Cleft Lip and Cleft Palate Scheme for health professionals

Health professional eligibility

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

• orthodontists
• oral and maxillofacial surgeons
• dentists

Health professionals must be registered with Medicare before you can bill Medicare for cleft lip and cleft palate services.

These are listed in Category 7 of the Medicare Benefits Schedule (MBS) which covers all of the following:

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

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

Patient eligibility

To be eligible for treatment under the scheme, your patient must meet all of these conditions:

• be enrolled in Medicare
• have started treatment before turning 22
• be under the age of 28 when receiving treatment.

They must also have been certified by a health professional before turning 22, as having one of these:

• a cleft lip
• a cleft palate
• other eligible condition.

Some Medicare items require a referral. For example, oral and maxillofacial service items require a referral from an orthodontist.

Prescribed dental patient certification

When providing treatment under the scheme, you must certify in your claims that your patient meets all of the eligibility requirements of a prescribed dental patient. This includes age and condition requirements.

You’ll need to 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 who were previously registered under the scheme with the agency.

For information on eligible conditions under the scheme, visit the Department of Health and Aged Care’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. Your patient must also have started treatment before turning 22.

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

Your patient can’t receive Medicare benefits for services provided under the scheme if they’re 22 or older and haven’t been certified as a prescribed dental patient.

Repair of previous reconstructive work

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

You'll 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:

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