Guideline for substantiating dental services where an eligible patient has been referred by a general practitioner under the Chronic Disease Dental Scheme

This guideline outlines what you can do to substantiate dental services by a general practitioner for Medicare Benefits Schedule (MBS) items 85011 to 85986.

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 by a general practitioner you may provide:

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

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 of the treatment plan and cover letter, facsimile or email to the referring general practitioner - clearly showing the patient's name, the date the treatment plan was created, to whom it was provided and the date it was provided to the general practitioner
  • 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 85011 to 85071 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 GP 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: 25 January 2016

This information was printed Thursday 8 December 2016 from humanservices.gov.au/health-professionals/enablers/guideline-substantiating-dental-services-where-eligible-patient-has 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.