Professional services related to Medicare patient claims 011-43010020

A professional service is defined as a clinically relevant service rendered by a medical or dental practitioner, an optometrist or an eligible allied health professional.

A clinically relevant service is defined as a service that is generally accepted in the medical, dental, optometric or allied health profession, as being necessary for the appropriate treatment of the patient to whom it is rendered.

Medicare benefits are paid under the Health Insurance Act 1973 (the Act) for professional services in accordance with fees set out in the Medicare Benefits Schedule (MBS). The MBS is a publication that is maintained and update by the Department of Health and Aged Care.

Each professional services contained in the MBS:

• has been allocated a unique item number:
• the Schedule fee and Medicare benefit are found with the item number and description for each service, and
• a reference to an explanatory note relating to the item (if applicable)

Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, state and territory laws. The day-to-day administration and payment of benefits under the Medicare arrangements is the responsibility of Services Australia.

The References page contains a link to the Health Insurance Act 1973.

There are some professional services which, because of their nature, do not attract a Medicare benefit. The Health Insurance (General Medical Services Table) Regulations 2018 states that the following services do not attract benefits:

• chelation therapy (that is to say, the intravenous administration of ethylenediamine tetra-acetic acid or any of its salts) otherwise than for the treatment of heavy-metal poisoning
• the injection of human chorionic gonadotrophin in the management of obesity
• the use of hyperbaric oxygen therapy in the treatment of multiple sclerosis
• the removal of tattoos
• the removal from a cadaver of kidneys for transplantation
• the transplantation of a thoracic or abdominal organ, other than a kidney, or a part of an organ of that kind, or
• the transplantation of a kidney in conjunction with the transplantation of a thoracic, or other abdominal organ, or a part of an organ of that kind, if the services are rendered to an in-patient of a hospital
• administering of microwave (UHF radio wave) cancer therapy, including the intravenous injection of drugs used immediately before or during the therapy

The References page contains a link to the Health Insurance Regulations 2018.

Unless the Minister otherwise directs, Medicare benefits are not payable for health screening services as stated in Section 19(5) of the Health Insurance Act 1973.

The Medicare Benefits Schedule (MBS) Explanatory Note titled Services which do not attract Medicare benefits defines a health screening service as a medical examination or test that is not reasonably required for the management of the medical condition of the patient.

Medicare benefits are not payable for health screening services.

Services considered to be health screening services include:

• multi-phasic testing
• mammography screening:
• except as provided for in items 59300/59303
• testing of fitness, to undergo physical training programs, vocational activities or weight reduction programs
• compulsory examinations or tests:
• to obtain a flying, commercial driving or other licence, except age or heath related medical examinations to obtain or renew a private motor vehicle licence
• to obtain entrance to schools and other educational facilities
• for the purpose of legal proceedings
• for admission to aged persons' accommodation and pathology services associated with clinical ecology

The References page contains links to the MBS and the Health Insurance Act 1973.

The Minister has directed that the following categories of health screening services attract Medicare benefits:

• symptomless patient
• pathology requested by the National Heart Foundation of Australia
• drivers licence
• unemployed person
• occupational STD blood testing
• adoption or fostering of a child
• social security benefits or allowances (including Centrelink and DVA)
• Ministerial exceptions

Symptomless patients

Medicare benefits are payable for medical examinations or tests on a symptomless patient by the patient's medical practitioner in the course of normal medical practice. This is to make sure the patient receives any medical advice or treatment necessary to maintain their state of health.

Benefits are payable for attendance and tests that are considered reasonably necessary according to patients individual circumstances (age, physical condition, past personal and family history).

The routine check-up should not necessarily be accompanied by an extensive series of diagnostic investigations.

Pathology requested by the National Heart Foundation of Australia

Medicare benefits are payable for a pathology service requested by the National Heart Foundation of Australia, Risk Evaluation Service.

Driver's licence

Medicare benefits are payable for medical examinations for reasons of age or health, for persons wanting to obtain or renew a licence to drive a private motor vehicle.

Unemployed person

Medicare benefits are payable for medical or optometrical examinations provided to an unemployed person (as defined by the Social Security Act 1991) at the request of a prospective employer.

Occupational STD blood testing

Medicare benefits are payable for medical examinations of, and/or blood collection from persons occupationally exposed to sexual transmission of disease.

This is in accordance with conditions determined by the relevant state or territory health authority (one examination or collection per person per week).

Benefits are not to be paid for pathology tests resulting from the examination or collection.

Adoption or fostering of a child

Medicare benefits are payable for medical examinations that are a condition of child adoption or fostering.

Social security benefits or allowances (including Centrelink and Department of Veterans' Affairs (DVA))

Medicare benefits are payable for medical examinations that are required for social security benefits and allowances.

DVA eligibility

Disability service pension administered by DVA.

Note: where a veteran receives medical screening for the purpose of obtaining a disability service pension through DVA, the account is paid through DVA's Medical Expenses Privately Incurred (MEPI) process.

Centrelink eligibility

Under direction made by the Minister under section 19(5) of the Health Insurance Act 1973, Medicare benefits are payable for medical examinations that are required to claim eligibility for the following Centrelink benefits or allowances:

• Disability Support Pension (DSP)
• Mobility Allowance (MOB)
• Carer Payment (CP)
• Carer Allowance (CA)
• JobSeeker Payment (JSP)
• Youth Allowance (YA)
• Special Benefit (SpB)
• Parenting Payment Single (PPS)
• Parenting Payment (Partnered)
• ABSTUDY
• Assistance for Isolated Children (AIC)
• Essential Medical Equipment Payment (EMEP)

Ministerial exceptions

There are Ministerial directions under section 19(5) of the Health Insurance Act 1973 that state Medicare benefits are payable for health screening services in the following circumstances:

• pathology arising from health screening in:
• Aboriginal & Torres Strait Islander Community Controlled Health Services in all states and territories
• Indigenous communities in rural or remote Central Australia (Northern Territory, South Australia or Western Australia)

The Minister can also direct in accordance with section 19(2) of the Health Insurance Act 1973 that Medicare benefits be payable for some professional services that would otherwise not be payable.

There are Ministerial directions under section 19(2) of the Health Insurance Act 1973 that state Medicare benefits are payable for services in the following circumstances:

The References page contains a link to the Health Insurance Act 1973.

Publicly funded bodies

The following is a list of publicly funded bodies where Medicare benefits are payable for services received:

• Aboriginal and Torres Strait Islander Community Controlled Health Services in all states and territories
• remote health centres engaged by the Northern Territory State Government
• Indigenous communities serviced by the Queensland State Government or Royal Flying Doctor Service
• Royal Flying Doctor Service, Rural Women's GP Service in all states and territories
• specific community health centres in Queensland, South Australia and Tasmania
• health services provided in Queensland, Western Australia, Northern Territory and New South Wales as part of the Council of Australian Governments' Improving Access to Primary Care Services in Rural and Remote Areas initiative
• services provided under the Nurse Practitioner - Aged Care Models Practice Program
• services provided under the Diabetes Care Project

For further information about Ministerial directions under Sections 19(2) and 19(5) of the Health Insurance Act 1973 contact Medicare Claims Policy.

The References page contains a link to the Health Insurance Act 1973.

The Medicare Benefits Schedule (MBS) Explanatory Note titled Services which do not attract Medicare benefits states that, unless the minister directs, a Medicare benefit is not payable where:

• medical expenses are incurred by the employer of the person to whom the service is rendered
• the person is employed in an industrial undertaking and that medical service is rendered for purposes related to the operation of the undertaking, or
• a person is required to attend a pre-employment screening service

Note: the Service Officer must return any claims relating to employment.

The References page contains a link to the Health Insurance Act 1973.

Pre-employment screening exception

A Medicare benefit is payable to a registered unemployed person for a medical or optometrical examination at the request of a potential employer for the purposes of employment.

Note:

• There is no particular item number to be used in this instance. The health professional can use the item number that best describes the consultation, as described in the MBS
• The onus is on the health professional to correctly itemise accounts and to only charge for services to unemployed persons (as defined by the Social Security Act 1991)

The References page contains a link to the Social Security Act 1991

Sporting bodies

A sporting body can be classified as an employer. Professional sports players who receive an income from a sporting body are considered employees of that sporting body.

On 30 October 2014, the Minister for Health signed a direction stating that Medicare benefits are payable for persons employed to play sport. This direction applies to claims received from 25 May 2014 until 30 October 2017.

A new direction was signed on 6 March 2017, revoking the direction signed on 30 October 2014. This new direction states that Medicare benefits shall be payable indefinitely in respect of a professional service rendered to a person where that person is employed to play sport.

For claims submitted by a sporting person, Service Officers can continue to process these indefinitely.

Medicare benefits are payable only where:

• there is a genuine commercial arrangement between the health professional and the patient, and
• the health professional expected to receive a payment in relation to the service

The Medicare Benefits Schedule (MBS) Explanatory Note titled Services which do not attract Medicare benefits states that:

• Medicare benefits are not paid for professional services rendered by a practitioner to:
• dependants
• a practice partner, or
• a practice partner's dependants

A dependant person is a spouse or a child.

A spouse, in relation to a dependant person, is a:

• person who is legally married to and not permanently living apart from the health professional
• de facto partner

A child, in relation to the dependant person, is aged:

• under 16 years and in the custody, control and care of the health professional or their spouse
• 16 years and over and in the custody, control and care of the health professional or their spouse
• 16 years and over and:
• in full-time education at a school, college or university
• not receiving a disability support pension under the Social Security Act 1991
• wholly or substantially dependant on the health professional or their spouse

The References page contains links to the MBS and the Social Security Act 1991.

See Register children (including children in care) for Medicare Safety Net.

Locum arrangements occur where a locum-tenens (locum) tenders a service on behalf of another health professional.

A locum is a health professional who temporarily fulfils the duties on behalf of a health professional in a practice. It is each locum's responsibility to ensure that their provider number is used on patient accounts.

It is an offence to use another health professional's allocated number.

Where a locum practices for more than 2 weeks or is at a practice for less than 2 weeks but on a regular basis, the locum should apply for a provider number for the relevant location.

Where either a:

• general practitioner (GP) acts as a locum for a specialist, or consultant physician
• specialist acts as a locum for a consultant physician
• GP acts as a locum for a principal health professional

The Medicare benefit is only payable at the level appropriate for the qualifications held by the locum, for example:

• GP level for GP locum
• specialist level for a referred service rendered by a specialist

Account documents

When a locum renders a service on behalf of another health professional, the account documents must indicate it is a locum service either by the word 'Locum' or the letters 'LT' (Locum Tenens).

The account must also include both the:

• locum's name and provider number (and their address if required)
• name, address and provider number of the doctor on whose behalf the locum is acting

PAYP lines

A pay provider (PAYP) line is used when an account indicates that the service(s) was performed by a locum, for example, 'locum' or 'LT'.

A PAYP line must be keyed regardless of whether a paid or unpaid account is involved.

Keying a PAYP line ensures that Medicare benefits are correctly assessed and made payable to the health professional for whom the locum is acting.

Note: for quality control purposes, locum details must be present for a PAYP line to be keyed.

See Table 2 Step 3 of Process digital self service claims (dept.local) for process instructions to modify claim lines.

New referrals

New referrals are not required for acting locums. Referrals to a health professional in the practice are accepted as applying to the locum.

Initial attendance

Medicare benefits are not payable at the initial attendance rate for an attendance by a locum if the health professional being replaced has already performed an initial attendance in respect of the particular instrument of referral.