Hospital Substitute Treatment (HST) claims for Medicare 011-43010080

The Department of Health and Aged Care advised that from 1 April 2007, private health insurers are able to pay benefits for a wider range of services.

Items previously only claimable from both Medicare and private health insurers when performed in-hospital, are claimable for patients being ‘hospitalised’ at home.

Hospitals and private health insurers receive the claims for HST first, which will be noted on accounts. The Private Health Insurers forward the claims to Medicare for processing.

All accounts must be clearly marked ‘Hospital Substitute Treatment’ or ‘HST’.

Section 10(2)(a)(ii) of the Health Insurance Act 1973 provides for a benefit to be paid at 75% of the schedule fee for a Hospital-Substitute Treatment.

Section 69-10 of the Private Health Insurance Act 2007 defines a Hospital Substitute Treatment as general treatment that:

• substitutes for an episode of *hospital treatment, and
• is any of, or any combination of:
• nursing
• medical
• surgical
• podiatric surgical
• diagnostic
• therapeutic
• prosthetic
• pharmacological
• pathology, or
• other services or goods intended to manage a disease, injury or condition, and
• is not specified in the Private Health Insurance (Complying Product) Rules as a treatment that is excluded from this definition

Hospitals and private health funds receive claims for HST first, which will be noted on accounts. The private health funds then pass these claims on to Medicare for processing.

All accounts must be clearly marked 'Hospital Substitute Treatment' or 'HST'.

This policy applies to all claiming channels. The References page contains links to the Health Insurance Act 1973 and the Private Health Insurance Act 2007.

When an out-of-hospital claim is received with the wording 'Hospital Substitute Treatment' or 'HST', Service Officer's must add a 'H' to the item number and process at 75%.

All accounts must be either original documents or certified true copies of the original.

The original account or the certified copy of the original account must include:

• 'HST account lodged with [name of health fund]'

Note: processing associated with this policy is subject to quality control.

Processing HST claims

The Process page describes how to process claims for HST presented either:

• over the counter, or
• by mail

Bulk bill claims

Bulk bill claims for HST must be submitted on a hospital header.