Health Insurance Regulations 2018

Health Insurance Regulations 2018

made under the

Health Insurance Act 1973

Compilation No. 26

Compilation date: 1 July 2026

Includes amendments: F2025L00983, F2026L00652, F2026L00657 and F2026L00824

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 July 2026 (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. The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. Any uncommenced amendments affecting the law are accessible on the Register (www.legislation.gov.au).

Application, saving and transitional provisions

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.

Presentational changes

The Legislation Act 2003 provides for First Parliamentary Counsel to make presentational changes to a compilation. Presentational changes are applied to give a more consistent look and feel to legislation published on the Register, and enable the user to more easily navigate those documents.

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. Any modifications affecting the law are accessible on the Register.

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If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.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 Name

3 Authority

4 Definitions

Part 2—Definitional material

Division 3—Definition of services

9 Professional services—medical services rendered by approved dental practitioners

10 Meaning of specialist trainee

11 Professional services rendered by specialist trainees

12 Health service not specified in an item—meaning of health service

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

Division 5—General practitioners

16 Medical practitioners who were on Vocational Register of General Practitioners

Division 6—Register of Approved Placements

26 Specified bodies, courses and programs

27 Removal from the Register

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

Division 2—Medicare benefits in relation to pathology services

Subdivision A—Simplified outline of this Division

29 Simplified outline of this Division

Subdivision B—Specifying services

30 Pathology service determined to be necessary by participating midwife

31 Pathology service determined to be necessary by participating nurse practitioner

Subdivision C—Requirements for requests for pathology services

32 Purpose of Subdivision

33 Information about requesting practitioner

34 Information about patient

35 Information about pathology service

36 Requests that specify an approved pathology practitioner

37 Further requests

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

Subdivision B—Specifying services for effective requests

39 Requests by dental practitioners

40 Requests by chiropractors

41 Requests by physiotherapists or osteopaths

42 Requests by podiatrists

43 Requests by participating midwives

44 Requests by participating nurse practitioners

Subdivision C—Specifying services for pre‑existing diagnostic imaging practices

45 Exemption from subsection 16B(1) of the Act—pre‑existing diagnostic imaging practices

Division 4—Medicare benefits in relation to radiation oncology services

46 Meaning of radiation oncology service

Division 5—Particulars of professional services that must be recorded so medicare benefit payable

47 Simplified outline of this Division

48 Purpose of Division

49 All services—particulars of patient, date of service and fees

50 All services—particulars of professional service rendered

51 Most general medical services and Group P9 pathology services—particulars of person rendering service

52 Certain radiation or nuclear services—particulars of person rendering service and person claiming or receiving fees

53 Certain radiation oncology services—use of equipment

54 Pathology services (other than Group P9)—particulars of person rendering service

55 Pathology services—other particulars

56 Diagnostic imaging services—particulars of person rendering service and person claiming or receiving fees

57 Diagnostic imaging services—other particulars

58 Services provided upon referral

59 Multiple professional services in a single day

60 Anaesthesia

Division 6—Professional services rendered by or on behalf of certain medical practitioners

61 Other circumstances in which subparagraphs 19AA(1)(b)(iv) and (2)(b)(iv) of the Act apply

62 Meaning of intern

Division 7—Payments to medical practitioners and approved billing agents

63 Circumstances for electronic payments to medical practitioners

64 Requirements for payments to specialists and consultant physicians

65 Approved billing agents—application requirements and fee

Division 7A—Assignment of medicare benefit

Subdivision A—Simplified outline of this Division

65A Simplified outline of this Division

Subdivision B—Bulk billing assignments

65B Requirements for bulk‑billing assignments

65C Requirements for episodic agreements

65CA Enduring agreements

65CB Requirements for enduring agreements

Subdivision C—Simplified billing assignments

65D Requirements for requested simplified billing assignments

Division 7B—Claims for medicare benefit

65E Requirements for claims for medicare benefit

Division 8—Eligible midwives

66 Meaning of eligible midwife—requirements

Part 4—Special provisions relating to pathology

67 Giving notice of termination of undertaking

68 Approved pathology authorities—other records of pathology services

69 Offences in relation to request forms—branded pathology request forms

Part 5—Special provisions relating to diagnostic imaging services

70 Requests for diagnostic imaging services—information and form requirements

71 Medical practitioners rendering diagnostic imaging services—other records of services

72 Diagnostic Imaging Register—other information to be included in application for registration

73 Diagnostic Imaging Register—other information to be included on Register

74 Primary information—types of diagnostic imaging equipment

75 Diagnostic imaging accreditation—information to be included on Diagnostic Imaging Register

Part 6—Prohibited practices in relation to pathology services and diagnostic imaging services

76 Meaning of permitted benefit—method for determining substantial difference from market value

77 Meaning of permitted benefit—method for determining market value

Part 7—Radiation Oncology Register

78 Radiation Oncology Register—other information to be included in application for registration

79 Radiation Oncology Register—other information to be included on the Register

80 Primary information—types of radiation oncology equipment

Part 8—Health program grants

81 Application for approval as an organization under Part IV of the Act

82 Application for approval of health service under Part IV of the Act

Part 9—Medicare Participation Review Committees

83 Meaning of professional organisation

Part 10—Quality assurance confidentiality

Division 1—Quality assurance activities—application for declaration

84 Application for declaration that quality assurance activity is activity to which Part VC of the Act applies

Division 2—Quality assurance activities—public interest criteria

85 Purpose of Division

86 Disclosure of information about quality assurance activities

87 Quality assurance activities engaged in in a single State or Territory

88 Quality assurance activities of a kind that has not previously been engaged in in Australia

89 Quality assurance activities of a kind that has previously been engaged in in Australia

Part 11—Miscellaneous provisions

Division 1A—Notification and record‑keeping requirements in relation to assignment of medicare benefit

Subdivision A—Bulk billing assignments

89AA Enduring agreements—notification requirements

89A Record‑keeping

Subdivision B—Simplified billing assignments

89B Notification requirements

89C Record‑keeping—kinds of records

89D Record‑keeping—retention day

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

Division 2—Recovery of amounts

91 Recovery of debts due to the Commonwealth—prescribed rate of interest

Division 3—Divulging and using information

92 Divulging information—treatment provided to veterans

93 Divulging information—complaints and investigations

94 Professional disciplinary and regulatory bodies

Division 4—Manner of patient referrals

95 Purpose and application of Division

96 Who can make referral

97 Requirement to consider need for referral

98 Requirements for form of referral

99 Requirements for contents of referral

100 Requirement to record certain referrals in hospital records

101 Receipt of referral by specialist or consultant physician

102 Period of validity for referrals

Part 12—Application, saving and 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

Division 2—Application, saving and transitional provisions relating to the Health Insurance Amendment (Assignment of Medicare Benefits and Other Measures) Regulations 2025

104 Definitions

105 Offers made before the commencement day

Schedule 1—Specialists

1 Organisations, specialties and qualifications

Endnotes

Endnote 1—About the endnotes

Endnote 2—Abbreviation key

Endnote 3—Legislation history

Endnote 4—Amendment history

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:

Act means the Health Insurance Act 1973.

approved collection centre has the same meaning as in Part IIA of the Act.

diagnostic imaging provider: see subsection 70(5).

enduring agreement has the same meaning as in subsection 20A(1A) of the Act.

episodic agreement: see subsection 65C(2).

episodic post‑agreement: see paragraph 65C(3)(b).

episodic pre‑agreement: see paragraph 65C(3)(a).

health practitioner means a person practising a profession that, under the Health Practitioner Regulation National Law, is regulated by a National Board.

Health Practitioner Regulation National Law means:

 (a) for a State or Territory other than Western Australia—the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld), as it applies (with or without modification) as a law of the State or Territory; or

 (b) for Western Australia—the Health Practitioner Regulation National Law (WA) Act 2010 (WA), so far as that Act corresponds to the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld).

identification number, in relation to an approved collection centre, means the identification number allocated to the centre under section 23DNBB of the Act.

MyMedicare means the registration program by that name administered by the Department.

National Board means any of the following:

 (a) the Aboriginal and Torres Strait Islander Health Practice Board of Australia;

 (b) the Chiropractic Board of Australia;

 (c) the Dental Board of Australia;

 (d) the Medical Board of Australia;

 (e) the Medical Radiation Practice Board of Australia;

 (f) the Nursing and Midwifery Board of Australia;

 (g) the Occupational Therapy Board of Australia;

 (h) the Optometry Board of Australia;

 (i) the Osteopathy Board of Australia;

 (j) the Physiotherapy Board of Australia;

 (k) the Podiatry Board of Australia;

 (l) the Psychology Board of Australia.

obstetrician means a medical practitioner who is a specialist in the specialty of obstetrics and gynaecology (however described).

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).

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.

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.

responsible person: see subsection 65CA(3).

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 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, 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 and Torres Strait Islander health practitioner services;

 (aa) Aboriginal and Torres Strait Islander health worker 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.

Division 5—General practitioners

16  Medical practitioners who were on Vocational Register of General Practitioners

 (1) This section prescribes a kind of medical practitioner for the purposes of paragraph (b) of the definition of general practitioner in subsection 3(1) of the Act.

Note: Medical practitioners of that kind are general practitioners as defined by that subsection.

 (2) The kind is a medical practitioner for whom the following conditions are met:

 (a) the practitioner holds general registration in the medical profession (and is not registered in the specialty of general practice) under the National Law;

 (b) immediately before the commencement of Schedule 1 to the Health Insurance Amendment (General Practitioners and Quality Assurance) Act 2020:

 (i) the practitioner held general registration in the medical profession (and was not registered in the specialty of general practice) under the National Law; and

 (ii) the practitioner’s name was entered in the Vocational Register of General Practitioners.

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.

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.

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

 (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.

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 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 1.2.18 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

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.

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 73825 to 73837 of the pathology services table is specified.

Note: Items 73825 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

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.

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.

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.

Periodontists, endodontists, paediatric dentistry specialists 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, paediatric dentistry specialist 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, paediatric dentistry, or orthodontics.

Oral medicine, oral and maxillofacial pathology, oral surgery and special needs dentistry 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, oral and maxillofacial pathology specialist, oral surgery specialist or special needs dentistry 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, oral and maxillofacial pathology, oral surgery or special needs dentistry.

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.

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.

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.

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.

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.

Subdivision C—Specifying services for pre‑existing diagnostic imaging practices

45  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.

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 Group T2 in the general medical services table.

Division 5—Particulars of professional services that must be recorded so medicare benefit payable

47  Simplified outline of this Division

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, 15900 to 15984 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, 15900 to 15984 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

 (b) the item relating to the service specifies it as a service that is to be rendered to a patient who has been referred.

 Note: Division 4 of Part 11 prescribes the manner in which patients are to be referred for the purposes of such items.

General

 (2) Subject to subsections (3) to (5), the following particulars are prescribed:

 (a) the name of the referring practitioner;

 (b) the address of the place of practice, or the provider number in respect of the place of practice, of the referring practitioner;

 (c) the date on which the patient was referred by the referring practitioner to the consultant physician or specialist;

 (d) the period of validity of the referral under section 102.

Lost referrals

 (3) If the service is rendered on the basis of a lost, stolen or destroyed referral:

 (a) paragraphs (2)(b) to (d) do not apply; and

 (b) the words “lost referral” are a prescribed particular.

Hospital referrals

 (4) If the service is rendered to a patient in a hospital who is not a public patient:

 (a) paragraphs (2)(b) to (d) do not apply; and

 (b) the words “referral within” followed by the name of the hospital are a prescribed particular.

Emergencies

 (5) If the service is rendered without a written referral in the circumstances described in subsection 98(2) or 101(3):

 (a) subsection (2) does not apply; and

 (b) the word “emergency” is a prescribed particular.

59  Multiple professional services in a single day

 (1) This section applies if a medical practitioner, dental practitioner, optometrist, participating midwife or participating nurse practitioner attends a person more than once on the same day, and on each occasion:

 (a) for a medical practitioner, dental practitioner or optometrist—renders a professional service specified in any of items 3 to 10948 of the general medical services table to the person; and

 (b) for a participating midwife or participating nurse practitioner—renders a professional service specified in the general medical services table to the person.

Note: Some professional services are specified in a determination made under subsection 3C(1) of the Act.

 (2) For each such professional service, a prescribed particular is the time at which the attendance started.

60  Anaesthesia

 (1) This section applies to a professional service that is specified in an item in Subgroup 21 of Group T10 of the general medical services table.

Management of anaesthesia

 (2) If the service is management of anaesthesia (other than when performed in association with a service to which item 22900 or 22905 of the general medical services table applies), the following particulars are prescribed:

 (a) the name of each medical practitioner who performed a procedure for which the anaesthesia was administered;

 (b) if item 25025 of the general medical services table applies to the service:

 (i) when the service time began; and

 (ii) when the service time ended; and

 (iii) the duration of the service time.

Perfusion to which item 25050 applies

 (3) If the service is perfusion to which item 25050 applies, the following particulars are prescribed:

 (a) when the service time began;

 (b) when the service time ended;

 (c) the duration of the service time.

Assistance in the management of anaesthesia

 (4) If the service is assistance in the management of anaesthesia, the following particulars are prescribed:

 (a) the name of the principal anaesthetist;

 (b) the name of each medical practitioner who performed a procedure for which the anaesthesia was administered;

 (c) if item 25030 of the general medical services table applies to the service:

 (i) when the service time began; and

 (ii) when the service time ended; and

 (iii) the duration of the service time.

Definition of service time

 (5) In this section:

service time has the meaning given by clause 5.9.3 in the general medical services table.

Division 6—Professional services rendered by or on behalf of certain medical practitioners

61  Other circumstances in which subparagraphs 19AA(1)(b)(iv) and (2)(b)(iv) of the Act apply

 (1) For the purposes of paragraph 19AA(3)(b) of the Act, this section specifies circumstances in which subparagraphs 19AA(1)(b)(iv) and (2)(b)(iv) of the Act apply in relation to:

 (a) for subparagraph 19AA(1)(b)(iv)—a professional service rendered by a medical practitioner; and

 (b) for subparagraph 19AA(2)(b)(iv)—a professional service rendered on behalf of a medical practitioner.

 (2) The circumstances are that:

 (a) the medical practitioner had been a person registered under section 3GA of the Act; and

 (b) the service was rendered in the period of:

 (i) 2 weeks after the end of the period of registration; or

 (ii) if the Chief Executive Medicare approves in writing—6 weeks after the end of the period of registration; and

 (c) the service was rendered in the location in respect of which the medical practitioner was registered.

62  Meaning of intern

  For the purposes of the definition of intern in subsection 19AA(5) of the Act, the following State and Territory laws are specified:

 (a) Medical Practice Act 1992 (NSW);

 (b) Medical Practice Act 1994 (Vic.);

 (c) Medical Act 1939 (Qld);

 (d) Medical Act 1894 (WA);

 (e) Medical Practitioners Act 1983 (SA);

 (f) Medical Act 1959 (Tas.);

 (g) Medical Practitioners Act 1930 (ACT);

 (h) Medical Act of 1995 (NT).

Division 7—Payments to medical practitioners and approved billing agents

63  Circumstances for electronic payments to medical practitioners

 (1) For the purposes of subsection 20(5) of the Act, this section prescribes the circumstances in which an amount may be paid under subsection 20(3) of the Act, by means of electronic transmission to a bank account, to a general practitioner, specialist or consultant physician by whom, or on whose behalf, a professional service was rendered.

Note: For payments to specialists and consultant physicians, see also subsection 20(6) of the Act and section 64 of this instrument.

 (2) An amount may be paid by electronic transmission if the claim for medicare benefit in respect of the service was made using one of the following electronic claiming channels:

 (a) Medicare Online;

 (b) Medicare Easyclaim;

 (c) ECLIPSE.

 (3) For a general practitioner, an amount may also be paid by electronic transmission if the general practitioner:

 (a) is enrolled, for the location at which the service was rendered, in the scheme known as the “90 Day Pay Doctor Cheque Scheme” administered by the Chief Executive Medicare for the purpose of making payments under subsection 20(3) of the Act; and

 (b) has given the Chief Executive Medicare written permission to give to the Reserve Bank of Australia:

 (i) the name and number of the account into which a payment may be made; and

 (ii) the name and BSB number of the bank at which that account is kept.

64  Requirements for payments to specialists and consultant physicians

 (1) For the purposes of subsection 20(6) of the Act, this section prescribes the manner in which a claim for medicare benefit must be made for subsections 20(3) to (5) of the Act to apply in relation to a professional service rendered by or on behalf of a specialist or consultant physician.

 (2) The claim for medicare benefit in respect of the service must have been made using an electronic claiming channel mentioned in subsection 63(2) of this instrument.

65  Approved billing agents—application requirements and fee

 (1) For the purposes of paragraph 20AB(2)(a) of the Act, an application for approval as a billing agent must be in the form approved by the Chief Executive Medicare.

 (2) For the purposes of paragraph 20AB(2)(b) of the Act, the fee to accompany an application is:

 (a) if the applicant has not previously been approved as a billing agent—$1,000; or

 (b) if the applicant has previously been approved—$500.

Division 7A—Assignment of medicare benefit

Subdivision A—Simplified outline of this Division

65A  Simplified outline of this Division

Subdivision B—Bulk billing assignments

65B  Requirements for bulk‑billing assignments

  For the purposes of paragraph 20A(1)(d) of the Act, the agreement must be:

 (a) an episodic agreement that meets the requirements specified in section 65C of this instrument; or

 (b) an enduring agreement that meets the requirements specified in section 65CB of this instrument.

65C  Requirements for episodic agreements

 (1) For the purposes of paragraph 65B(a), this section specifies the requirements that must be met in relation to an episodic agreement.

 (2) An episodic agreement is an agreement under subsection 20A(1) of the Act, entered into either before or after a professional service (an agreement service) described in the agreement is rendered, that provides that the assignor assigns the assignor’s right to the payment of medicare benefit payable in respect of that professional service to the professional.

Note: The agreement may also provide that the assignor’s right to the payment of medicare benefit payable in respect of other professional services that are not described in the agreement is assigned: see paragraph (c) of column 2 of items 1 and 3 in the table in subsection (4).

 (3) There are 2 types of episodic agreement:

 (a) an episodic pre‑agreement, which is an episodic agreement that:

 (i) is entered into before an agreement service is rendered; and

 (ii) may cover more than one agreement service to be rendered during the 6‑month period beginning on the day on which the agreement is entered into; and

 (b) an episodic post‑agreement, which is an episodic agreement:

 (i) in respect of which neither party offers entry into the agreement until after an agreement service is rendered; and

 (ii) that may cover more than one agreement service, each of which has been rendered before the agreement is entered into.

 (4) The professional must ensure that the assignor is given the following information, in writing, before or at the time either party offers entry into an episodic agreement:

 (a) the name of the person to whom the agreement services covered by the agreement are or will be rendered;

 (b) the date on which the agreement is proposed to be entered into;

 (c) whether the agreement is an episodic pre‑agreement or an episodic post‑agreement;

 (d) for each agreement service covered by the agreement—the information mentioned in column 2 of the item of the following table that applies in relation to the agreement service.

 (5) For the purposes of items 4 to 6 in the table in subsection (4), the identifying details of the professional are:

 (a) the name of the professional and the address of the place of practice from which the professional is, or expects to be, practising at the time the agreement service is rendered; or

 (b) the provider number allocated to the professional in respect of:

 (i) the place of practice from which the professional is, or expects to be, practising at the time the agreement service is rendered; or

 (ii) if subparagraph (i) does not apply—any place of practice.

 (6) The agreement must:

 (a) include the information that was required to be given to the assignor in accordance with subsection (4); and

 (b) specify whether the assignor is the person to whom the agreement service is or will be rendered; and

 (c) be a written agreement that is signed and dated by the assignor.

65CA  Enduring agreements

 (1) For the purposes of subsection 20A(1A) of the Act, this section provides for and in relation to enduring agreements.

Circumstances in which enduring agreements may be entered into

 (2) An enduring agreement may be entered into by an eligible person (the assignor) in respect of one or more kinds of professional services (the agreement services) only if, at the time the agreement is entered into:

 (a) the assignor is at least 14 years old; and

 (b) if the professional services will be rendered to a person other than the assignor:

 (i) the assignor is a responsible person for the other person; and

 (ii) in the case that the other person is at least 14 years old—that person has provided a written declaration in respect of the agreement that meets the requirements of subsection (4); and

 (c) any of subsections (5), (6) and (6A) apply in relation to the agreement.

 (3) An assignor is a responsible person for the other person if the assignor is:

 (a) a parent, stepparent or foster parent of the other person; or

 (b) a spouse or de facto partner of the other person; or

 (c) a relative of the other person if the relative is:

 (i) at least 18 years old; and

 (ii) a member of the other person’s household; or

 (d) a guardian of the other person; or

 (e) a person exercising an enduring power of attorney granted by the other person that is exercisable in relation to decisions about the other person’s health.

 (4) For the purposes of subparagraph (2)(b)(ii), a written declaration in respect of an enduring agreement meets the requirements of this subsection if the declaration includes:

 (a) the agreement of the person to the enduring agreement being entered into; and

 (b) if subsection (5) applies in relation to the enduring agreement:

 (i) a statement that the person understands that after each occasion on which an agreement service is rendered to the person a notification will be sent to the assignor in relation to the rendering of the service; and

 (ii) the agreement of the person to such notifications being sent.

 (5) This subsection applies if:

 (a) the person (the patient) to whom the agreement services will be rendered is registered with MyMedicare; and

 (b) the professional by whom, or on whose behalf, the agreement services will be rendered:

 (i) is a medical practitioner (except a consultant physician, or a specialist, in a particular speciality other than general practice); and

 (ii) is registered with MyMedicare at the practice (the agreement location) at which the patient is registered with MyMedicare; and

 (c) the agreement location is not a practice or clinic referred to in subparagraph (6)(c)(i); and

 (d) the agreement only covers agreement services to be rendered at or from the agreement location; and

 (e) a provider number that is allocated to the professional identifies the agreement location as a place where the professional practices the professional’s profession; and

 (f) if any other enduring agreements are in effect in respect of the patient—each of those agreements only cover professional services to be rendered to the patient at or from the agreement location for an enduring agreement to which this subsection, or subsection (6A), applies.

 (6) This subsection applies if:

 (a) the person (the patient) to whom the agreement services will be rendered is a patient of an Aboriginal Community Controlled Health Organisation or an Aboriginal Medical Service (the relevant ACCHO/AMS); and

 (b) the agreement is to be entered into with an agent of the relevant ACCHO/AMS; and

 (c) the agreement only covers agreement services to be rendered:

 (i) at or from the practices or clinics (collectively, the agreement location) the patient may attend as a patient of the relevant ACCHO/AMS; and

 (ii) by each professional employed by the relevant ACCHO/AMS, from time to time, to render services at or from the agreement location; and

 (d) if any other enduring agreements are in effect in respect of the patient—each of those agreements only cover professional services to be rendered to the patient at or from the agreement location for an enduring agreement to which this subsection, or subsection (6A), applies.

 (6A) This subsection applies if:

 (a) the person (the patient) to whom the agreement services will be rendered is in a residential care home (within the meaning of the Aged Care Act 2024); and

 (b) the professional by whom, or on whose behalf, the agreement services will be rendered is a medical practitioner (except a consultant physician, or a specialist, in a particular speciality other than general practice); and

 (c) the agreement only covers agreement services to be rendered at or from the following places (collectively, the agreement location):

 (i) the residential care home;

 (ii) a practice or clinic in relation to which the professional has been allocated a provider number that identifies that practice or clinic as a place where the professional practices the professional’s profession.

Termination of enduring agreements

 (7) An enduring agreement may be terminated at any time by a written notice given by:

 (a) a party to the agreement to the other party; or

 (b) the patient to the party to the agreement who is not the assignor.

Circumstances in which enduring agreements cease to be in effect

 (8) An enduring agreement ceases to be in effect as follows:

 (a) if subsection (5) applied in relation to the agreement at the time the agreement was entered into—when a circumstance mentioned in paragraph (5)(a), (b), (e) or (f) ceases to exist in relation to the agreement;

 (b) if subsection (6) applied in relation to the agreement at the time the agreement was entered into—when a circumstance mentioned in paragraph (6)(a) or (d) ceases to exist in relation to the agreement;

 (ba) if subsection (6A) applied in relation to the agreement at the time the agreement was entered into—when a circumstance mentioned in paragraph (6A)(a) ceases to exist in relation to the agreement;

 (c) if the patient is not a party to the agreement, and was under 14 years old at the time the agreement was entered into—when the patient turns 14 years old;

 (d) if the agreement is terminated in accordance with subsection (7)—when the agreement is terminated;

 (e) if the agreement is entered into on or before 30 June 2027 and is not registered with Services Australia before the first anniversary of the day the agreement is entered into—when the agreement has been in effect for 12 months.

 (9) To avoid doubt for the purposes of paragraph (8)(ba), a circumstance mentioned in paragraph (6A)(a) does not cease to exist in relation to an agreement if the patient is temporarily admitted for hospital treatment.

65CB  Requirements for enduring agreements

 (1) For the purposes of paragraph 65B(b), this section specifies the requirements that must be met in relation to an enduring agreement.

 (2) Before or at the time the assignor enters into the enduring agreement, the other party to the agreement must ensure that the assignor is given the following information, in writing:

 (a) that the agreement is an enduring agreement;

 (b) the name of the person (the patient) to whom professional services covered by the agreement will be rendered;

 (c) a description of the kinds of professional services covered by the agreement that is sufficient to identify the items in the table that specify the services;

 (d) if subsection 65CA(5) applies in relation to the agreement:

 (i) the name of the professional and the address of the agreement location referred to in that subsection; or

 (ii) the provider number allocated to the professional that identifies the agreement location as a place where the professional practices the professional’s profession;

 (e) if subsection 65CA(6) applies in relation to the agreement:

 (i) the name of the agent referred to in that subsection; and

 (ii) a provider number allocated to a professional that identifies at least one of the practices or clinics mentioned in subparagraph 65CA(6)(c)(i) as a place where the professional practices the professional’s profession;

 (ea) if subsection 65CA(6A) applies in relation to the agreement:

 (i) the name of the professional and the address or addresses of the agreement location referred to in that subsection; or

 (ii) a provider number allocated to the professional that identifies at least one of the practices or clinics mentioned in subparagraph 65CA(6A)(c)(ii) as a place where the professional practices the professional’s profession;

 (f) the method by which written notifications will be provided to the assignor under section 89AA in respect of professional services covered by the agreement;

 (g) how the parties to the agreement, or the patient, may terminate the agreement.

 (3) Without limiting paragraph (2)(c), kinds of professional services may be described by reference to the Groups or Subgroups of the table that include the items that specify the services.

 (4) The information mentioned in paragraph (2)(f) may be given by providing an electronic link or website address to the assignor that the assignor can use to access the information.

 (5) The enduring agreement must:

 (a) include the information that was required to be given to the assignor in accordance with subsection (2); and

 (b) include the name of the assignor; and

 (c) specify whether the assignor is the patient in respect of the agreement; and

 (d) if the assignor is not the patient—specify how the assignor is a responsible person for the patient; and

 (e) if subparagraph 65CA(2)(b)(ii) applies in relation to the agreement—include the written declaration mentioned in that subparagraph; and

 (f) be a written document; and

 (g) be signed and dated by the assignor; and

 (h) if the agreement is entered into on or after 1 July 2027—be registered with Services Australia.

Subdivision C—Simplified billing assignments

65D  Requirements for requested simplified billing assignments

Information that must be given before request is made

 (1) For the purposes of paragraph 20AAA(3)(d) of the Act, the responsible provider must give, or cause to be given, the following information, in writing, to the assignor before a request under paragraph 20AAA(3)(a) of the Act is made in relation to the medicare benefit in respect of a professional service:

 (a) the name of the person to whom the professional service was or will be rendered;

 (b) in relation to the complying health insurance policy that covers (wholly or partly) the liability of the assignor or another person to pay fees and charges in respect of the professional service:

 (i) the name of the private health insurer; and

 (ii) the membership number or other unique identifier allocated by the insurer to the person to whom the professional service was or will be rendered;

 (c) that the request would be made to the following person:

 (i) in the case of hospital treatment authorised by the operator of a hospital—the operator of the hospital;

 (ii) in the case of hospital‑substitute treatment authorised by an organization—the organization;

 (iii) in the case of hospital‑substitute treatment to which subparagraph (ii) does not apply—the professional;

 (d) the information specified in subsection (2);

 (e) either:

 (i) if the professional service was or will be rendered while hospital treatment requiring a hospital admission is provided—the date of admission; or

 (ii) otherwise—the date on which the professional service was or will be rendered;

 (f) a description of the hospital treatment or hospital‑substitute treatment during which the professional service was or will be rendered;

 (g) the name of the person to whom the right to payment of the medicare benefit will be taken to be assigned, as specified in subsection 20AAA(4) of the Act;

 (h) either:

 (i) if the professional service was or will be rendered in a hospital—the name of the hospital; or

 (ii) if the professional service was or will be rendered in a private residence—a statement to that effect; or

 (iii) if neither subparagraph (i) nor (ii) apply—the address at which the professional service was or will be rendered.

 (2) For the purposes of paragraph (1)(d), the information is as follows:

 (a) if the request would be made to the operator of a hospital or an organization—either:

 (i) the name of each professional who wishes to be covered by the request, being a professional who is authorised by the operator of the hospital or the organization (as the case may be) to provide the hospital treatment or hospital‑substitute treatment during which the professional service was or will be rendered; or

 (ii) a statement that the professional service may be rendered by, or on behalf of, any person who is authorised by the operator of the hospital or the organization (as the case may be) to provide the hospital treatment or hospital‑substitute treatment during which the professional service was or will be rendered;

 (b) if the request would be made to a professional—the name of the professional.

Note: For the purposes of subparagraph (a)(i), the hospital treatment or hospital‑substitute treatment may be provided by a named professional directly, or under a named professional’s management or control: see subsection 20AAA(7) of the Act.

Making a request

 (3) For the purposes of paragraph 20AAA(3)(a) of the Act, the request:

 (a) must include the information that was required to be given to the assignor in accordance with subsection (1) of this section; and

 (b) must be made in writing; and

 (c) must be made before or as soon as practicable after the professional service is rendered.

Modifying a request

 (4) For the purposes of paragraph 20AAA(3)(b) of the Act, if, after a professional service is rendered, the responsible provider or a person authorised by the responsible provider intends to modify a request, the responsible provider must:

 (a) give the assignor, in writing, a revised version of the information that must be given under subsection (1) of this section that accounts for the proposed modification; and

 (b) obtain the assignor’s written approval to so modify the request.

Note: If the assignor does not approve the modification, the assignor’s right to payment of a medicare benefit is only taken to be assigned under subsection 20A(2) of the Act in relation to a medicare benefit covered by the original request.

 (5) The modification:

 (a) must be made in writing; and

 (b) must only be made in circumstances in which the original request does not cover the medicare benefit in respect of a professional service (the new professional service) rendered to the eligible person:

 (i) if the professional service covered by the original request was to be rendered while hospital treatment requiring a hospital admission is provided—during that hospital treatment; or

 (ii) otherwise—on the date on which the professional service covered by the original request was to be rendered; and

 (c) must cover the new professional service; and

 (d) must be made as soon as practicable after the new professional service has been rendered.

Division 7B—Claims for medicare benefit

65E  Requirements for claims for medicare benefit

  For the purposes of paragraph 20B(1)(a) of the Act, a claim for a medicare benefit in respect of a professional service must include the following:

 (a) the particulars prescribed under subsection 19(6) of the Act in relation to professional services generally;

 (b) any particulars prescribed under that subsection in relation to each class of professional services in which the professional service is included;

 (c) if the claim is made on the basis that the right to payment of the medicare benefit is taken to be assigned under subsection 20A(2) of the Act—a declaration, by the person making the claim, that paragraphs 20A(2)(a) to (c) and (e) of the Act are satisfied.

Division 8—Eligible midwives

66  Meaning of eligible midwife—requirements

  For the purposes of paragraph 21(1)(b) of the Act, the requirement for a person to be an eligible midwife is that the person is endorsed by the Nursing and Midwifery Board of Australia.

Part 4—Special provisions relating to pathology

67  Giving notice of termination of undertaking

  For the purposes of sections 23DE and 23DH of the Act, a notice of termination must be sent:

 (a) by pre‑paid post to Pathology Registration, Department of Human Services, GPO Box 9822, Melbourne VIC 3001; or

 (b) by fax to (03) 9605 7984; or

 (c) by email to provider.registration@humanservices.gov.au; or

 (d) by any other electronic method for giving a notice of termination that is provided on the website of the Human Services Department.

68  Approved pathology authorities—other records of pathology services

 (1) This section is made for the purposes of subsection 23DKA(1) of the Act.

 (2) An approved pathology authority must prepare and maintain a record of each pathology service rendered in an accredited pathology laboratory of which the authority is the proprietor.

 (3) The record of each pathology service rendered must include a copy of a report of the service.

 (4) The records must be kept in a manner that enables information to be retrieved using the name of the person in relation to whom the service was rendered and the date on which the service was rendered.

69  Offences in relation to request forms—branded pathology request forms

 (1) For the purposes of subsection 23DP(3) of the Act, this section applies to a pathology request form that includes:

 (a) the registered name or trading name of:

 (i) if the form is provided by an approved pathology authority—the approved pathology authority; or

 (ii) if the form is provided by an approved pathology practitioner—an approved pathology authority that employs or engages the approved pathology practitioner; and

 (b) the location of one or more specimen collection centres.

 (2) The pathology request form must include a statement that informs a person in relation to whom a pathology service is requested that:

 (a) the request may be taken to a pathology provider of the person’s choice; and

 (b) if the person’s treating practitioner has specified an approved pathology practitioner on clinical grounds, a medicare benefit will be payable only if the service is conducted by that practitioner.

 (3) In this section:

pathology provider means:

 (a) a person who renders pathology services; or

 (b) a person who carries on the business of rendering pathology services; or

 (c) a person who employs, or engages under a contract of service, a person mentioned in paragraph (a) or (b).

Part 5—Special provisions relating to diagnostic imaging services

70  Requests for diagnostic imaging services—information and form requirements

 (1) This section is made for the purposes of subsection 23DQ(1) of the Act.

Information that must be included

 (2) The following information must be included in a subsection 16B(1) request:

 (a) the name of the person making the request;

 (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 making the request;

 (c) the date of the request;

 (d) a description of the diagnostic imaging service being requested that provides, in terms that are generally understood throughout the medical profession, sufficient information to identify the item of the diagnostic imaging services table that relates to the service.

Branded diagnostic imaging request forms

 (3) Subsection (4) applies to a subsection 16B(1) request if:

 (a) the request is made using a document for use in making a subsection 16B(1) request that is supplied, or made available to, a practitioner (within the meaning of section 23DQ of the Act) by a diagnostic imaging provider on or after 1 August 2012; and

 (b) the document, as supplied or made available, contains:

 (i) the registered name or trading name of the diagnostic imaging provider; and

 (ii) one or more locations where the diagnostic imaging provider renders diagnostic imaging services.

 (4) The request must include a statement that informs the person in relation to whom the diagnostic imaging service is requested that the request may be taken to a diagnostic imaging provider of the person’s choice.

 (5) In this section:

diagnostic imaging provider means:

 (a) a person who renders diagnostic imaging services; or

 (b) a person who carries on the business of rendering diagnostic imaging services; or

 (c) a person who employs, or engages under a contract of service, a person mentioned in paragraph (a) or (b).

71  Medical practitioners rendering diagnostic imaging services—other records of services

 (1) This section is made for the purposes of subsection 23DS(1) of the Act.

 (2) A medical practitioner who renders a diagnostic imaging service (the providing practitioner) must prepare and maintain a record of the service.

 (3) The record of each diagnostic imaging service rendered must include the following:

 (a) a copy of a report of the service by the providing practitioner;

 (b) if the service is rendered in the circumstances mentioned in subsection 16B(8) of the Act (emergencies)—the nature of the emergency;

 (c) if the service is rendered in the circumstances mentioned in subsection 16B(9) of the Act (lost requests)—the date and manner of confirmation that the request had been made as mentioned in paragraph 16B(9)(b) of the Act;

 (d) if the service is rendered in the circumstances mentioned in subsection 16B(10A) of the Act (substituted services):

 (i) the date that the providing practitioner consulted with the person who made the subsection 16B(1) request; or

 (ii) if the providing practitioner did not so consult—the steps that the providing practitioner took to consult.

 (4) If a diagnostic imaging procedure is performed, as part of an ultrasound service, by a registered sonographer under the supervision, or at the direction, of the providing practitioner, the report mentioned in paragraph (3)(a) must include the name of the registered sonographer.

 (5) The records must be kept in a manner that enables information to be retrieved using the name of the person in relation to whom the service was rendered and the date on which the service was rendered.

 (6) In this section:

registered sonographer means a person whose name is entered on the register of sonographers maintained by the Chief Executive Medicare.

Note: Maintaining a register of sonographers is a function of the Chief Executive Medicare under section 32 of the Human Services (Medicare) Regulations 2017.

ultrasound service means a service specified in an item in Group I1 in the diagnostic imaging services table.

72  Diagnostic Imaging Register—other information to be included in application for registration

  For the purposes of paragraph 23DZP(1)(d) of the Act, the other information that must be included in an application for registration of diagnostic imaging premises or a base for mobile diagnostic imaging equipment is the following:

 (a) the nature of the practice at the premises or base;

 (b) for diagnostic imaging premises—the quantity of each type of diagnostic imaging equipment ordinarily located at the premises;

 (c) for each piece of diagnostic imaging equipment ordinarily located at the premises or base:

 (i) the age of the piece of equipment (worked out in the same way it is worked out under subclause 1.2.2(1) of the diagnostic imaging table); and

 (ii) whether the piece of equipment has been upgraded (within the meaning given by subclause 1.2.2(3) of the diagnostic imaging table);

 (d) for each piece of diagnostic imaging equipment ordinarily located at the premises or base that has a serial number or other identifying number—that number;

 (e) the functionality of each piece of diagnostic imaging equipment ordinarily located at the premises or base;

 (f) if the premises are, or the base is, accredited under a diagnostic imaging accreditation scheme—the information mentioned in subsection 75(1) of this instrument.

Example: For paragraph (a), the practice might be a base for mobile equipment, a specialist diagnostic imaging 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.

73  Diagnostic Imaging Register—other information to be included on Register

  For the purposes of subparagraph 23DZQ(1)(b)(iv) of the Act, the other information that must be included on the Diagnostic Imaging Register for premises or a base is the information mentioned in section 72 of this instrument that was included in the application for registration.

74  Primary information—types of diagnostic imaging equipment

  For the purposes of subsection 23DZR(2) of the Act, the types of diagnostic equipment mentioned in the following table are prescribed.

75  Diagnostic imaging accreditation—information to be included on Diagnostic Imaging Register

 (1) For the purposes of subsection 23DZZIAB(1) of the Act, the information that must be recorded on the Diagnostic Imaging Register in relation to the accreditation of diagnostic imaging premises or a base for mobile diagnostic imaging equipment is the following:

 (a) the name of the approved accreditor;

 (b) the commencement date of the accreditation;

 (c) the diagnostic imaging procedures for which the premises or base is accredited;

 (d) the date on which, if the premises or base has not been accredited again, the accreditation must be revoked.

Note: See the scheme under subsection 23DZZIAA(1) of the Act.

 (2) For the purposes of subsection 23DZZIAB(2) of the Act, if the accreditation of diagnostic imaging premises or a base for mobile diagnostic imaging equipment is varied by changing the diagnostic imaging procedures for which the premises or base is accredited, the information that must be recorded on the Diagnostic Imaging Register is:

 (a) if a diagnostic imaging procedure has been added—the date on which the diagnostic imaging procedure was added; and

 (b) if a diagnostic imaging procedure has been removed—the date on which the diagnostic imaging procedure was removed.

Part 6—Prohibited practices in relation to pathology services and diagnostic imaging services

76  Meaning of permitted benefit—method for determining substantial difference from market value

  For the purposes of subsection 23DZZIF(9) of the Act, the amount of a payment or of consideration for property, goods or services is substantially different from the market value for the property, goods or services if the difference is more than 20% of the market value.

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 2 of Group T2 in the general medical services table;

 (ab) kilovoltage 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.

Part 8—Health program grants

81  Application for approval as an organization under Part IV of the Act

  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  Application for approval of health service under Part IV of the Act

  An application under subsection 41(1) of the Act by an approved 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

84  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

  If a 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 1A—Notification and record‑keeping requirements in relation to assignment of medicare benefit

Subdivision A—Bulk billing assignments

89AA  Enduring agreements—notification requirements

Scope

 (1) This section is made for the purposes of paragraph 127(2)(c) of the Act.

 (2) Paragraph 127(2)(e) of the Act applies in relation to this section.

Requirement to notify assignor of claim for payment of medicare benefit

 (3) A professional must give a notification in accordance with subsection (4) or (5) (as applicable) to a person (the assignor) if:

 (a) the professional has entered into an enduring agreement with the assignor; and

 (b) subsection 65CA(5) applies in relation to the agreement; and

 (c) a claim is made for the payment of medicare benefit in respect of the rendering of a professional service covered by the agreement.

 (4) Within 24 hours after the professional makes such a claim (including a new claim made in substitution of an earlier claim), the professional must give notification of the making of the claim.

 (5) Within 24 hours after the professional becomes aware of an error in a notification given under subsection (4), the professional must give a notification correcting the error.

 (6) A notification under subsection (4) or (5) must include the following:

 (a) the name of the professional;

 (b) the person to whom the professional service was rendered;

 (c) the date on which the professional service was rendered;

 (d) the amount of the medicare benefit claimed.

Requirement to notify assignor of intention to terminate enduring agreement

 (7) If a professional intends to terminate an enduring agreement entered into with a person (the assignor), the professional must, at least 2 days before terminating the agreement, give the assignor notification of the intention to terminate the agreement.

Manner and form of notification

 (8) A notification under this section must:

 (a) be in writing; and

 (b) include the date on which it is made; and

 (c) be given to the assignor in the manner agreed by the assignor.

89A  Record‑keeping

 (1) This section specifies kinds of records that must be kept by a relevant person for the purposes of subsection 127A(1) of the Act.

Note: A relevant person may be a professional mentioned in subsection 20A(1) of the Act, an insurer or an approved billing agent.

Enduring agreements

 (2) The following kinds of records are specified in relation to an enduring agreement:

 (a) the enduring agreement (or copy);

 (b) if the enduring agreement is not signed by the relevant person—any documents (or copies) that record the consent of the relevant person to:

 (i) enter into the enduring agreement; and

 (ii) the enduring agreement covering the kinds of professional services described in the agreement;

 (c) any written notifications (or copies) given under section 89AA in relation to professional services covered by the enduring agreement;

 (d) a written notice (or copy) that terminates the enduring agreement.

Episodic agreements

 (3) The kind of record that is specified in relation to an episodic agreement in respect of which a claim for a medicare benefit assigned to the relevant person is made under section 20B of the Act is the episodic agreement (or copy).

Subdivision B—Simplified billing assignments

89B  Notification requirements

Notification of payment of medicare benefit

 (1) For the purposes of subparagraph 127(3)(d)(i) of the Act, this section specifies the requirements an insurer or approved billing agent must meet in giving a notification mentioned in paragraph 127(3)(d) of the Act to an assignor or another eligible person.

 (2) The notification must include the following:

 (a) the name of the person to whom the professional service, in respect of which the assignor is taken to have assigned the medicare benefit, was rendered;

 (b) in relation to the complying health insurance policy that covered (wholly or partly) the liability of the assignor or another person to pay fees and charges in respect of the professional service:

 (i) the name of the private health insurer; and

 (ii) the membership number or other unique identifier allocated by the insurer to the person to whom the professional service was rendered;

 (c) the name of the professional who rendered, or on whose behalf was rendered, the professional service;

 (d) the date on which the professional service was rendered;

 (e) the number of the item that specifies the professional service;

 (f) the amount of medicare benefit paid;

 (g) the name of the insurer or approved billing agent (as the case may be).

Manner and form of notification

 (4) The notification must be given:

 (a) in writing; and

 (b) in the manner agreed by the assignor or other eligible person (as applicable).

89C  Record‑keeping—kinds of records

Private health insurer

 (1) For the purposes of subsection 127A(1) of the Act, if, under subsection 20A(2) of the Act, the right to payment of a medicare benefit in respect of a professional service is taken to be assigned to an insurer, the kinds of records that must be kept by the insurer are as follows:

 (a) a copy of the complying health insurance policy under which the assignor or another person is covered (wholly or partly) for liability to pay fees and charges in respect of the professional service;

 (b) a copy of the notification that the insurer is required to give the assignor or other eligible person under paragraph 127(3)(d) of the Act;

 (c) if subsection 20AAA(1) of the Act applies to the assignor’s right to the payment of the medicare benefit in respect of the professional service—records of the arrangement, mentioned in paragraph (a) of that subsection, under which the insurer made, or is required to make, a payment in relation to the rendering of the professional service.

Approved billing agent

 (2) For the purposes of subsection 127A(1) of the Act, if, under subsection 20A(2) of the Act, the right to payment of a medicare benefit in respect of a professional service is taken to be assigned to an approved billing agent, the kinds of records that must be kept by the billing agent are as follows:

 (a) records of the complying health insurance policy under which the assignor or another person is covered (wholly or partly) for liability to pay fees and charges in respect of the professional service;

 (b) a copy of the notification that the billing agent is required to give the assignor or other eligible person under paragraph 127(3)(d) of the Act.

Operator of the hospital

 (3) Subsection (4) applies to an operator of a hospital if

 (a) under subsection 20A(2) of the Act, the assignor’s right to the payment of the medicare benefit in respect of a professional service is taken to be assigned; and

 (b) the professional service is rendered while hospital treatment authorised by the operator of the hospital is provided.

 (4) For the purposes of subsection 127A(3) of the Act, the kinds of records that must be kept by the operator of the hospital are as follows:

 (a) records of the authorisation to provide the hospital treatment (see subsection 20AAA(7) of the Act);

 (b) if subsection 20AAA(1) of the Act applies to the assignor’s right and the insurer made, or is required to make, a payment in relation to the rendering of the professional service under an arrangement with the operator of the hospital:

 (i) a copy of that arrangement; and

 (ii) a copy of the arrangement, under which treatment is provided to persons insured by the insurer, between the operator of the hospital and the professional who rendered, or on whose behalf was rendered, the professional service;

 (c) if subsection 20AAA(3) of the Act applies to the assignor’s right and the assignor made a request to the operator of the hospital for the purposes of paragraph (a) of that subsection:

 (i) a copy of the request; and

 (ii) a copy of any modification to the request; and

 (iii) a copy of the assignor’s written approval of any such modification;

 (d) if subsection 20AAA(5) of the Act applies to the assignor’s right in respect of the professional service (the secondary professional service) and subsection 20AAA(1) or (3) of the Act applies to the assignor’s right in respect of another professional service (the related professional service) rendered while the hospital treatment mentioned in paragraph (3)(b) of this section is provided—a record of evidence that the secondary professional service:

 (i) was rendered for a complication that arose during the related professional service; or

 (ii) was unplanned but was rendered during planned treatment of which the related professional service was part, and was, in the view of the professional who rendered or on whose behalf was rendered the secondary professional service, necessary and urgent.

Organization

 (5) Subsection (6) applies to an organization if:

 (a) under subsection 20A(2) of the Act, the assignor’s right to the payment of the medicare benefit in respect of a professional service is taken to be assigned; and

 (b) the professional service is rendered while hospital‑substitute treatment authorised by the organization is provided.

 (6) For the purposes of subsection 127A(3) of the Act, the kinds of records that must be kept by the organization are as follows:

 (a) records of the authorisation to provide the hospital‑substitute treatment (see subsection 20AAA(7) of the Act);

 (b) if subsection 20AAA(1) of the Act applies to the assignor’s right and the insurer made, or is required to make, a payment in relation to the rendering of the professional service under an arrangement with the organization:

 (i) a copy of that arrangement; and

 (ii) a copy of the arrangement, under which treatment is provided to persons insured by the insurer, between the organization and the professional who rendered, or on whose behalf was rendered, the professional service;

 (c) if subsection 20AAA(3) of the Act applies to the assignor’s right and the assignor made a request to the organization for the purposes of paragraph (a) of that subsection:

 (i) a copy of the request; and

 (ii) a copy of any modification to the request; and

 (iii) a copy of the assignor’s written approval of any such modification;

 (d) if subsection 20AAA(5) of the Act applies to the assignor’s right in respect of the professional service (the secondary professional service) and subsection 20AAA(1) or (3) of the Act applies to the assignor’s right in respect of another professional service (the related professional service) rendered while the hospital‑substitute treatment mentioned in paragraph (5)(b) of this section is provided—a record of evidence that the secondary professional service:

 (i) was rendered for a complication that arose during the related professional service; or

 (ii) was unplanned but was rendered during planned treatment of which the related professional service was part, and was, in the view of the professional who rendered or on whose behalf was rendered the secondary professional service, necessary and urgent.

Professional

 (7) Subsection (8) applies to a professional if:

 (a) under subsection 20A(2) of the Act, the assignor’s right to the payment of the medicare benefit in respect of a professional service is taken to be assigned; and

 (b) the professional service is rendered while hospital‑substitute treatment to which paragraph 127A(3)(b) of the Act does not apply is provided.

 (8) For the purposes of subsection 127A(3) of the Act, the kinds of records that must be kept by the professional are as follows:

 (a) if subsection 20AAA(1) of the Act applies to the assignor’s right and the insurer made, or is required to make, a payment in relation to the rendering of the professional service under an arrangement with the professional—a copy of that arrangement;

 (b) if subsection 20AAA(3) of the Act applies to the assignor’s right and the assignor made a request to the professional for the purposes of paragraph (a) of that subsection:

 (i) a copy of the request; and

 (ii) a copy of any modification to the request; and

 (iii) a copy of the assignor’s written approval of any such modification;

 (c) if subsection 20AAA(5) of the Act applies to the assignor’s right in respect of the professional service (the secondary professional service) and subsection 20AAA(1) or (3) of the Act applies to the assignor’s right in respect of another professional service (the related professional service) rendered while the hospital‑substitute treatment mentioned in paragraph (7)(b) of this section is provided—a record of evidence that the secondary professional service:

 (i) was rendered for a complication that arose during the related professional service; or

 (ii) was unplanned but was rendered during planned treatment of which the related professional service was part, and was, in the view of the professional who rendered or on whose behalf was rendered the secondary professional service, necessary and urgent.

89D  Record‑keeping—retention day

  For the purposes of paragraph 127A(5)(c) of the Act, for a record of a kind specified in column 1 of an item in the following table, the day mentioned in column 2 of the item is specified.

Note: For the retention period for records of a kind not specified in the table, see paragraphs 127A(5)(a) and (b) of the Act.

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;

 (iva) the Treatment Benefits (Special Access) Act 2019;

 (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 Australian Health Practitioner Regulation Agency;

 (ii) a National Board;

 (iia) each State or Territory Board of a National Board;

 (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 health 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 health 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 health practitioner is the subject of an investigation by the Chief Executive Medicare.

 (6) However, information may only be provided to a State or Territory authority under subsection (5) if:

 (a) the health practitioner is, was, or is applying to be, registered or licensed to practice in that State or Territory; or

 (b) the health 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 health practitioner who is the subject of a complaint or investigation mentioned in subsection (2), (3) or (5):

 (a) name;

 (b) the address of each location at which the health practitioner practises (including any former location at which the health practitioner practised in the period that is the subject of the complaint or investigation);

 (c) if the health practitioner has been allocated a provider number or requester number—the number;

 (d) whether the health practitioner has previously been the subject of an investigation by the Chief Executive Medicare and, if so, the status of the investigation.

 (8) Information relating to a service may be provided if:

 (a) a health practitioner who is the subject of a complaint or investigation mentioned in subsection (2), (3) or (5):

 (i) rendered the service; or

 (ii) supervised the rendering of the service; or

 (iii) requested the service; or

 (iv) claimed or received payment of fees in relation to the service; or

 (v) was 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; and

 (b) 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 the patient has made a complaint mentioned in subsection (2) or (3).

 (9A) The information mentioned in subsection (10) relating to a patient may also be provided if:

 (a) the patient has received a service; and

 (b) a health practitioner who is the subject of a complaint or investigation mentioned in subsection (2), (3) or (5):

 (i) rendered the service; or

 (ii) supervised the rendering of the service; or

 (iii) requested the service; or

 (iv) claimed or received payment of fees in relation to the service; or

 (v) was 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; and

 (c) the Chief Executive Medicare reasonably believes that the service is relevant to the complaint or investigation.

 (10) For the purposes of subsections (9) and (9A), 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; and

 (ii) expected date of departure from Australia; and

 (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) include the 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—Application, saving and 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