Health Insurance Regulations (Amendment)

Administered by Department of Health, Disability and Ageing

Legislation au F1996B02842 Regulations Not in force Legislative Instrument

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Health Insurance Regulations (Amendment) 1996 No. 234

EXPLANATORY STATEMENT

STATUTORY RULES 1996 No. 234

Issued by authority of the Minister for Health and Family Services

Health Insurance Act 1973

Health Insurance Regulations (Amendment)

The Health Insurance Act 1973 (the Act) provides, in part, for the payment of Medicare benefits for professional services rendered by medical practitioners and for certain professional services rendered by dental practitioners and optometrists.

Section 19(6) of the Act provides that Medicare benefits are not payable unless the person by or on behalf of whom the professional service was rendered, or an employee of that person, records certain prescribed particulars on the account or receipt, or, in the case of claims which are bulk billed, the form of the assignment or agreement for fees in respect of the service.

Regulation 13 of the Health Insurance Regulations prescribes the particulars which need to be recorded on accounts, receipts and bulk billing assignments or agreements for professional services for the purposes of subsection 19(6) of the Act.

Subsection 16B(1) of the Act provides, in part that Medicare benefits are not payable for an R-type diagnostic imaging service rendered by the providing practitioner unless there was a written request for the service by a medical or dental practitioner or a chiropractor, a physiotherapist or a podiatrist. Subsection 23DQ(1) of the Act provides that regulations may specify the information that must be included in a written request under subsection 16B(1).

Regulation 19(1) of the Health Insurance Regulations prescribes the information that must be included in subsection 16B(1) requests by practitioners.

Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.

The Regulations amend the Health Insurance Regulations in accordance with the Government's 1996-97 Budget commitments. The Regulations will assist the Commonwealth to obtain data relating to the use of Medicare funded services in hospital settings in order to facilitate better assessment of funding levels to State and Territory hospitals.

The Regulations require:

* all practitioners providing professional services to identify on their accounts, receipts or assignments of benefit; and

* all practitioners requesting R-type diagnostic imaging services to identify on their written requests

those services which in their opinion are hospital-related services.

Identifying these services will not affect the payment of Medicare benefits.

The Regulations amend Regulation 13 of the Health Insurance Regulations by prescribing additional particulars to be recorded on accounts, receipts and bulk billing assignments or agreements.

Subregulation 13(20) provides that where a practitioner forms an opinion that a professional service is a hospital-related service, within the meaning of subregulation 13(21), the practitioner is to record on the account or receipt the prescribed particular, namely, the letter "A". If it is a bulk billed hospital-related service the practitioner is to record on the assignment or agreement the prescribed particular, namely, the letter "A", except where the practitioner notifies the Health Insurance Commission, by means of an approved form known as a form DB1C, of an assignment or agreement in relation to the Medicare benefit in respect of the service.

Subregulation 13(21) defines a professional service which is a "hospital-related service" as:

(a) a professional service provided in relation to a person for a condition in relation to which the person will, or is likely to, receive treatment in a hospital or day hospital facility within 4 weeks of the service being provided; or

(b) a professional service provided in relation to a person for a condition in relation to which the person had received treatment in a hospital or day hospital facility in the 4 weeks immediately before the service was provided; or

(c) a professional service provided in relation to a person for a condition in relation to which, immediately before receiving the service, the person had presented for treatment to a recognised hospital and was referred or redirected to the practitioner who provided the service; or

(d) a professional service provided at a recognised hospital in relation to a person who is not admitted to that hospital in connection with that service.

Subregulation 13(22) provides that, in reaching an opinion as to whether a professional service is such a hospital-related service, the practitioner must have regard to the nature of the professional service provided to the person concerned, and all the circumstances in which the service was provided, including, but not limited to:

(a) the results of any examination of the person by the practitioner; and

(b) the results of any tests in relation to the person conducted by, or made available to, the practitioner; and

(d) any letter, form or document given to the practitioner in connection with the provision by the practitioner of the service.

The Regulations also amend Regulation 19 of the Health Insurance Regulations by requiring additional information be included in requests for diagnostic imaging services.

Paragraph 19(1)(d) provides that where a requesting practitioner forms an opinion that the requested R-type diagnostic imaging service is a hospital-related service, within the meaning of subregulation 19(1A) the request should be identified by the letter "A".

Subregulation 19(1A) defines an R-type diagnostic type service which is a "hospital-related service" as:

(a) a diagnostic imaging service requested in relation to a person for a condition in relation to which the person will, or is likely to, receive treatment in a hospital or day hospital facility within 4 weeks of the service being provided; or

(b) a diagnostic imaging service requested in relation to a person for a condition in relation to which the person had received treatment in a hospital or day hospital facility in the 4 weeks immediately before the service was provided; or

(c) a diagnostic imaging service requested in relation to a person for a condition in relation to which, immediately before receiving the service, the person had presented for treatment to a recognised hospital and was referred or redirected to the practitioner who provided the service; or

(d) a diagnostic imaging service requested at a recognised hospital in relation to a person who is not admitted to that hospital in connection with that service.

Subregulation 19(1B) sets out the criteria a practitioner should have regard to when reaching an opinion as to whether a diagnostic imaging service is a such a hospital-related service, namely, the nature of the diagnostic imaging service and all the circumstances in which the .service was provided, including, but not limited to:

(a) the results of any examination of the person by the practitioner; and

(b) the results of any tests in relation to the person conducted by, or made available to, the practitioner; and

(d) any letter, form or document given to the practitioner in connection with the provision by the practitioner of the service.

The Regulations will commence on 1 November 1996.

Overview

The Health Insurance Regulations (Amendment) 1996 No. 234 was enacted to address the need for better data collection on the use of Medicare funded services in hospital settings, thereby facilitating more accurate assessment of funding levels to state and territory hospitals. This regulatory amendment was made under the authority of the Health Insurance Act 1973 and issued by the Minister for Health and Family Services. The policy objective of these amendments was to enhance the Commonwealth's ability to gather essential data on Medicare-funded services provided in hospitals, which would ultimately contribute to more precise funding allocations to state and territory hospitals. The amendments require practitioners to identify hospital-related services on accounts, receipts, and bulk billing assignments or agreements, and also mandate that requests for R-type diagnostic imaging services include specific information to identify such services. These requirements do not impact the payment of Medicare benefits but are designed to ensure that the Commonwealth can effectively monitor and assess the use of hospital-related services. The Regulations came into effect on 1 November 1996.

Scope and Application

The Health Insurance Regulations (Amendment) 1996 No. 234 amends the Health Insurance Regulations to enhance the collection of data on the use of Medicare-funded services in hospital settings. These amendments apply to all medical, dental, and optometry practitioners in Australia, ensuring that they record specific details on accounts, receipts, and bulk billing assignments or agreements for professional services. These amendments are in line with the Commonwealth's commitment to better assess funding levels to state and territory hospitals. The regulations require practitioners to identify hospital-related services by recording the letter "A" on relevant documents, which does not affect the payment of Medicare benefits. Additionally, the regulations specify that requests for R-type diagnostic imaging services must also identify hospital-related services with the letter "A", based on the practitioner's opinion and the criteria outlined in the regulations. These amendments aim to facilitate more accurate data collection for assessing hospital funding, and they will commence on 1 November 1996.

Key Provisions

The Health Insurance Regulations (Amendment) 1996 No. 234 introduce significant amendments to the Health Insurance Regulations, aimed at improving the Commonwealth's ability to assess funding levels for State and Territory hospitals by obtaining better data on the use of Medicare-funded services in hospital settings. Under section 19(6) of the Health Insurance Act 1973, Medicare benefits are not payable unless specific prescribed particulars are recorded on accounts, receipts, or bulk billing assignments or agreements for services rendered by medical, dental, and optometry practitioners. Regulation 13 of the Health Insurance Regulations specifies these particulars, and the amendments now require practitioners to identify on their accounts, receipts, or assignments those services they consider to be hospital-related services. Practitioners are required to record the letter "A" on accounts or receipts for hospital-related services, as defined by subregulation 13(21). This definition includes services provided for conditions in relation to which a person will receive treatment in a hospital or day hospital facility within four weeks, or had received treatment in the four weeks immediately prior to the service. Similarly, for diagnostic imaging services, practitioners must identify hospital-related services by including the letter "A" in their written requests, as per subregulation 19(1A). The criteria for determining whether a service is hospital-related are outlined in subregulation 19(1B) and include considerations such as examination results, test results, and the patient's history. The Regulations impose specific obligations on practitioners. They must record the letter "A" on their accounts, receipts, or bulk billing assignments or agreements if they form an opinion that a service is hospital-related, as per subregulations 13(20) and 19(1). This obligation applies to all types of professional services, including those rendered in a hospital setting or those likely to lead to hospital treatment within a specified timeframe. Failure to comply with these requirements may result in Medicare benefits not being payable for the service in question. Additionally, practitioners must ensure that written requests for diagnostic imaging services include the letter "A" if they consider the service to be hospital-related. Failure to comply with the requirements set out in the Regulations can lead to civil and administrative consequences. Specifically, if a practitioner does not record the necessary particulars on accounts, receipts, or bulk billing assignments or agreements, Medicare benefits may not be payable for the service in question. This can result in financial losses for the practitioner and potentially affect the patient's access to benefits. While the Regulations do not explicitly outline criminal penalties for non-compliance, repeated or deliberate non-compliance could lead to further scrutiny or penalties under other provisions of the Health Insurance Act 1973 or related legislation. The Regulations commenced on 1 November 1996, and practitioners are expected to adhere to these new requirements to ensure the accurate recording of hospital-related services.

Area of Law: Health Law; Insurance Law
Instrument: Regulation
Concepts: Definitions & Interpretation; Reporting & Disclosure Obligations; Compliance Obligations; Offence Provisions

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Sourced from the Federal Register of Legislation at 26 August 2026. For the latest information on Australian Government law please go to https://www.legislation.gov.au.

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