Guideline for substantiating dental prosthetic services where an eligible patient has been referred under the Chronic Disease Dental Scheme

This guideline outlines what you can do to substantiate dental prosthetists for Medicare Benefits Schedule (MBS) items 87011 to 87777.

What you need to know

The guideline is not exhaustive and you can respond to a Medicare compliance audit or review using any documents you think substantiate the concern raised.

However, the Department of Human Services may determine more information is needed and request additional documentation to substantiate services you have claimed.

Read the health professional guidelines about substantiating claims for Medicare compliance purposes before proceeding.

Under the Chronic Disease Dental Scheme you may be required to substantiate that:

  • a referral was received
  • a written quote was provided
  • a treatment plan was given to the patient
  • a copy or written summary of the treatment plan was given to the GP who first referred the patient for dental services, and
  • each service claimed was provided to the patient.

Documents you may use to substantiate a claim

Any document you give us should have been created at the time the service was rendered or initiated or as soon as practicable afterwards. It should include the patient's name and the date the treatment was provided.

To substantiate that the patient was referred you may provide:

  • a copy or excerpt of a referral form from a general practitioner - that has been published by the Department of Health, or a referral from that substantially complies with that form. The form must include the patient's details, the referring general practitioner details and should be dated and signed by the general practitioner

Note: a general practitioner may refer a patient to an eligible dental prosthetist only if the patient has no natural teeth and requires only dental prosthetic services, or requires only repairs or maintenance to an existing denture.

  • a copy or excerpt of a written referral from an eligible dentist - clearly showing the patient's name, the name of the referring eligible dentist and the date of referral
  • a copy or excerpt of a written referral from an eligible dental specialist - clearly showing the patient's name, the name of the referring eligible dental specialist and the date of referral
  • a copy or excerpt of a written referral from an eligible dental prosthetist - clearly showing the patient's name, the name of the referring eligible dental prosthetist and the date of referral
  • an excerpt from the patient's clinical note - clearly showing the patient's name, the name of the referring eligible dentist, eligible dental specialist or eligible dental prosthetist and the date of referral

To substantiate that a written quote and a treatment plan were created and provided to the patient you may provide:

  • a copy of the written quote and a treatment plan - clearly showing the patient's name and the date they were created
  • an excerpt from the patient's clinical file - clearly showing the patient's name and a reference confirming that a quote and a treatment plan were created and the date it was provided to the patient.

To substantiate that a written summary of the treatment plan was provided to the referring general practitioner you may provide:

  • a copy or written summary of the treatment plan clearly showing the patient's name, the date the treatment plan was created
  • an excerpt from the patient's clinical file clearly showing the patient's name and a reference confirming that a copy or written summary was sent to the referring general practitioner, including the date it was sent
  • a statement from the referring general practitioner confirming receipt of a copy or written summary of the treatment plan

To substantiate that the service was provided to the patient you may provide:

  • an excerpt from the patient's clinical file clearly showing the patient's name, the date each service was provided and a description or item number for the service. Additional records may include dental laboratory invoices

Note: MBS items 87011 to 87071 can be claimed prior to the provision of a written quote and a treatment plan.

For the purposes of this document, a 'patient' refers to a person who has a general practitioner management plan and team care arrangements in place and who is eligible to receive services under the Chronic Disease Dental Scheme.

In most cases, a patient's clinical information will be the only way to confirm there was a referral, a quote and treatment plan, and to substantiate you received the correct Medicare benefit.

If you need to use a patient's clinical information you can censor any details that aren't relevant. You can also choose to provide the information to one of our medical advisers.

Note: there are legal requirements for billing Chronic Disease Dental Scheme services and it is the responsibility of health professionals to ensure they meet those requirements.

Resources

Page last updated: 21 July 2016

This information was printed Sunday 4 December 2016 from humanservices.gov.au/health-professionals/enablers/guideline-substantiating-dental-prosthetic-services-where-eligible It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.