Cleft Lip and Cleft Palate Scheme for health professionals

Eligible patients can access Medicare benefits for corrective services under the Cleft Lip and Cleft Palate Scheme.

Health professional eligibility

There are 3 categories of health professionals eligible to provide treatment under the scheme:

  • orthodontists
  • oral and maxillofacial surgeons
  • dentists

Health professionals must be recognised by Medicare before they can bill Medicare for cleft lip and cleft palate services listed in Category 7 of the Medicare Benefits Schedule (MBS).

Category 7 of the MBS covers the following:

  • Group C1 - Orthodontic Services
  • Group C2 - Oral and Maxillofacial Surgical Services, and
  • Group C3 - General and Prosthodontic Services

For information on cleft lip and cleft palate services available under the scheme, visit the Department of Health’s MBS Online website.

Patient eligibility

To be eligible for treatment under the scheme, a patient must:

  • be enrolled in Medicare
  • before turning 22 years of age, be certified by a health professional as having:
    • a cleft lip
    • a cleft palate, or
    • other eligible condition
  • have started treatment before turning 22, and
  • be under the age of 28 when receiving treatment

Prescribed dental patient certification

From 1 December 2015, when providing treatment under the scheme, you must certify that your patient meets all of the eligibility requirements of a ‘prescribed dental patient’. This includes age and condition requirements.

To do this you must include the text ‘certified dental patient’ on the patient’s account or in the text field of a Medicare claim for benefits.

This requirement applies for new patients and also existing patients that were previously registered under the scheme with the department.

For information on eligible conditions under the scheme, visit the Department of Health’s MBS Online website.

Age limits

To receive treatment under the scheme, your patient must have been certified as a prescribed dental patient by a medical or dental practitioner before turning 22 years of age. Your patient must also have started treatment before turning 22 years of age.

Medicare benefits can then be paid for treatment until your patient reaches 28 years of age.

If your patient is 22 years of age or older and has not been certified as a prescribed dental patient, they cannot receive Medicare benefits for services provided under the scheme.

Repair of previous reconstructive work

If your patient is 28 years or over and was certified as a prescribed dental patient under the scheme, you can seek approval from us to undertake repairs to previous reconstructive work. Medicare benefits for this treatment can only be paid if the application is approved.

You will need to provide clinical details about the need for the repair of previous reconstructive surgery to support your application.

Applications including clinical details should be addressed to:

Cleft Lip and Cleft Palate Scheme
Department of Human Services
PO Box 7788
Canberra BC ACT 2610

More information can be found on the Department of Health’s MBSOnline website.

Page last updated: 5 February 2016

This information was printed Tuesday 27 September 2016 from humanservices.gov.au/health-professionals/services/medicare/cleft-lip-and-cleft-palate-scheme-health-professionals 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.