Information to help you understand your legal obligations when referring and requesting services under Medicare.
What you need to know
Specialist referrals or requests for diagnostic imaging and pathology services must meet the requirements of the Health Insurance Act 1973, the Health Insurance Regulations 1975 and, in the case of pathology, the Health Insurance (Pathology Services) Regulations 1989 in order for the service to be billed to Medicare.
Referrals for specialist treatment
Where a service performed by a specialist or consultant physician needs a referral to be eligible for Medicare benefits, it must contain the following information:
- 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
Referring practitioners don’t need to address a referral to a specific specialist or consultant physician. Patients should also be given the choice of where to present the referral, including where the referral is submitted electronically.
Single course of treatment
A referral will cover a single course of treatment for the referred condition. A single course of treatment involves an initial attendance by the specialist and then the continuing management of the condition as needed until the patient is referred back to the referring practitioner.
For each single course of treatment, an initial attendance item can be billed by the specialist. Subsequent attendance items are then to be billed for the continuing management of that condition.
A new referral doesn’t necessarily mean a new course of treatment is needed.
Where a patient's referral has expired and they present a new referral for the continuing management of a previously referred condition, attendances provided under the new referral must be billed under the subsequent attendance items.
Where there has been a significant change in condition for the patient, or the patient has a new or unrelated condition, the specialist can start a new course of treatment.
GP referral to a specialist
Referrals from a general practitioner (GP) to a specialist last 12 months, unless otherwise specified. This period begins from the date the specialist first attends the patient, not the date the referral is issued by the GP.
If a patient’s condition needs continuing care and management by a specialist or consultant physician, GPs can write a referral for longer than 12 months. GPs may also decide that an indefinite referral to the specialist or consultant physician is appropriate.
If a patient on an indefinite referral has a new or unrelated condition, the GP must issue a new referral for that condition.
Specialist referral to another specialist
Referrals from specialists and consultant physicians are valid for 3 months unless the referred patient is an admitted patient. Referrals for admitted patients are valid for 3 months or the duration of the admission, whichever is longer.
Requests for diagnostic imaging services
For diagnostic imaging services to be eligible for Medicare benefits, a request must contain:
- a description of the services requested
- the requesting practitioner’s full name, provider number or practice address, and
- the date of the request
Patients don’t need to present a request to a specific diagnostic imaging practice and should be given the choice of where to present the request. This also applies to requests submitted electronically.
Requests for pathology services
For pathology services to be eligible for Medicare benefits, a request must contain:
- the name and address of the patient
- the hospital status of the patient
- 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 perform the service, the patient must be given the choice of where to present the request. This also applies to requests submitted electronically.