Provider numbers for health professionals in Medicare and the Provider Directory System (PDS) 012-42010010

A provider number is:

• allocated by Services Australia (the agency) to a registered medical practitioner, allied health professional or non-medical health professional (dentist, optometrist, nurse practitioner or midwife). It identifies the person and their health profession at the practice location/s where the person practises their profession
• generated within PDS when processing of an application for a provider number and is allocated from a provider number stack held in the database tables
• not automatically granted with access to Medicare benefits. The issuing of a provider number does not mean the following are eligible to attract Medicare benefits for their professional services:
• medical practitioner
• non-medical health professional, or
• allied health professional

'Provider number' refers to the number issued by the agency to identify health professionals in the Medicare PDS system.

A provider number may allow health professionals to gain access to any of the following once eligibility requirements are met:

• refer their patient to another health professional (usually a specialist or consultant physician), or
• request diagnostic imaging or pathology services if their patient can claim Medicare benefits at the referred rate, or
• access Medicare benefit rebates for their services (subject to any legislative restrictions or requirements). Medicare benefit eligibility is determined by the Health Insurance Act 1973 (the Act) and supporting Regulations and Determinations. The References page contains a link to this Act

Refer all enquiries about a health professional's eligibility to access Medicare benefits for their services to Provider Registration staff. Only give advice about a health professional's eligibility after a security check is completed, to:

• the health professional, or
• a third party

A provider number consists of:

• 6 numerals referred to as the provider stem, for example 123456
• an alpha or numeric character that identifies the practice location, for example 1234561
• an alpha check digit, for example 1234561A

Note: the 8 character provider number is calculated using an algorithm. All 8 characters must be included in written correspondence to the provider, including any leading zeros.

A provider number can be allocated where the health professional:

• can access Medicare benefit rebates for their services (subject to any legislative restrictions or requirements)
• can refer or request services for which their patient can claim a Medicare rebate
• has relevant qualifications or eligibility as set out in the Act and supporting regulations or related program guidelines

Eligible health professionals are issued a provider number for providing services included under the Medicare program.

The References page contains a link to the Act.

A health professional should have a provider number for every practice location where they provide services. This policy is supported by the Health Insurance Regulations 2018.

There are exceptions to this rule, such as:

• Locum Tenens provisions, see the Resources page for MBS Online
• Mobile services
• Home visits and telehealth

These exceptions do not apply when the health professional is subject to any restrictions on accessing Medicare benefits or are participants in an Other Medical Practitioners Program (OMPS).

Health professionals can request an additional provider number, even if they have an existing provider number at the same location, for the purpose of:

• Medicare Urgent Care Clinics (UCC), or
• a General Practitioner Respiratory Clinic (GPRC)

A practice address is recorded in PDS and is known as the provider number or provider location address. The address in PDS is available to authorised recipients, including:

• private health funds
• Department of Health and Aged Care (DoHAC)
• Department of Veterans' Affairs (DVA)

Recording the correct practice address in PDS allows payment of Medicare incentive items. The incentive payment is linked to the Rural, Remote, and Metropolitan Area (RRMA) and the Modified Monash Model (MMM) 2019 geographical classification system for the location where the service is performed.

See Provider location details for health professionals in Medicare.

Legislation requires a claim for a Medicare benefit must include:

• the name of the health professional and the address of the place of practice, or
• the provider number of the health professional for the practice location

See Account and receipt documents for Medicare claims processing.

Use of a home address as the provider number location address

The agency is unable to suppress a provider number address. Therefore, health professionals should carefully consider using a home address for a provider number, as the provider number location address may be publicly available. For example:

• viewable on pay doctor via claimant (PDVC) cheques. Note: health professionals can request a pay group link to direct payment of Medicare benefit cheques to a PO Box address. See Payment pay group link for Medicare benefit cheques for more details and the form required
• requests for pathology services
• available to private health funds for the purposes of their business

Information for health professionals about using a home address as a practice location with the address being publicly available is included in the Application for a Medicare provider number (HW019 and HW093).

Note: provider addresses are no longer visible in a patient's myGov or My Health Record claims history, effective February 2021.

Requests from health professionals to use an alternative provider location address (such as a PO Box)

An increasing number of health professionals are providing telehealth services (currently included in the Medicare Benefits Schedule (MBS) from their home address.

The agency is aware some health professionals have expressed safety concerns following their move to home-based consultations.

The agency may consider recording an alternative address (such as PO Box), for a health professional where:

• the home is the only practice location, and
• the health professional is only providing telehealth services or mobile consultations

Note: the agency does not accept parcel lockers as an alternative address. The PO Box must be registered to the health professional.

All health professionals requesting an alternative address must:

• submit a signed request, and
• include the below details:
• current practice location arrangements, if applicable. For example, only providing telehealth services from the home location
• reason for using an alternate address. For example, safety concerns
• proposed alternative address. For example, a PO Box (this cannot be a parcel locker)
• physical practice (home address). This is recorded in the Notes section of PDS

Note: the process for requesting a provider number for a new location, including home addresses, remains the same.

Medical or non-medical practitioner requests to use alternative provider location address

• All requests from medical practitioners and non-medical health professionals are escalated to a Programme Officer via Local Peer Support (LPS)
• The requests are assessed on a case-by-case basis to make sure legislative requirements are met
• The use of an alternative location address may affect eligibility with other programs

Allied health professional requests to use alternative location address

Service Delivery assess requests from allied health professionals. For details on eligibility criteria and process, see Allied health and non-medical professionals provider number applications and requests.

A new provider stem number is automatically created in PDS when a health professional requires locations more than the 31 locations allowed under each stem.

A health professional who has a provider number for:

• one health profession (for example medical), and
• has a qualification in a second (or more) health profession (for example dental) must be allocated a separate provider stem for each health profession they are registered under

The second stem is required to monitor:

• registration status of the health professional in their respective health profession
• appropriate access to Medicare benefits for each health profession

Online application via HPOS

Many health professionals are eligible to apply for a provider number online using HPOS. See Providers numbers issued via HPOS for eligibility details.

Applying via HPOS is a secure and faster option to apply for Medicare provider numbers. Delegates acting on behalf of a provider can also apply online for a provider’s subsequent provider number only. A delegate cannot apply online for a provider’s initial provider number.

Information for providers and their delegates is available on the Health Professional Education Resources website. See the Resources page for the link.

See Allied health and non-medical health professional registrations for Medicare about eligible Ahpra registered allied health professionals.

Manual application

Health professionals not eligible to apply via HPOS can apply by manual application and:

• complete, sign, and date an application for a provider number form for their health profession
• attach the documentation as indicated on the form
• follow instructions on the form on how to submit

Available submission options are listed on the application form 'Returning your form'.

From 8 December 2019, a new function in PDS creates Medicare shell records. It uses a data feed directly from the Australian Health Practitioner Regulation Agency (Ahpra).

To complete the Medicare provider number registration process, Service Officers must use:

• the shell record, and
• details provided in the application form, when:
• a Medicare shell record exists in PDS, and
• application has been manually submitted

Service officers should only promote the shell record once it has been determined a Medical provider number (MPN) can be issued. The current MPN process continues to apply if a Medicare shell record does not exist.

If a shell record does not exist, escalate to a Programme Officer via Local Peer Support (LPS).

The Resources page contains a link to archived provider number history and to the Application for a provider number form.

The PDS is the Services Australia database which records and stores details about health professionals providing services for Medicare. Services Australia, the Department of Health and Aged Care and other external stakeholders use PDS data for various reasons.

For example, claims assessment, statistical reporting and analysis, etc. The accuracy of this data is critical to these functions.

Details held in PDS include:

• personal
• primary qualifications
• contact
• professional registration
• specialties
• practice location/s
• track and scale (participating medical practitioners only)
• employment information (sometimes referred to as business structure information)
• provider service rules (if applicable)
• pay group links (PGL) (if applicable)
• 90 Day Pay Doctor via Cheque (PDVC) Scheme registration (if applicable)

Provider directory history screens

All changes made to a provider's details are recorded in the PDS and can be viewed to determine any changes to a record made over a period and to locate source documents.

Registration details include:

• area of registration (national/state/territory)
• registration number
• effective dates
• status
• comments regarding limitations or conditions

Status of registration

The Australian Health Practitioner Regulation Agency (Ahpra) works with 16 national Health Practitioner Boards in implementing the National Registration and Accreditation Scheme. The agency recognises 12 of those professions and receives a daily data feed from Ahpra.

The Resources page contains details about the health professional's registration status.

A Provider Service Rule (PSR) is a code applied to a health professional’s record in PDS. These are created by the Provider Eligibility team.. These are applied at the time of processing a provider number application or by the Provider Eligibility team when required.

A PSR can be used for the following reasons:

• a health professional is restricted from accessing Medicare benefits for certain services following a determination by Professional Services Review
• to prevent access to Medicare benefits:
• where the health professional is not eligible to provide Medicare for services in that location but may require a provider number for other reasons. For example, to write referrals for diagnostic imaging or pathology tests, or refer a patient on to another health professional
• for medical practitioners who are not eligible to provide Medicare services for a period at a particular location. For example, there is a gap period between the cessation and commencement dates of a 19AB exemption
• where business structure requirements have not been met

PSRs are applied, where applicable, to:

• restrict Medicare claiming by a single item or by a range of items
• restrict all Medicare claiming at individual or all practice locations (location specific)

Multiple PSRs can be used at the same time.

PSRs hinder electronic claiming and should not be used unless there is a genuine need.

Only PSR 618 can be removed over the phone and only where the 618 service rule was placed on the location when initially created as the business structure and banking details were not supplied for allied health, non-medical and standard medical providers only.

Note: do not remove the service rule from:

• nurse practitioners
• midwives
• medical practitioners subject to section 19AB
• Other Medical Practitioners Extension Program (OMPEP), or
• General Practitioner Respiratory Clinics (GPRC) locations

All exceptional requests to remove a service rule must be referred to a Programme Officer via Local Peer Support (LPS).

Important changes resulting from the Health Legislation Amendment (Improved Medicare Compliance and Other Measures) Act 2018 (the Act) took effect 1 July 2018. The Act amends the Health Insurance Act 1973.

Shared Debt Recovery Scheme

The Act also introduced the Shared Debt Recovery Scheme (SDRS) on 1 July 2019. The Scheme allows the Commonwealth to hold both a practitioner (primary debtor) and another party (secondary debtor) responsible for repayment of compliance debts, arising because of incorrectly claiming Medicare benefits, through the making of a shared debt determination.

The Scheme was introduced because Medicare billing is often delegated to non-health professionals, administered through centralised billing areas and can be influenced by organisational processes and policies. In some instances, this has led to incorrect billing practices.

The agency assesses Provider Registration applications in the date order received unless exceptional circumstances apply. For these, the agency can prioritise the application for quicker processing. This is done to support customers in getting continued access health services or if a practice/community is affected by a disaster.

Applying online using HPOS is the fastest and most secure option to apply for a provider number. Eligibility to apply online must be checked and discussed with the provider before fast tracking an application.

The Process page contains:

• the exceptional circumstances criteria and assessment, and
• what to do if health professional or third party calls and asks for their application to be prioritised

An extended processing timeframe is not an exceptional circumstance.

Eligible health professionals can create their own provider number via HPOS.

The Resources page contains a link to HPOS information and how providers can apply for a prescriber number.

If a provider asks if their application has been received:

• confirm when and how the application was submitted, and
• advise applications can take 2 days to be classified in the system from when the application is received by Services Australia

If the application was submitted 3 days before the enquiry, perform a search of the following work types in PaNDA Provider Registration Program:

• Applications
• Health
• Specialist Recognition Advisory Committee (SRAC)
• Pending Registration
• HPOS Digital Provider Number Request (DPNR) Allied Health Professional (AHP) Prescriber Number Request
• HPOS DPNR AHP Provider Number Request
• National office escalation

Unable to locate the application - Non-Provider Registration trained staff

• If unable to locate the application (submitted at least 3 days prior), warm transfer the caller to the Provider Registration team. Note: do not tell the provider the agency cannot see their application
• Say to the customer: ’I’ll need to transfer you to the Provider Registration team. Please hold the line’
• Transfer the call to the Provider Registration Team using Soft phone option Medicare Provider Registration T2

Unable to locate the application - Provider Registration trained staff

For non-posted applications, if this cannot be located in PaNDA and it has been:

• more than 3 days since the application was submitted, ask Local Peer Support (LPS) or a Team Leader to check the Medicare Provider Registration mailbox
• less than 3 days, tell the caller to check again once 3 days has passed

Note: documents sent by email must not be password protected and/or be larger than 10 megabytes. Attachments that do not meet these criteria cannot be classified in the agency’s system and/or be accessed.

The agency is responsible for maintaining records relating to personal and business information. Customers provide information with the understanding this will be protected from unauthorised access, use or disclosure. It is important for customers to remain confident that the agency will protect their information and comply with the privacy provisions of the various legislation it administers.

A privacy incident can occur when information is inappropriately collected, lost, subject to unauthorised use/access/modification, and/or disclosure.

Privacy incidents may include cases where personal information held is discovered to be:

• incorrect
• inaccurate
• not up to date
• incomplete
• irrelevant, or
• misleading

All privacy incidents should be reported immediately to the team leader. See Privacy incidents for more details.

The Resources page contains:

• a table of provider types
• links to external and internal websites, and
• contact details

Requests to backdate a provider number may be granted in certain circumstances.

Before processing a request to backdate a provider number, the health professional must:

• have had current registration, and
• meets the eligibility requirements for refer, request and/or access to Medicare benefit rebates for their services at the time of the requested location start date

Note: if the application is for a provider number for a General Practitioner Respiratory Clinic (GPRC) requesting a backdate, do not back date to before 30 June 2023.

A request to backdate may be where:

• a completed provider number application is received, requesting a new provider number location start date before the date of lodgement and is signed by the health professional, or
• a written request is received, requesting an existing provider number location start date be amended before existing start date

A written request can be:

• an email, providing the email is received from the email address recorded on the stem in PDS
• a letter signed by the health professional

If the health professional meets these requirements, the Service Officer can start/backdate the location as per the application or written request. Services Australia national office approval is not required. There is no restriction on how far a provider number can be backdated if the health professional meets these requirements.

Note: requests to backdate can be processed via the phone, under the following conditions:

• A full security check has been performed successfully, by either the provider or a third party
• A provider is eligible and is unrestricted from the requested start date (add note to stem)

If the health professional does not meet the above requirements, the start date of the location should be:

• the date the health professional held current registration, or
• the date when the relevant access is required

The above process does not apply for locations with 3GA placements or for medical practitioners subject to section 19AB of the Act. Follow current processing requirements for these health professionals.

For help with backdating requests contact Local Peer Support (LPS).

A health professional must only be issued a provider number in the name in which they are registered with the relevant registration board or professional body.

A change of provider name is not actioned unless:

• evidence of the new name being used by the relevant registration body or professional association is provided
• a link between the provider's previous name and new name is evident or confirmed by supporting documentation

The link between the provider's previous name and new name can be confirmed. For example, when they have the same Medical, Allied Health or Dental Board registration board number. When in doubt, contact Local Peer Support (LPS), a Programme Officer can request confirmation of name change documentation, such as a marriage certificate.

Direct enquiries about provider names to Local Peer Support (LPS). If further clarification is required, the LPS can escalate to a Programme Officer.

Health professionals with an active HPOS account can have the outcome of their applications sent to them via mail and a HPOS notification including:

• confirmation letters
• rejection letters

The Process page contains more details in Table 4.

Provider Registration staff can also send previously issued letters to eligible health professionals through HPOS when the request is received from a phone call.