Information to help you understand your legal obligations when referring and requesting services under Medicare.
What you need to know
To bill a referred or requested type service to Medicare, specialist referrals or requests for diagnostic imaging and pathology services must comply with the:
- Health Insurance Act 1973
- Health Insurance Regulations 1975, and
- for pathology services, the Health Insurance (Pathology Services) Regulations 2018
This page outlines the requirements for payment of Medicare benefits for referred or requested services. Specialists and consultant physicians, diagnostic imaging and pathology practices may need more information before they accept a referral or request.
Referrals for specialist treatment
Patients can be referred to a specialist or consultant physician for treatment of their condition. The referral must include:
- relevant clinical information about the patient’s condition for investigation, opinion, treatment and/or management
- the date of the referral, and
- the signature of the referring practitioner
Referrals don’t need to be made out to a certain specialist or consultant physician.
Referrers should let patients choose where to present the referral, this also applies to electronic referrals.
Single course of treatment
A referral will cover a single course of treatment for the referred condition. A single course of treatment is an initial attendance by the specialist or consultant physician. The single course of treatment includes subsequent attendances for the continuing management of the condition until the patient is referred back to the referring practitioner.
A new referral doesn’t always mean a new course of treatment.
If a referral is for continuing management of a condition, the specialist or consultant physician must bill subsequent attendance items. However, an initial attendance item can be billed if:
- the referring practitioner decides the patient’s condition needs to be reviewed, and
- the patient is seen by the specialist or consultant physician after the expiry of the last referral, and
- the patient was last seen by the specialist or consultant physician more than 9 months earlier
If the patient has a new or unrelated condition, the specialist can start a new course of treatment if there is a new referral in place.
Referral periods from a GP to a specialist
A referral from a general practitioner (GP) to a specialist lasts 12 months, unless noted otherwise. The referral starts from the date the specialist first attends the patient, not the date issued.
If a patient needs continuing care, GPs can write a referral beyond 12 months or for an indefinite period.
If a patient on an indefinite referral has a new or unrelated condition, the GP must issue a new referral for that condition.
Referral periods from a specialist to another specialist
Referrals from specialists and consultant physicians are valid for 3 months unless the patient is an admitted patient.
Referrals for admitted patients are valid for 3 months or the duration of admission, whichever is longer.
Lost, stolen or destroyed referrals
A written referral that is lost, stolen or destroyed is valid for only one attendance on the patient. A valid referral must be received before any subsequent services are billed. The account, receipt or assignment form must include:
- the referring medical provider’s name
- practice address or provider number of the referring medical provider (if known), and
- the words ‘lost referral’
Requests for diagnostic imaging services
Requests for diagnostic imaging services must have:
- the requesting practitioner’s full name, provider number or practice address
- the date of the request, and
- a description of the services requested
Patients can choose a provider and don’t need to give a request to a specific practice. This also applies to electronic requests.
Requests for pathology services
Requests for pathology services must have:
- the patient’s name and address
- the patient’s hospital status
- the requesting practitioner’s full name, provider number and practice address
- a description of the services requested, and
- the date of the request
If a specific pathologist isn’t clinically needed to do the service, the patient can choose a provider. This also applies to electronic requests.
Electronic referrals and requests
You must comply with the Electronic Transactions Act 1999 when sending referrals and requests electronically between third parties. Section 10 has more information about electronic signatures.
You must save, store and retain access to electronic referrals or requests so you can retrieve them unaltered. Your records may need to be checked in the event of an audit.