Medicare benefits for health professionals

Information for health professionals about eligibility, applying for a provider number and claiming Medicare benefits

Important information

  • You must apply for a unique provider number for each place of practice and profession you practice in.
  • You can’t claim a Medicare benefit until we have issued your provider number for that location.
  • You can’t use anyone else’s Medicare provider number.
  • You aren’t eligible to claim Medicare benefits if we’ve suspended your membership/ registration or if it has expired. You’re also no longer eligible if your membership level has changed.
  • If you don’t have access to Medicare, you must let patients know before you treat them that they won’t get a Medicare benefit for your services.

Eligibility to access Medicare benefits

General eligibility requirements

We determine eligibility to access Medicare benefits using the Health Insurance Act 1973 (the Act) and related regulations.

To provide a service that attracts a Medicare benefit, you as a health professional must:

  • have a Medicare provider number for each practice location
  • meet eligibility requirements set out in the Act or the relevant legislation relating to your specific health profession
  • have been advised in writing that you’re eligible to access Medicare benefits for your services

If you don’t meet these requirements

If you don’t meet these requirements, you can still practise medicine. You still have to satisfy requirements set out by your registration body. You just can’t claim a Medicare benefit for your services.

You must let patients know that they won’t get a Medicare benefit before you provide a service to them. It’s an offence under section 19CC of the Act to provide a service without doing this.

Medical practitioner eligibility requirements

Section 19AA of the Health Insurance Act outlines eligibility for medical practitioners to claim Medicare benefits.

Read more about Medical practitioner eligibility requirements

Nurse and midwife eligibility requirements

To claim a Medicare benefit for a service, nurses and midwives must:

  • meet the qualification requirements set out in the Health Insurance (Midwife and Nurse Practitioner) Determination 2011
  • be registered and authorised by the Nursing and Midwifery Board of Australia (NMBA)
  • be in private practice. Nurses and midwives who are employed by a public hospital or health services aren’t eligible to claim Medicare benefits
  • have a collaborative care arrangement in place

Collaborative arrangements must include at least one medical practitioner. Collaborative arrangements can’t include entities such as health services.

You can demonstrate collaborative arrangements by:

  • being employed or engaged by a medical practitioner or an entity that provides medical services
  • seeing patients who have a written referral from a medical practitioner having a signed written agreement with a medical practitioner

Section 84AAF/84AAJ of the National Health Act 1953 has more information about:

  • claiming Medicare benefits, and
  • applying for prescriber number as a nurse or midwife

Allied health practitioner eligibility requirements

To claim Medicare benefits, allied health professionals must:

  • meet the qualification requirements set out in the Health Insurance (Allied Health Services) Determination 2014
  • be registered with the AHPRA or a respective board or organisation
  • be recognised as an allied health professional in their field by Medicare
  • be in private practice, and
  • be working in a private capacity

Allied health professionals who may qualify include:

  • Aboriginal Health Workers
  • audiologists
  • chiropractors
  • diabetes educators
  • dietitians
  • exercise physiologists
  • mental health nurses
  • occupational therapists
  • orthoptists
  • osteopaths
  • physiotherapists
  • podiatrists
  • psychologists
  • social workers
  • speech pathologists

An allied health professional is also eligible for registration under the allied health professional initiative if they’re employed by:

  • an Aboriginal and Torres Strait Islander Community Controlled Health Service, or
  • a state or territory clinic that has an exemption under subsection 19(2) of the Act

Dental practitioners eligibility requirements

To claim Medicare benefits, dental practitioners must:

  • meet the qualification requirements set out in the Health Insurance (Dental Services) Determination 2007
  • be registered with AHPRA or a respective board or organisation
  • be recognised as a dental practitioner in their field by Medicare
  • be in private practice, and
  • be working in a private capacity

Dental prosthetists

Dental prosthetists can register for a Medicare provider number, but they can’t use their provider number for Medicare billing.

Optometrists eligibility requirements

To claim Medicare benefits, optometrists must:

Apply for a Medicare provider number

About Medicare provider numbers

A Medicare provider number:

  • is required if you bill, prescribe or request services that are eligible for a Medicare benefit
  • identifies your qualifications, registration, eligibility status and any restrictions in your access to Medicare benefits.
  • identifies your practice location so we and the Department of Veterans’ Affairs can process your claims
  • lets you refer patients to another health service where they can claim a Medicare benefit

We’ll always record your name on your provider number exactly as it’s registered with the relevant registration board or professional body.

You’ll need more than 1 Medicare provider number if you:

  • deliver health services in different locations
  • are registered in multiple health professions

We’ll tell you in writing if you’re eligible and we’ll include your Medicare provider number for each practice location. Until you have this letter you can’t bill, refer, prescribe or request services that attract a Medicare benefit.

You can’t use another health professional’s Medicare provider number under any circumstances.

Example of a Medicare provider number

Your provider number has:

  • a 6 digit number that identifies you, such as 123456
  • 2 other characters that identify your practice location, such as 1A

In this example, the Medicare provider number would be 1234561A.

Who can apply for a provider number

Health professionals who are registered with the Australian Health Practitioner Regulation Agency (AHPRA), or a relevant registration body can apply for a Medicare provider number.

We assess your application for a provider number based on the information you provide:

  • on your application form, and
  • in your supporting documentation

Applying for a Medicare provider number

You can apply online using HPOS or by filling in a form.

Read more about applying for a Medicare provider number

Processing times for applications

We assess your application to see if you’re eligible to access Medicare benefits. If you’re eligible we’ll update your Medicare Provider Record to show your new status.

We’ll send you a letter to let you know when your application has been finalised. The letter will tell you the date you’ll be eligible to start claiming the MBS items. You can start claiming under Medicare benefits from that start date.

Claim a benefit

When you can claim

We assess your application to see if you’re eligible to access Medicare benefits. If you’re eligible we’ll update your Medicare Provider Record to show your new status.

We’ll send you a letter to let you know when your application has been finalised. The letter will tell you the date you’ll be eligible to start claiming the MBS items. You can start claiming under Medicare benefits from that start date.

Claiming options

To claim Medicare benefits you can either:

Claiming information

Claims need to clearly show:

  • the address and provider number of the place of practice
  • that the service qualifies for Medicare benefits
  • that the person who provided the service is a registered medical practitioner at the place of practice

You should only claim:

  • while working in a private capacity, and
  • if you’re not getting other government funding for your services

Having a provider number doesn’t mean you’ll get Medicare benefits for all the services you provide.

Some Medicare provider numbers can only be used to refer or request services for your patients.

Manage your provider numbers in HPOS

Keeping your details up to date

You can update your bank account details and contact details using HPOS. It’s important to keep your details up-to-date so that your payments aren’t delayed.

Applying for a subsequent provider number location

Eligible non-restricted health professionals can apply online for subsequent Medicare provider numbers for additional approved locations. You can manage your locations through HPOS using your PRODA account.

Closing a location

If you’re no longer working at a practice location, you must close the provider number for the location. You can manage your locations through HPOS using your PRODA account.  

Page last updated: 19 September 2018