Private billing procedures for health professionals

Information to help you understand your legal obligations if you choose to privately bill a patient.

You can choose to privately bill a patient for a Medicare service.

If you do, make sure you understand and meet the requirements under the Health Insurance Regulations 2018. This will help us pay the Medicare benefit to the claimant.

Read the Health Insurance Regulations on the Federal Register of Legislation.

Itemised accounts

A Medicare benefit isn’t payable unless it’s on an account that includes the fee and service details, including:

  • the name of the patient
  • the date of the service
  • the amount charged
  • the total amount paid
  • any amount still owing
  • an item number and/or a description to identify the service.

Under the Health Insurance Act 1973, you’re legally responsible for services billed to Medicare under either:

  • your Medicare provider number
  • your name.

You're also responsible for incorrect claims. This includes when someone else records the information on your behalf, for example, the practice manager.

Health professional details required on account or receipt

Under section 51 of the Health Insurance Regulations 2018, you must include certain information on an account or receipt.

You can provide either or both:

  • the name of the health professional that’s providing the service and address of the place of practice for the service
  • the provider number of the health professional.

We can record more than one practice location for you. Always use the provider number for the practice location where you provide the services.

When a locum provides a service on behalf of another health professional, the account documents must use either:

  • the word Locum
  • the letters LT.(Locum Tenens).

Referral details required on account or receipt

You need to provide referral details on the account or receipt for patients referred to you. You need to include the following:

  • the name of the referring health professional
  • the address or provider number of the referring health professional
  • the patient’s referral date
  • the period the referral is valid for.

If a referral is valid for anything other than 12 months, you should reflect it in months. For example, write 3 months. You can also write indefinitely.

Multiple attendances on the same day

We can pay Medicare benefits if you attend to a patient several times on the same day. As long as they’re not continued from the initial or earlier visit.

If you attend to a patient more than once in the same day, include each time on the account. This will help us assess the claims.

Read more about billing multiple MBS items.

Services to in-patients

Mark the account with an asterisk * or the letter “H” if you provide or request services for an in-patient:

  • of a hospital
  • at an approved day hospital facility.

You can provide services as part of a privately insured episode of hospital-substitute treatment. The patient may choose to receive a benefit from a private health insurer, if so the claim should include either:

  • hospital-substitute treatment directly after an item number and brief description of the professional service
  • hospital-substitute treatment and a description of the professional service identifying the item related to the service.

Ask us to include the account reference details in your Medicare statement of benefit.

This will help you work out which account we’ve paid the Medicare benefit for. The account can hold up to 11 alphabetical and numeric characters.

If we can’t clearly identify the service as qualifying for Medicare benefits, we may delay or not pay the claim.

Benefits for professional services

The claimant is the person who incurred or is liable for the expense for the medical services. We pay Medicare benefits to the claimant.

The claimant and patient aren’t always the same. For example, a parent may pay for the service but they may not be the patient.

Paid accounts

The claimant may pay your account and then claim the Medicare benefit with us.

Unpaid and partially paid accounts

If the claimant hasn’t paid your account, they can present the unpaid or partially paid account to us.

In this case, we’ll forward a Medicare benefit cheque to the claimant made payable to you, the service provider. This is a Pay Doctor via Claimant Cheque (PDVC).

The claimant is responsible for providing the cheque to you and for paying any outstanding balance of the account.

The 90-day pay doctor cheque scheme lets us cancel a PDVC cheque for eligible health professionals. We’ll then pay you the Medicare benefit by EFT instead.

Read more about the 90 day pay doctor cheque scheme.

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Page last updated: 1 October 2019