of presentation.
102 Period of validity for referrals
(1) Subject to this section:
(a) a referral that states it is valid for a fixed period is valid until the end of that period after the first service rendered in accordance with the referral; and
(b) a referral that states it is valid indefinitely is valid for an indefinite period; and
(c) a referral that does not state a time for which it remains valid is valid until 12 months after the first service rendered in accordance with the referral.
Referrals given by particular persons
(2) A referral given by a specialist or consultant physician is valid:
(a) for a maximum of 3 months after the first service given in accordance with the referral; or
(b) if the referred person is a patient in a hospital at the time of referral and continues to be so for more than 3 months—until the person ceases to be a patient in a hospital.
(3) A referral given by a participating midwife is valid for a maximum of 12 months after the first service is given in accordance with the referral, and for one pregnancy only.
(4) A referral given by a participating nurse practitioner is valid for a maximum of 12 months after the first service is given in accordance with the referral.
Special cases
(5) A referral for a professional service to a patient in a hospital who is not a public patient is valid until the patient ceases to be a patient in the hospital who is not a public patient.
(6) A referral that does not comply with subsection 98(1), and is given in the circumstances described in subsection 98(2) (emergencies), is valid for only one attendance on the patient.
(7) A written referral that is lost, stolen or destroyed is valid for only one attendance on the patient.
Part 12—Transitional provisions
Division 1—Transitional matters relating to the repeal of the Health Insurance Regulations 1975
103 Things done under the Health Insurance Regulations 1975
(1) If:
(a) a thing was done for a particular purpose under the Health Insurance Regulations 1975 as in force immediately before that instrument was repealed; and
(b) the thing could be done for that purpose under this instrument;
the thing has effect for the purposes of this instrument as if it had been done for that purpose under this instrument.
(2) Without limiting subsection (1), a reference in that subsection to a thing being done includes a reference to a notice, application or other instrument being given or made.
Schedule 1—Specialists
Note: See sections 10 and 13.
1 Organisations, specialties and qualifications
(1) The following table lists organisations, the specialty or specialties in relation to which the organisation is a relevant organisation for the purposes of subsection 3D(5) of the Act, and relevant qualifications in relation to each relevant organisation.
(2) In addition, a medical practitioner who is enrolled in and undertaking a training program with an organisation listed in the following table is a specialist trainee for the purposes of subsection 3(20) of the Act.
| Relevant organisations, specialties and relevant qualifications | |||
| Item | Column 1 Organisation | Column 2 Specialties | Column 3 Qualifications |
| 1 | Australasian College for Emergency Medicine | Emergency Medicine | Fellowship of the Australasian College for Emergency Medicine (FACEM) |
| 2 | Australasian College of Sport and Exercise Physicians | Sport and Exercise Medicine | Fellowship of the Australasian College of Sport and Exercise Physicians (FACSEP) Fellowship of the Australasian College of Sports Physicians (FACSP) |
| 3 | Australian and New Zealand College of Anaesthetists | Anaesthesia | Fellowship of the Australian and New Zealand College of Anaesthetists (FANZCA) |
| 4 | Australian and New Zealand College of Anaesthetists | Pain Medicine | Fellowship of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (FFPMANZCA) |
| 5 | College of Intensive Care Medicine of Australia and New Zealand | Intensive Care Medicine | Fellowship of the College of Intensive Care Medicine of Australia and New Zealand (FCICM) Fellowship of the Faculty of Intensive Care, Australian and New Zealand College of Anaesthetists (FFICANZCA) Fellowship of the Royal Australian College of Physicians (FRACP) |
| 6 | Royal Australasian College of Dental Surgeons | Oral and Maxillofacial Surgery | Fellowship of the Royal Australasian College of Dental Surgeons (Oral and Maxillofacial Surgery) (FRACDS (OMS)) |
| 7 | Royal Australasian College of Surgeons | Cardio‑thoracic Surgery General Surgery Neurosurgery Orthopaedic Surgery Otolaryngology—Head and Neck Surgery Paediatric Surgery Plastic Surgery Urology Vascular Surgery | Fellowship of the Royal Australasian College of Surgeons (FRACS) |
| 8 | The Australasian College of Dermatologists | Dermatology | Fellowship of the Australasian College of Dermatologists (FACD) |
| 9 | The Royal Australasian College of Physicians | Addiction Medicine | Fellowship of the Australasian Chapter of Addiction Medicine (FAChAM) |
| 10 | The Royal Australasian College of Physicians | Palliative Medicine | Fellowship of the Australasian Chapter of Palliative Medicine (FAChPM) |
| 11 | The Royal Australasian College of Physicians | Sexual Health Medicine | Fellowship of the Australasian Chapter of Sexual Health Medicine (FAChSHM) |
| 12 | The Royal Australasian College of Physicians | Occupational and Environmental Medicine | Fellowship of the Australasian Faculty of Occupational and Environmental Medicine (FAFOEM) Fellowship of the Australasian Faculty of Occupational Medicine (FAFOM) |
| 13 | The Royal Australasian College of Physicians | Public Health Medicine | Fellowship of the Australasian Faculty of Public Health Medicine (FAFPHM) |
| 14 | The Royal Australasian College of Physicians | Rehabilitation Medicine | Fellowship of the Australasian Faculty of Rehabilitation Medicine (FAFRM) Fellowship of the Australasian College of Rehabilitation Medicine (FACRM) |
| 15 | The Royal Australasian College of Physicians | Cardiology Clinical Genetics Clinical Pharmacology Community Child Health Endocrinology Gastroenterology and Hepatology General Medicine General Paediatrics Geriatric Medicine Haematology Immunology and Allergy Infectious Diseases Medical Oncology Neonatal and Perinatal Medicine Nephrology Neurology Nuclear Medicine Paediatrics and child health Paediatric Cardiology Paediatric Clinical Pharmacology Paediatric Emergency Medicine Paediatric Endocrinology Paediatric Gastroenterology and Hepatology Paediatric Haematology Paediatric Immunology and Allergy Paediatric Infectious Diseases Paediatric Intensive Care Medicine Paediatric Medical Oncology Paediatric Nephrology Paediatric Neurology Paediatric Nuclear Medicine Paediatric Palliative Medicine Paediatric Rehabilitation Medicine Paediatric Respiratory and Sleep Medicine Paediatric Rheumatology Respiratory and Sleep Medicine Rheumatology | Fellowship of the Royal Australasian College of Physicians (FRACP) |
| 16 | The Royal Australian and New Zealand College of Obstetricians and Gynaecologists | Obstetrics and Gynaecology Gynaecological Oncology Maternal‑fetal Medicine Obstetrics and Gynaecological Ultrasound Reproductive Endocrinology and Infertility Urogynaecology | Fellowship of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG) Fellowship of the Royal Australian College of Obstetricians and Gynaecologists (FRACOG) |
| 17 | The Royal Australian and New Zealand College of Ophthalmologists | Ophthalmology | Fellowship of the Royal Australian and New Zealand College of Ophthalmologists (FRANZCO) Fellowship of the Royal Australian College of Ophthalmologists (FRACO) |
| 18 | The Royal Australian and New Zealand College of Psychiatrists | Psychiatry | Fellowship of the Royal Australian and New Zealand College of Psychiatrists (FRANZCP) |
| 19 | The Royal Australian and New Zealand College of Radiologists | Diagnostic Radiology Diagnostic Ultrasound Nuclear Medicine Radiation Oncology | Fellowship of the Royal Australian and New Zealand College of Radiologists (FRANZCR) Fellowship of the Royal Australasian College of Radiologists (FRACR) |
| 20 | The Royal College of Pathologists of Australasia | General Pathology Anatomical Pathology (including Cytopathology) Chemical Pathology Forensic Pathology Haematology Immunology Microbiology | Fellowship of the Royal College of Pathologists of Australasia (FRCPA) |
Schedule 2—Forms
Note: See sections 81 and 82.
Form 1—Application for approval as an organization under Part IV of the Act
HEALTH INSURANCE ACT 1973
APPLICATION FOR APPROVAL AS AN ORGANIZATION UNDER PART IV
To: the Minister for Health.
(Name of applicant organization)
of ,
(Address of applicant organization)
applies under subsection 40(1) of the Health Insurance Act 1973 for approval as an organization under Part IV of that Act.
Dated this day of , 20
(Signature of person authorised to
sign application)
(Position in organization)
Form 2—Application for approval of a health service
HEALTH INSURANCE ACT 1973
APPLICATION FOR APPROVAL OF A HEALTH SERVICE
To: the Minister for Health.
(Name of applicant organization)
of ,
(Address of applicant organization)
being an approved organization within the meaning of Part IV of the Health Insurance Act 1973, applies under subsection 41(1) of that Act for approval of the health service described in the Schedule, being a health service provided, or to be provided, by the organization.
SCHEDULE
(Description of health service and address or addresses at which the service is, or is to be, provided.)
Dated this day of , 20
(Signature of person authorised to
sign application)
(Position in organization)
Endnotes
Endnote 1—About the endnotes
The endnotes provide information about this compilation and the compiled law.
The following endnotes are included in every compilation:
Endnote 1—About the endnotes
Endnote 2—Abbreviation key
Endnote 3—Legislation history
Endnote 4—Amendment history
Abbreviation key—Endnote 2
The abbreviation key sets out abbreviations that may be used in the endnotes.
Legislation history and amendment history—Endnotes 3 and 4
Amending laws are annotated in the legislation history and amendment history.
The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.
The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.
Editorial changes
The Legislation Act 2003 authorises First Parliamentary Counsel to make editorial and presentational changes to a compiled law in preparing a compilation of the law for registration. The changes must not change the effect of the law. Editorial changes take effect from the compilation registration date.
If the compilation includes editorial changes, the endnotes include a brief outline of the changes in general terms. Full details of any changes can be obtained from the Office of Parliamentary Counsel.
Misdescribed amendments
A misdescribed amendment is an amendment that does not accurately describe the amendment to be made. If, despite the misdescription, the amendment can be given effect as intended, the amendment is incorporated into the compiled law and the abbreviation “(md)” added to the details of the amendment included in the amendment history.
If a misdescribed amendment cannot be given effect as intended, the abbreviation “(md not incorp)” is added to the details of the amendment included in the amendment history.
Endnote 2—Abbreviation key
| ad = added or inserted | o = order(s) |
| am = amended | Ord = Ordinance |
| amdt = amendment | orig = original |
| c = clause(s) | par = paragraph(s)/subparagraph(s) |
| C[x] = Compilation No. x | /sub‑subparagraph(s) |
| Ch = Chapter(s) | pres = present |
| def = definition(s) | prev = previous |
| Dict = Dictionary | (prev…) = previously |
| disallowed = disallowed by Parliament | Pt = Part(s) |
| Div = Division(s) | r = regulation(s)/rule(s) |
| ed = editorial change | reloc = relocated |
| exp = expires/expired or ceases/ceased to have | renum = renumbered |
| effect | rep = repealed |
| F = Federal Register of Legislation | rs = repealed and substituted |
| gaz = gazette | s = section(s)/subsection(s) |
| LA = Legislation Act 2003 | Sch = Schedule(s) |
| LIA = Legislative Instruments Act 2003 | Sdiv = Subdivision(s) |
| (md) = misdescribed amendment can be given | SLI = Select Legislative Instrument |
| effect | SR = Statutory Rules |
| (md not incorp) = misdescribed amendment | Sub‑Ch = Sub‑Chapter(s) |
| cannot be given effect | SubPt = Subpart(s) |
| mod = modified/modification | underlining = whole or part not |
| No. = Number(s) | commenced or to be commenced |
Endnote 3—Legislation history
| Name | Registration | Commencement | Application, saving and transitional provisions |
| Health Insurance Regulations 2018 | 27 Sept 2018 (F2018L01365) | 1 Oct 2018 (s 2(1) item 1) | |
| Health Insurance Legislation Amendment (2018 Measures No. 3) Regulations 2018 | 26 Oct 2018 (F2018L01481) | Sch 1 (items 108–113): 1 Nov 2018 (s 2(1) item 1) | — |
| Health Insurance Legislation Amendment (2018 Measures No. 4) Regulations 2018 | 5 Nov 2018 (F2018L01534) | Sch 1 (item 1): 1 Jan 2019 (s 2(1) item 1) | — |
| Health Insurance Legislation Amendment (Services for Patients in Residential Aged Care Facilities) Regulations 2019 | 22 Feb 2019 (F2019L00179) | Sch 1 (items 10–14): 1 Mar 2019 (s 2(1) item 1) | — |
| Health Insurance Legislation Amendment (2019 Measures No. 1) Regulations 2019 | 24 Sept 2019 (F2019L01256) | Sch 1 (items 77–81): 1 Nov 2019 (s 2(1) item 2) | — |
Endnote 4—Amendment history
| Provision affected | How affected |
| Part 1 | |
| s 2............................................. | rep LA s 48D |
| Part 2 | |
| Division 6 | |
| s 26........................................... | am F2018L01534 |
| Part 3 | |
| Division 1 | |
| s 28........................................... | am F2018L01481; F2019L00179; F2019L01256 |
| Division 3 | |
| Subdivision B | |
| s 39........................................... | am F2018L01481 |
| s 42........................................... | am F2018L01481 |
| s 44........................................... | am F2018L01481 |
0
0
0